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

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 20 hours per week of direct applied behavioral analysis (ABA) therapy provided from 8/24/17 through 2/24/18. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the autism spectrum disorder.  The physician reviewer found the request for 20 hours per week of direct ABA therapy provided from 8/24/17 through 2/24/18 were and are medically necessary for treatment of the patients autism. Several medical studies support the efficacy of ABA therapy in relation to life skills and personal appearance for the treatment of autistic adults (Smith, et al; McClannahan, et al). According to the National Institute for Health and Care Excellence (NICE) guidelines for autistic adults, ABA also plays an important role in the treatment of aggression and outburst behaviors in adults. In this case, the patient presents with aggressive and self-injurious behaviors. He continues to require a high level of behavioral supports. Given the support in the peer-reviewed literature, the services at issue were and are medically necessary for treatment of the patients autism. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 57-year-old male enrollee has requested reimbursement for automated nerve conduction testing during anterior cervical discectomy and fusion performed on 10/20/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the patient underwent intraoperative neurophysiological monitoring during multiple level anterior cervical discectomy and fusion in the presence of myelopathy. Intraoperative neurophysiological monitoring during surgery is recommended when such procedures have a risk of significant complications that can be detected and prevented through use of neurophysiological monitoring. Intraoperative monitoring of somatosensory evoked potentials and transcranial electrical motor evoked potentials in procedures that involve the spinal cord itself can predict adverse surgical outcomes in complex cases. However, the evidence-based guidelines do not recommend intraoperative electromyography (EMG) and nerve conduction velocity monitoring on peripheral nerves during cervical spine surgery. An abnormal EMG response during the surgical procedure may or may not be associated with a clinically significant injury (Resnick, et al). Therefore, intraoperative electromyography is not recommended. In sum, intraoperative EMG and nerve conduction velocity monitoring on peripheral nerves during surgery is not recommended. In sum, the somatosensory and motor evoked potentials were medically necessary; however, the intraoperative electromyography and neuromuscular junction testing has not been substantiated. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


The parent of a 15-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure, Anser IFX assay testing (CPT code 84999) performed on 11/17/15.  The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease.  The physician reviewer found the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Some evidence exists that low serum levels of infliximab (IFX) or adalimumab (ADA) or the presence of IFX or ADA antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). As such, the clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Given the lack of support in the peer-reviewed literature, the unlisted chemistry procedure, Anser IFX assay testing (CPT code 84999) performed on 11/17/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Based upon the information set forth above, the testing at issue was 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


The parent of a 15-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure, Anser IFX assay testing (CPT code 84999) performed on 11/17/15.  The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease.  The physician reviewer found the unlisted chemistry procedure, Anser IFX assay testing (CPT code 84999) performed on 11/17/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The testing at issue is standard for patients treated with infliximab. The information received from Anser IFX assay testing may lead to a shortened interval or increased dose or possibly change of medication. In addition, Anser IFX assay testing indicates whether serum levels of the drug are in the range to be beneficial and effective or if the patient has antibodies that could potentially lead to a reaction or failure to respond. Anser IFX assay testing results can help guide the provider in dosing or may lead them to discontinue the drug if the patient is not likely to benefit from the medication. This can also prevent the patient from having a flare and prevent potential side effects. All told, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Based upon the information set forth above, the testing at issue was 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


