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

Summary Reviewer 1


A 66-year-old male enrollee has requested reimbursement for LINX procedure/device performed on 7/27/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has history of belching and heartburn. The physician reviewer found that in this patients case, he has gastroesophageal reflux disease (GERD) based on pH recording. However, the records indicate that his heartburn has benefited, to a significant degree, from acid suppression treatment and as such cannot be considered medically refractory to acid blocker drugs. Moreover, the patients issues with belching was not eliminated upon LINX placement. Therefore, in this patients case, the LINX procedure/device was not likely to be more beneficial than any available standard therapy for treatment of the patients medical condition. 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 Upheld

Summary Reviewer 2

A 66-year-old male enrollee has requested reimbursement for LINX procedure/device performed on 7/27/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has history of belching and heartburn. The physician reviewer found For this patient, the services at issue were not superior to the available standard therapy for treatment of his medical condition. There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other standard surgical anti-reflux procedures. Per Sheu and colleagues in Curr Opin Gastroenterol, the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined.  Loh and colleagues concluded that further studies are required to determine its long term outcomes and its relative efficacy as compared to other established treatments. Adverse events, such as erosion through the esophagus, have been reported since U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Moreover, the American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). The available peer-reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial, in this patients case, than standard treatment of surgical fundoplication. As such, per the available literature and relevant clinical guidelines, LINX procedure/device performed on 7/27/16 was not likely to be more effective than other standard therapy for the treatment of this patient. 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 Upheld

Summary Reviewer 3


A 66-year-old male enrollee has requested reimbursement for LINX procedure/device performed on 7/27/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has history of belching and heartburn. The physician reviewer found that there is sufficient support for the efficacy of the services at issue in this clinical setting. LINX is a minimally invasive anti-reflux procedure that has been approved by the U. S. Food and Drug Administration. The medical literature has shown that the LINX device has less side effects and may have the potential to be completely reversible. This patient has a diagnosis of persistent chronic GERD that has been partly responsive to PPI dosing and behavioral/dietary modification. The patients GERD appeared controlled and the patient was weaned off PPI. Therefore, in the absence of clear data to establish a standard for treatment of GERD, the LINX procedure/device performed on 7/27/16 was likely to be more effective than the other forms of therapy for treatment of this patients medical condition. 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 38-year-old female with severe chronic pelvic pain. She underwent imaging of the pelvis, which showed dilated vessels, left larger than right. The physician reviewer found that this patient has clinical findings and imaging studies suggestive of pelvic congestion syndrome. There is limited data regarding the standard of care or optimal strategy to manage this diagnosis. For women with pelvic congestion syndrome, invasive treatment is an appropriate option. However, since randomized trials have not been performed, an optimal procedure is not known. As in this case, gonadal vein embolization is an accepted practice in the medical community. Case reports have shown the benefit of this procedure. The reported technical success rates of ovarian vein embolization range from 89 to 100 percent with clinical success rates of 58 to 100 percent (follow-up period of up to five years). Complication rates of 4 to 8 percent have been reported for ovarian vein embolization. Gonadal vein embolization is safe, well-tolerated, and allows for a minimally invasive approach. Thus, vascular embolization is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 27-year-old male enrollee has requested reimbursement for the pneumatic compressor or deep vein thrombosis (DVT) system provided from 4/5/16 through 5/4/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees left knee with patellar tendon rupture, anterior cruciate ligament (ACL) rupture, medial cruciate ligament (MCL) injury and medial meniscus injury. The physician reviewer found that in the peer-reviewed medical literature, Kakkos and colleagues concluded that the addition of intermittent mechanical leg compression augments the efficacy of anticoagulation in preventing DVT in patients undergoing both knee and hip replacement. Further research on the role of combined modalities in thromboprophylaxis in joint replacement and in other high-risk situations, such as fracture of the hip, is warranted. This patient underwent left knee arthroscopic surgery for ACL reconstruction on 4/5/16. He was prescribed an intermittent pneumatic compression device for mechanical DVT prophylactic therapy from 4/5/16 to 5/4/16. 

