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

Summary Reviewer 1

A 70-year-old male enrollee has requested reimbursement for service code 97139, unlisted therapeutic procedure, performed on 4/20/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the specifics of how the service in question is physically administered upon patients are not described in the medical literature. There is no clear description of the technique on the serviceas website. The website makes no reference to any published, peer-reviewed, medical, scientific or clinical studies involving this service specifically. The technical features of this service appear proprietary. As best as can be discerned from the records provided by the facility where the patient received this service, the service involves a patient being secured to a thoracic harness and a pelvic harness, with tension then applied. The patient in this case received 50 lbs of tension for 25 minutes on his earlier visits, and this was gradually increased to 100 lbs of tension for 25 minutes by mid/late June 2020. The service in question, overall, appears to be a lumbar traction table, likely provided in an intermittent/cyclical manner, and marketed in a manner to suggest that exposure to this device improves an intervertebral discas health or anutrition.a
There is no reasonable expectation that exposure to the service in question will provide any health or functional benefits that would be different to exposure to other types of lumbar traction devices. This is to say that no health or functional benefits would be expected from exposure to this specific device. The intervertebral discs are routinely offloaded from pressure in the recumbent position (e.g., during sleep). There is no proven clinical benefit of providing exogenously applied force aimed at distraction of the discs, whether continuously or rhythmically. The literature, overall, does not support the use of lumbar traction for back pain conditions attributed to disc degeneration or pathology. The support for the use of this type of intervention is anecdotal. The focus of treatment of benign, musculoskeletal/mechanical low back pain includes patient education (particularly with respect to the natural history of the condition), independently applied topical modalities for palliation, common analgesics for palliation, if warranted, exercise and remaining active. The service in question was not likely to have been more beneficial for treatment of the patientas condition than routine management involving the above. There are no simple, proven interventions (including lumbar traction) that provide marginally superior benefits than the above. Therefore, the unlisted therapeutic procedure provided on 4/20/20 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 70-year-old male enrollee has requested reimbursement for service code 97139, unlisted therapeutic procedure, performed on 4/20/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. The services at issue were not likely to have been superior over standard therapy of physical therapy, epidural steroid injections, modification of the activity that may exacerbate the pain, and medication management. A review of the literature does not reveal sufficient evidence regarding the effectiveness of this procedure for this patientas condition. Therefore, the unlisted therapeutic procedure provided on 4/20/20 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 70-year-old male enrollee has requested reimbursement for service code 97139, unlisted therapeutic procedure, performed on 4/20/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient presented with complaints of grade 5-7/10 low back pain radiating into the right buttock, posterior thigh, and anterior lower leg. Symptoms were aggravated by walking and relieved by sitting. Functional limitations were noted in activities of daily living. He had failed to improve with previous conservative treatment, including nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and chiropractic care. He underwent 38 sessions of the novel IntraDiscNutrosis therapy from 4/20/20 to 6/24/20. Under consideration is a request for reimbursement of this therapy, billed using the unspecified CPT code 97139. Literature available on the chiropractic provideras website indicated that this therapy consisted of whole body vibration, Pettibon wobble chair, disc oscillation therapy (North American Medical Device), and a soft back brace. There is a lack of current evidence-based medical literature to support this therapy. There is a lack of large volume, long-term, peer-reviewed outcome studies to support the use of these procedures for this patient. There is no compelling rationale to support this combination of physical medicine care in an extensive therapy protocol over any available standard therapy. Therefore, the unlisted therapeutic procedure provided on 4/20/20 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1
A 42-year-old female enrollee requested authorization and coverage for CPT 58674 (Acessa procedure - laparoscopic radiofrequency ablation). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.  The physician reviewer found that the desired procedure is a minimally invasive radiofrequency ablation treatment that reduces fibroid-related symptoms by reducing fibroid volume. The procedure is performed through a laparoscopic approach. Alternative standard therapy to the procedure includes more aggressive interventions, such as hysterectomy or myomectomy. Interventional radiology embolization procedures are only successful in a certain patient population with fibroids in specific locations. The procedure is done as an outpatient basis, with return to normal activity within approximately one week. Using ultrasound guidance to identify the fibroid, a conductive needle array punctures the fibroid and transmits radiofrequency energy, which causes coagulative necrosis. An ultrasound probe is used to monitor the tissue effect until the bulk of the fibroid is treated. Over subsequent months, fibroids are reabsorbed, with a decrease in fibroid volume and a resultant reduction in fibroid-related symptoms. This is directed therapy and allows for treatment in the proper candidate within a minimally invasive surgical approach. The medical evidence supports the requested services in this clinical setting. Therefore, CPT 58674 (Acessa procedure - laparoscopic radiofrequency ablation) is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2