The parent of a 15-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure, Anser IFX assay testing (CPT code 84999) performed on 11/17/15.  The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Testing for the presence of antibodies to infliximab (ATI) is appropriate in the setting of an acute infusion reaction, even when not severe. These reactions are important immunological events which should prompt ATI and infliximab trough level determination (Lichtenstein, et al). The presence of ATI can help to determine likelihood of a future reaction. Patients who have ATI have more than a two-fold risk of a subsequent reaction, and nearly a six-fold risk of a severe reaction, compared to those who do not have ATI (OMeara, et al). In addition, allowing for assessment of future infusion reaction risk, the presence of ATIs may also help to guide therapeutic decision-making in regard to the potential addition of concomitant immunomodulatory therapy, which is known to decrease ATI level and decrease drug reaction risk (Ben-Horin, et al). Accordingly, the unlisted chemistry procedure, Anser IFX assay testing (CPT code 84999) performed on 11/17/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 44-year-old female enrollee has requested reimbursement for monitored anesthesia care provided on 7/17/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  There is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, monitored anesthesia care provided on 7/17/15 was 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 46-year-old female enrollee has requested reimbursement for continuous positive airway pressure (CPAP) device provided on 1/3/18. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees obstructive sleep apnea. The physician reviewer found that current practice guidelines from the American Academy of Sleep Medicine (AASM) noted that OSA be treated as a chronic disease. In addition, Epstein and colleagues recommended that all patients with OSA should have ongoing, long-term management for their disorder. Patients on chronic therapy such as CPAP should have regular, ongoing follow-up to monitor adherence to therapy, side effects, development of medical complications related to OSA, and continued resolution of symptoms. In this case, the medical records provided demonstrate that the patient was diagnosed with OSA, was titrated on CPAP, and prescribed a CPAP for home use. Based on the current guidelines, CPAP is recommended as the first-line treatment for use in OSA. In this clinical setting, the CPAP device provided on 1/3/18 was medically necessary for treatment of this patients OSA. Based on the forgoing discussion, the device at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 52-year-old male enrollee has requested authorization and coverage for CPT 43284 (magnetic sphincter augmentation). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that magnetic sphincter augmentation (LINX) is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Skubleny and colleagues concluded, aLong-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation.a Additionally, LINX (more than surgical fundoplication) is associated with aseverea dysphagia requiring endoscopic intervention. Sheu and Rattner concluded, aThe long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined.a There are 29 reports of LINX erosion through the esophagus in the publicly-accessible FDA Adverse Events database, among other adverse events. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment. LINX has significant potential adverse effects and can be associated with poor outcomes. Therefore, CPT 43284 (magnetic sphincter augmentation) is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 52-year-old male enrollee has requested authorization and coverage for CPT 43284 (magnetic sphincter augmentation). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the LINX Reflux Management System works by augmenting the lower esophageal sphincter with a ring of magnets. Eligible patients must demonstrate typical gastroesophageal reflux disease symptoms, an abnormal pH study, at least partial response to daily proton pump inhibitor (PPI) therapy, and absence of a large hiatal hernia or severe esophagitis. This patient meets all of these criteria. Warren and colleagues performed a manometric study of 121 patients before and after the procedure. LINX was associated with an overall increase in the median lower esophageal sphincter resting pressure, residual pressure, and distal esophageal contraction amplitude. Sixty-seven percent of patients with a manometrically defective lower esophageal sphincter were restored to a normal sphincter with LINX. Seventy-seven and 56 percent of those with a structurally defective or severely defective lower esophageal sphincter improved to a normal lower esophageal sphincter. Only 18 percent of patients with a normal preoperative manometric lower esophageal sphincter deteriorated after the procedure. In the study by Ganz and colleagues, the long-term safety and efficacy of the LINX prosthesis was evaluated in a prospective single-group trial of 100 patients with long-standing gastroesophageal reflux disease. Gastroesophageal reflux disease-related quality of life was better. No device erosions, migrations, or malfunctions occurred. There is support for the requested services in this clinical setting. Therefore, CPT 43284 (magnetic sphincter augmentation) is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 52-year-old male enrollee has requested authorization and coverage for CPT 43284 (magnetic sphincter augmentation). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that scientific evidence has not been established via well-designed controlled studies with adequate follow-up demonstrating safety and efficacy of the use of the LINX procedure. Evidence arises largely from case series and cohort studies. Direct comparative studies between surgical interventions are needed to better assess the long-term safety and efficacy of this therapeutic intervention in patients. There is lack of randomized controlled trials comparing LINX with other surgical anti-reflux interventions, such as the Nissen fundoplication. Sheu and Rattner concluded that the long-term safety and efficacy of LINX remains to be determined by evaluating and investigating the safety, efficacy and durability of the intervention over time. Adverse events including erosion through the esophagus have been reported in particular cases. The LINX procedure has not been rigorously tested in randomized controlled trials against other alternative therapies. The superior efficacy of the requested services has not been established. Therefore, CPT 43284 (magnetic sphincter augmentation) is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The parent of a 10-month-old female enrollee has requested authorization and coverage for lansoprazole. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the clinical practice guidelines adopted by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition support the use of proton pump inhibitors in infants with severe gastroesophageal reflux disease if a trial of hydrolyzed formula has failed. The use of proton pump inhibitors in infants with severe gastroesophageal reflux disease is consistent with the standard of care. The safety and efficacy of this class of medications are well-established and supported by sufficient scientific evidence. This patient has already failed to respond to hydrolyzed formula and to acid suppression with H2 blockers. A trial of a proton pump inhibitor is the most appropriate next step in the management of this patient. Therefore, lansoprazole is likely to be more efficacious than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