There are limited DVT risk factors identified for this patient. DVT risk factors included undergoing arthroscopic surgery, length of surgery, and obesity with a body mass index (BMI) of 30.4. It is noted that the patient was a current every day smoker. However, there is no documentation that anticoagulation therapy would be contraindicated, or standard compression stockings insufficient, to warrant the use of mechanical prophylaxis. Therefore, the pneumatic compressor or DVT system provided from 4/5/16 through 5/4/16 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 equipment 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 27-year-old male enrollee has requested reimbursement for the pneumatic compressor or deep vein thrombosis (DVT) system provided from 4/5/16 through 5/4/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees left knee with patellar tendon rupture, anterior cruciate ligament (ACL) rupture, medial cruciate ligament (MCL) injury and medial meniscus injury. The physician reviewer found that use of an intermittent mechanical compression device was appropriate for use in this specific patient in preventing DVT and the complication of pulmonary embolism. The use of mechanical compression devices in DVT prophylaxis and prophylaxis of pulmonary embolism with potentially fatal consequences is supported by American Association of Orthopaedic Surgeons (AAOS) guidelines. The AAOS guidelines support the use of compressive devices with a moderate recommendation. Thus, it was likely to be beneficial for an intermittent mechanical compression device to have been used in the treatment of this patient after ACL reconstruction in this patients high-velocity multiple lower extremity injury. Accordingly, the pneumatic compressor or DVT system provided from 4/5/16 through 5/4/16 was 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 equipment at issue was 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 27-year-old male enrollee has requested reimbursement for the pneumatic compressor or deep vein thrombosis (DVT) system provided from 4/5/16 through 5/4/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees left knee with patellar tendon rupture, anterior cruciate ligament (ACL) rupture, medial cruciate ligament (MCL) injury and medial meniscus injury. The physician reviewer found that the use of intermittent pneumatic compression in this case was supported by the high risk for DVT as a result of the prolonged disability, obesity, and history of smoking. In addition, dynamic intermittent compression combined with cryotherapy decreases analgesic drug requirements after ACL reconstruction and improves the postoperative recovery of range of knee motion. Murgier and Cassard reported that the use of intermittent pneumatic compression combined with cryotherapy after ACL reconstruction resulted in decreased pain, inflammation, and need for narcotics after surgery in addition to the mechanical DVT prophylaxis. Waterman and colleagues found that the efficacy of combined cryotherapy and dynamic compression compared to cryotherapy alone demonstrates the advantage of using this combination after ACL reconstruction. In light of the foregoing, the use of intermittent pneumatic compression or DVT system provided from 4/5/16 through 5/4/16 was reasonable, appropriate, and better than any other available standard treatment. Based upon the information set forth above, the equipment at issue was 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 Upheld

Summary Reviewer

The patient is a 40-year-old male with a history of cocaine abuse. The patient reported that his cocaine abuse started about nine years ago, and increased from intermittently to daily. He was previously treated in March 2016. The patient relapsed one day after discharge and spent the next 4.5 months using 1 gram of cocaine a day. He was then admitted to psychiatric residential treatment center (RTC) on 7/17/16 with the diagnoses of cocaine use disorder, severe and major depressive disorder, severe. He related a history of depression and noted that prior treatment with Lexapro many years ago was helpful. He denied any other psychiatric symptomatology, past or present. He denied any medical problems. He said he used alcohol occasionally and it did not represent a problem, and denied use of any other substance. He reported sleep disturbance. There was no prior history of blackouts or seizures. He denied suicidal or homicidal ideation. The patient participated actively in his treatment plan, involving multiple modalities including relapse prevention, individual therapy, and group therapy. He continuously struggled with issues of self-worth, shame, and feelings of loneliness. He was treated with Seroquel 50 mg and no other medications. His vital signs were stable, and cravings were reported as infrequent to none. The patient has requested reimbursement for psychiatric RTC services provided from 7/23/16 through 8/30/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. Post-acute withdrawal symptoms in cocaine use disorders are not to be expected, nor were anything akin to these reported.  He was not a danger to himself or others, and he was not violent or aggressive. There were no emotional, behavioral, or cognitive issues that warranted residential treatment. There was no evidence of mania or psychosis, or any other symptom complex which would have interfered with his recovery at a lower level of care. He was medically and psychiatrically stable. He was treated with Seroquel 50 mg and this was not adjusted. He was cooperative and engaged in his treatment. The issues addressed in his individual therapy did not require RTC level of care. The patient could have safely and effectively stepped down to a lower level of care as of 7/23/16. Thus, psychiatric RTC services provided from 7/23/16 through 8/30/16 were not medically necessary for treatment of the patients medical condition.  Based on the foregoing discussion, 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 Upheld