A 42-year-old female enrollee requested authorization and coverage for CPT 58674 (Acessa procedure - laparoscopic radiofrequency ablation). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that minimally invasive therapies to treat symptoms of uterine myomas can be effective alternatives to major surgery. Such modalities include pharmacologic agents, uterine artery embolization, magnetic resonance-guided focused ultrasound, and laparoscopic radiofrequency ablation, known as the Acessa procedure. Acessa is used to treat women with symptomatic myomas and was approved by the U.S. Food and Drug Administration in 2012. Brucker and colleagues compared the mean hospital discharge times and perioperative outcomes for radiofrequency volumetric thermal ablation of fibroids and laparoscopic myomectomy. The authors noted, Radiofrequency volumetric thermal ablation resulted in the treatment of more fibroids, a significantly shorter hospital stay, and less intraoperative blood loss than laparoscopic myomectomy. Lin and colleagues performed a meta-analysis of eight studies. The authors assessed the short-term and long-term symptom relief and quality of life improvement, procedure-related adverse event rate, reintervention rate, and days missed from work after laparoscopic radiofrequency ablation. The authors noted, All subscales of quality of life improved significantly, and most of the changes remained stable in long-term follow-up. In conclusion, laparoscopic radiofrequency ablation therapy Acessa is an efficacious way to treat small-sized and nonpedunculated symptomatic uterine fibroids, providing stable long-term symptom relief and quality of life improvement. Therefore, CPT 58674 (Acessa procedure - laparoscopic radiofrequency ablation) is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 42-year-old female enrollee requested authorization and coverage for CPT 58674 (Acessa procedure - laparoscopic radiofrequency ablation). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the patient is requesting a treatment for symptoms related to her fibroid uterus. She has heavy menstrual bleeding that has led to the need for treatment. The patient would like her fibroids treated with the Acessa procedure. Studies have supported the Acessa technique under certain clinical criteria for patient selection. One of the criterion is uterine size. The maximum allowable uterine size is 16 weeks gestational age. This patients uterus has several fibroids that measure 4.7  7.6 cm, thus meeting the size criteria. Another criterion is fibroid location. The fibroids are intramural, which falls within the procedure guidelines. The patient wishes to have a minimally invasive procedure to preserve fertility. It is likely that shrinking multiple fibroids will result in improvement in the patients pain and bleeding and improve her quality of life. Therefore, CPT 58674 (Acessa procedure - laparoscopic radiofrequency ablation) is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 61-year-old female enrollee has requested authorization and coverage for Viekira Pak. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  It is advantageous to treat patients before they progress to cirrhosis.  Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Viekira Pak is medically indicated 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 


A 59-year-old female enrollee has requested has requested reimbursement for physical therapy treatment provided from 12/1/14 through 12/30/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees hip pain, wrist pain, spinal stenosis and shoulder pain. The physician reviewer found that physical therapy is a widely used treatment for lumbar spine pathology and patellofemoral pain. The duration and frequency of treatment are not adequately addressed in the medical literature. Delitto and colleagues indicate that there is benefit to therapeutic exercise tailored to the patients condition. In this case, the patient received documented therapeutic benefit through the first 13 sessions of physical therapy. However, the documentation submitted for review does not show a need for continued skilled services as of 12/1/14. The patient underwent physical therapy for an extended period of time without adequate support for the medical necessity of these interventions. She had more than 20 physical therapy sessions for her lumbar stenosis and patellofemoral pain by 12/1/14. Additional skilled treatment for these conditions was not medically necessary. In addition, the patient had wrist and shoulder pain in 2015 but the physical therapy notes do not show these issues being systematically evaluated and treated. The physical therapy sessions provided for her wrist and shoulder pain were not medically necessary. As such, physical therapy treatment provided from 12/1/14 through 12/30/15 has not been established as medically necessary for treatment of the patients medical condition. 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 24-year-old male enrollee has requested reimbursement for s physiotherapy on 12/7/17 and 12/14/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees arm pain. The physician reviewer found that there documentation provided does not support the medical necessity of the services at issue in this clinical setting. Musicians are at risk for musculoskeletal injury due to overuse and potential underlying factors such as hypermobility (Bird).  Early, specialized assessment, often greatly facilitated by examination during actual play of the musical instrument, is considered essential (Rietveld).  Key diagnostic issues include recognition of posture related problems, osteoarthritis and entrapment neuropathies.  Focused exercise is an appropriate intervention in the setting of some chronic tendinopathies (Childress and Beutler).  In addition, relative rest is an important consideration in the setting of overuse conditions. In the current case, the patient had chronic symptoms affecting his upper limbs. There were posture issues, potential overuse and anxiety issues.  The patient had been undergoing physical therapy for a prolonged period of time, and had maximized the benefit derivable from formal therapy prior to 12/7/17.  Based on the documentation provided, his symptoms were largely correlated with stress/anxiety and relieved by stress reduction interventions more than physical therapy.  The patient was working on general trunk and core exercises at of the time period in question, with no indications that he could not have been doing these basic conditioning and strengthening exercises independently.  