The parent of a 10-month-old female enrollee has requested authorization and coverage for lansoprazole. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. This patient has been diagnosed with gastroesophageal reflux disease. On 1/07/19, while the patient was on lansoprazole, the provider suggested a trial of hypoallergenic formula. The provider also recommended gastroenterology evaluation. On 2/15/19, the records noted that that the patient was intolerant of the hypoallergenic formula. However, the records do not provide additional details regarding the symptoms of intolerance. Proton pump inhibitor therapy is recommended in infants only when there are findings of erosive esophagitis or in the presence of certain anatomic abnormalities (such as repaired tracheoesophageal fistula/esophageal atresia). Given that esophagitis was not documented in this case, lansoprazole is not likely to be more effective than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

The parent of a 10-month-old female enrollee has requested authorization and coverage for lansoprazole. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that Lansoprazole may be indicated in select cases, such as patients with esophagitis and postoperative esophageal dysmotility. The article by Hassall and colleagues noted the presumed safety and efficacy of proton pump inhibitor therapy in this age-group, but this was in the setting of defined esophagitis. It is difficult to label an infant as having an acid-related disease based on clinical assessment alone. The trend has shifted away from routine use of prolonged acid suppression in otherwise healthy infants. There may be a role for empiric use in the setting of feeding aversions or poor weight gain, but neither of those situations were demonstrated here. Thus, lansoprazole is not likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 59-year-old female with a history of severe osteoporosis. The patient has requested authorization and coverage for Forteo. The physician reviewer found that osteoporosis is a growing public health problem. Once considered an inevitable consequence of aging, it is now eminently preventable and treatable. Multiple agents are currently available for treatment of this condition. Forteo (teriparatide) is of particular importance as it modulates the bone architecture acting on bone formation, rather than being an anti-resorptive agent like most of the other medications. Recent studies have demonstrated the ability of Forteo to reduce the likelihood of occurrence of vertebral and non-vertebral fractures in osteoporosis patients. The current medical evidence supports the requested medication in this clinical setting. Therefore, Forteo is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a six-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) therapy provided from 10/3/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism spectrum disorder (ASD).  The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. There is support in the medical literature demonstrating that ABA is effective for reducing aggression and self-injury. Mohammadzaheri and colleagues examined the use of ABA and pivotal response treatment in school age children with autism and disruptive behavior. The authors found these interventions to be very effective in decreasing maladaptive and disruptive behaviors even in school age children.  In this case, the patient has made slow, but steady improvements with ABA at 30 hours per week. He still has significant maladaptive behaviors specifically aggression and self-injury. There is no evidence that his behavior is at a point that a reduction in ABA is indicated.  Based on the support in the peer-reviewed literature, the request for 30 hours per week of ABA was and is medically necessary for treatment of the patients medical condition. Therefore, the services at issue were and are 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 48-year-old female who has been diagnosed with atopic dermatitis of the face. She has failed therapy with topical triamcinolone. The patient has requested authorization and coverage for Dupixent prefilled syringe 300 mg/2 ml. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that Dupixent has been approved by the U.S. Food and Drug Administration for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. There are very few treatments approved for this condition, and this  drug has quickly become a standard/preferred therapeutic option by dermatologists in the community. The data supporting its use in moderate-to-severe atopic dermatitis is substantial, and it has a favorable side effect profile in comparison to other systemic agents that would be available to this patient. Based on the submitted documentation, the patient appears to be a good candidate for this treatment. Therefore, Dupixent prefilled syringe 300 mg/2 ml is medically necessary for the treatment of this patient.