Summary Reviewer 1

The patient is a 43-year-old female with a history of major depressive disorder, chronic pain and insomnia. The patient has failed multiple medications for the treatment of her depression. The patient has also failed transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT). The patient had a suicide attempt in 2016 after an overdose on her narcotics. This caused a hypoxic brain injury. The patient has requested authorization and coverage for CPT 64568 (implantation of vagus nerve neurostimulator electrode). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  This patient has had an extensive treatment history for her depression, including medications, TMS and ECT. However, there was no mention of her psychotherapy history to address her childhood trauma. There was no mention of psychotherapy to help manage her chronic pain. The medical literature has mixed results about the efficacy of the effectiveness of vagus nerve stimulation for treatment-resistant depression. Evidenced-based therapy such as cognitive processing therapy, prolonged exposure therapy, and intensive psychodynamic therapy along with pain management therapy could be utilized to help with the treatment of this patient. Therefore, the requested CPT 64568 (implantation of vagus nerve neurostimulator electrode) is not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested services are 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 Upheld

Summary Reviewer 2

The patient is a 43-year-old female with major depressive disorder.  She reports insomnia and chronic pain. She has a history of a prior suicide attempt. The patient has been treated with a myriad of medications. She has also been treated with electroconvulsive therapy (ECT) and an incomplete trial of transcranial magnetic stimulation (TMS). The patient has requested authorization and coverage for CPT 64568 (implantation of vagus nerve neurostimulator electrode). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  The submitted documentation fails to demonstrate the superior efficacy of the requested services. While a myriad of medications are listed, the doses and durations are not provided. Therefore, the adequacy of her medication trials cannot be established. It cannot be determined that she is a true medication non-responder based on the information provided. Based on the records, the patient may be a candidate for a recurrent trial of ECT, which is community standard. Vagus nerve stimulation is a longer term and less effective treatment than either ECT or TMS. All told, CPT 64568 (implantation of vagus nerve neurostimulator electrode) is not likely to be more efficacious than other available treatment options. Based upon the information set forth above, the requested services are 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 Upheld

Summary Reviewer 3

The patient is a 43-year-old female with major depressive disorder. Per the records, she sustained hypoxic brain damage after an overdose on medications.  She has tried multiple medications for the treatment of her major depressive disorder. The records noted prior treatment with electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS). The clinical notes document a history of abuse, insomnia and chronic pain. The patient has requested authorization and coverage for CPT 64568 (implantation of vagus nerve neurostimulator electrode). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient. The current medical evidence does not support the requested services in this patients case. On 1/29/18, the progress notes indicated that the patient was experiencing paranoia. These progress notes indicate that the patient was diagnosed with major depressive disorder with psychosis. There is a lack of support for the requested services for patients with psychosis. It is not clear whether the patient received evidence-based forms of psychotherapy for her major depressive disorder, which are the standard of care. The literature has limited support for the use of vagus nerve stimulation in unipolar depression. Thus, CPT 64568 (implantation of vagus nerve neurostimulator electrode) is not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested services are 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 Upheld

Summary Reviewer 1

A 45-year-old male enrollee has requested authorization and coverage for radiofrequency ablation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. Yang and colleagues performed a literature search for publications on the effectiveness of sacral lateral branch radiofrequency ablation for sacroiliac joint pain. The authors noted, aOne pragmatic study did not show any difference between radiofrequency ablation and control treatment consisting of a standardized exercise program for sacroiliac joint pain. However, recalculation of success rates according to intention to treat analysis demonstrates a significantly higher success rate associated with sacral lateral branch radiofrequency ablation and exercise compared with exercise alone.a However, the authors also indicated, aHeterogeneity in technology and technique call into question the generalizability of the current literature.a Furthermore, the authors noted, aEstablishing the prevalence of posterior sacroiliac joint pain with pain that is relieved by multisite, multi-depth blocks is essential to furthering our understanding of sacroiliac joint region pain and optimizing treatment. Randomized, placebo-controlled studies using multisite, multi-depth sacral lateral branch (SLB) blocks to enroll patients for sacral lateral branch radiofrequency ablation compared with sham treatments are needed to assess the efficacy of this procedure.a  In this case, the patient has a history of positive response to diagnostic procedure with no benefit from definitive procedure in both the lumbar spine for fusion as well as the spinal cord stimulator trial and implantation. The requested treatment is not superior to standard treatments. Therefore, the requested radiofrequency ablation is not likely to be more beneficial for treatment of the patient than any available standard therapy.