He was receiving manual therapy. Formal manual therapy is not proven to be any more effective than self-applied interventions such as using a foam roller, stretching or applying thermal modalities in the long term. Accordingly, physiotherapy provided on 12/7/17 and 12/14/17 were not medically necessary for treatment of this patients medical condition. 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 37-year-old female enrollee has requested authorization and coverage for Remicade injections 100 mg. 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 this patient has moderate to severe Crohns disease based on extensive (orofacial and bowel) involvement. Per American Gastroenterological Association guidelines for therapy of moderate to severe Crohns disease, immunosuppressants such as azathioprine, 6-mercaptopurine, and methotrexate are not recommended as primary monotherapy, and tumor necrosis factor (TNF) inhibitors such as Remicade are recommended. American College of Gastroenterology guidelines also do not recommend immunosuppressants or methotrexate as primary monotherapy for the induction of remission of Crohns disease. In this case, the patient is unlikely to respond to conventional alternatives such as immunosuppressants, corticosteroids, and 5-aminosalicylate therapy, and she is at risk for additional Crohns disease complications such as fistula, stricture, hospitalization, and the need for surgery if induction and maintenance of remission is not effective. Therefore, Remicade injections 100 mg are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 46-year-old female enrollee has requested authorization and coverage for the Flexitouch pneumatic compression pump and leg garment. The Health Insurer has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the request for Flexitouch pneumatic compression pump and leg garment is not medically necessary for treatment of the patients medical condition. The documentation submitted for review does not document that she has failed a sustained trial of compression or documentation that she has failed treatment with a compression pump. Given the lack of documentation of conservative treatments, the requested equipment is not indicated. Therefore, the medical necessity for Flexitouch pneumatic compression pump and leg garment has not been established in this clinical setting. Therefore, the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer


The patient is a 48-year-old female who had previously undergone augmentation mammoplasty for apparent aesthetic concerns. She is noted to have evidence of bilateral silicone implant rupture, as documented on radiographic studies and confirmed on the operative report dated 12/11/17. The patient has requested reimbursement for removal of mammary implant material provided on 12/11/17. 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 submitted documentation supports the medical necessity of the services at issue. The records document ruptured silicone implant. The significance of a ruptured silicone implant is not known. Given this uncertainty, the U.S. Food and Drug Administration (FDA) recommends removal of ruptured silicone implants. It is well-known that free silicone can travel to lymph nodes and cause painful nodules. Thus, the services at issue were medically indicated. The fact that the original surgery was done for cosmetic reasons does not change the functional concern associated with ruptured silicone implants. All told, removal of mammary implant material provided on 12/11/17 was medically necessary of the treatment of this patient. Therefore, the services at issue were 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 patient is a 15-year-old female diagnosed with major depressive disorder, recurrent, severe, alcohol use disorder, severe, and self-harm. The records dated 2/8/17 reveal that she was admitted to intensive outpatient program (IOP) therapy on 2/9/17. During the course of treatment, the patient has described detachment and possible dissociation and is described herself as a mediator between her parents. On 4/10/17, she indicated in group therapy that she does not express her anger in adaptive ways and in the past drank alcohol as a method of coping. She indicated that she wanted to learn more adaptive strategies. Her parent has requested reimbursement and prospective authorization and coverage for mental health IOP services from 4/10/17 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary. By 4/10/17, the patient is noted to have a rather sophisticated understanding of her behavior in response to the dysfunction of her family. She appeared to be prepared to continue individual therapy supported by psychotropic medication. In addition to her diagnoses of major depression, and substance abuse, consideration might have been given to reactive attachment disorder with focus on treatments such as acceptance and commitment therapy as well as intensive in-home therapy with multiple systems therapy. These considerations are important because of the patients own experience of having to mediate conflict within the family (Cohen, et al). All told, the records provided for review do not support the medical necessity of the IOP services provided to this patient from 4/10/17 forward.  Based on the foregoing discussion, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 21-year-old female enrollee has requested authorization and coverage for inpatient upper jaw surgery. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees midface retrusion and class III malocclusion.  The physician reviewer found that according to the documentation submitted for review, the patient has evidence of class III malocclusion, maxillary retrusion and hyponasal speech. Cleft palate patients with maxillary retrusion have significant sleep apnea from malposition of the maxilla. This produces obstruction in the nasal airway, the nasopharynx, and velum. This demonstrated with hyponasal speech such as the patient in this case. Orthognathic surgery for this patient is medically necessary for correction of the nasal airway obstruction and sleep apnea that results from maxillary retrusion. Moreover, LeFort 1 surgery will move the maxilla forward and give the patient improved speech, improved nasal breathing and relief from sleep apnea and secondary consequences of sleep apnea. Based on the medical documentation provided for review, the request for inpatient upper jaw surgery has been established as medically necessary for treatment of the patients medical condition.  Therefore, the requested surgery is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.