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

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/26/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  The medical literature supports the service at issue in this patients case.  The study by Mansour and colleagues demonstrated that screening sensitivity of full field digital mammography was increased from 60% to 94.5%, and specificity increased from 20.7% to 74% when digital breast tomosynthesis was applied.  Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings. Digital breast tomosynthesis allowed unnecessary biopsy to be avoided in 37.3% of patients.  Thus, breast tomosynthesis performed on 9/26/16 was likely to have been more effective than other modalities for evaluating this patient.  Based upon the information set forth above, the service 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 Upheld

Summary Reviewer 1

A 46-year-old female enrollee has requested reimbursement for CPT code 84999 performed on 1/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the prognosis for cutaneous melanoma has classically been determined by applying the staging spelled out by Balch. Mitotic index has also been thought to add a bit more to these statistics.  By Balch staging, this melanoma would be classified as a T1a (stage 1A), with an expected ten-year survival of at least 88%.  DecisionDx is a study of 31 genes in an individuals melanoma cells. It then classifies that melanoma as either Class 1 (with a 90-92% disease-free survival at five years), or Class 2 (with a 48-77% five-year disease-free survival). Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx classification, in patients who had undergone sentinel node biopsy. However, it is not clear how the five-year DecisionDx data compares to the ten-year Balch data, and, most importantly, whether it can be used additionally to make clinical decisions. This is especially true in this patient with an excellent prognosis. At this time, the superior effectiveness of CPT code 84999 performed on 1/12/17 has not been established. 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 Upheld

Summary Reviewer 2

A 46-year-old female enrollee has requested reimbursement for CPT code 84999 performed on 1/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the DecisionDx-Melanoma testing has been developed in patients with stage I and II cutaneous melanoma. However, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. In sum, CPT code 84999 performed on 1/12/17 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 46-year-old female enrollee has requested reimbursement for CPT code 84999 performed on 1/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, CPT code 84999 performed on 1/12/17 was not likely to have been more efficacious than other available methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a one-year-old male enrollee has requested reimbursement for inpatient hospital level of care provided on 3/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD).  The physician reviewer found the patient was a five-month-old ex-premature infant who was approximately 44 weeks post conceptual age at the time that he presented for apnea and cyanosis associated with vomiting for which he was treated with back blows by his mother. The apneic episode resolved by the time of presentation to the hospital and he appeared to be healthy when evaluated by the provider. He was admitted for observation and cardiopulmonary monitoring. He was diagnosed with an apparent life threatening event (ALTE) due to gastroesophageal reflux disease (GERD). Other than monitoring, he received a suppository to treat constipation. He had no further apnea or cyanosis in the hospital. He tolerated oral intake without emesis. He remained well appearing and had no signs of acute illness. The medical literature supports hospitalization for observation for cardiopulmonary monitoring for 23 hours after an ALTE in the majority of infants (Fu and Moon; McGovern and Smith). However, certain individuals can be discharged from the emergency department without hospitalization (Kahn and European Society for the Study and Prevention of Infant Death). Given that the patient was well-appearing at the time of presentation, had no further events during observation in the hospital, did not require specific interventions or extensive evaluation beyond observation, and was discharged home on the same day of admission, he met criteria for observation but not admission. Based upon the information provided and reviewed and the medical literature reviewed, the inpatient hospital level of care provided on 3/31/16 was not medically necessary for treatment of the patients medical condition. For the reasons provided, 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

A 56-year-old female has requested reimbursement for percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of urinary frequency and urgency. The physician reviewer found that percutaneous tibial nerve stimulation may have a role in reducing uninhibited bladder contractions when first-line behavior modification and second-line medical therapy have failed to resolve symptoms of overactive bladder. In this patients case, there is also the complexity of past interventions, ongoing neuropathic issues, and diabetes increasing the risk of urinary tract infections. It is not standard of care to proceed with percutaneous tibial nerve stimulation prior to exhausting standard first-line behavior modification and second-line medical therapy. Percutaneous tibial nerve stimulation has not be shown to be more effective than these treatment approaches per the current evidence. Therefore, percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18 was not likely to have been of greater benefit than other available treatment options. 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 56-year-old female has requested reimbursement for percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of urinary frequency and urgency. The physician reviewer found that there is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of percutaneous tibial nerve stimulation in patients with urinary urgency and frequency. However, most trials have a small number of patients with short-term follow-up. American Urological Association (AUA) guidelines recommend that clinicians should offer behavioral therapies, such as bladder training, bladder control strategies, pelvic floor muscle training and fluid management, as first-line therapy to all patients with overactive bladder. Behavioral therapies may be combined with pharmacologic management. Clinicians should offer oral antimuscarinics or oral 3-adrenoceptor agonists as second-line therapy. If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a 3-adrenoceptor agonist may be tried. Patients who are refractory to behavioral and pharmacologic therapy should be evaluated by an appropriate specialist if they desire additional therapy. The guidelines rate percutaneous tibial nerve stimulation as a third-line therapy. Botox injection is a standard third-line therapy which is graded better. The use of percutaneous tibial nerve stimulation has not been proven to be superior to other alternatives. In this case, the records do not document that the patient had a complete trial and failure of first-line and second-line therapy. The documentation does not support prior failure of behavior modification. She was prescribed low dose Toviaz, the response to which is unknown. The first intervention would be dose escalation if she had no response to low dose Toviaz. In sum, percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18 was not likely to have been superior over other treatment options. 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 56-year-old female has requested reimbursement for percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of urinary frequency and urgency. The physician reviewer found that percutaneous tibial nerve stimulation is considered to be an appropriate third-line salvage therapy for patient with intractable irritative lower urinary tract symptoms, including frequency and urgency incontinence. This patient did not have any urodynamic findings suggestive of overactive bladder. It appears that the patient was started on antimuscarinic therapy simultaneously with percutaneous tibial nerve stimulation. It would have been prudent for this patient to assess the outcome of antimuscarinic therapy prior to therapy with percutaneous tibial nerve stimulation. Thus, percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18 was not likely to have been more effective than other available treatment modalities. 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 27-year-old male enrollee has requested reimbursement for laboratory services (81243, 88230, 88262, 88289) provided on 10/19/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Per the records, the laboratory services in dispute are 88230, tissue culture for non-neoplastic disorders, lymphocyte, 88262, chromosome analysis, count 15-20 cells, two karyotypes, with banding, 88289, chromosome analysis, additional high resolution study, and 81243, fragile X (FMR1). Codes 88230, 88262 and 88289 can be grouped together, as the tissue culture is needed for chromosome analysis. In this patients case, it is unclear why the provider ordered both standard chromosome analysis and high resolution chromosome analysis, but neither were indicated. The providers notes state that this was ordered due to the patients sisters infertility and his mothers miscarriages. Either of these would be indications for chromosome analysis in the affected individual, but are not indications for analysis in this patient. With regards to 81243, the notes indicate that this was ordered due to a history of anxiety, depression, and obsessive-compulsive disorder in the patient, family history of autistic-like behaviors in the patients brother, and family history of psychiatric illness. This testing was not indicated. Fragile X is a common cause of significant intellectual disability and autism spectrum disorders, not reported in this patient (or his brother with autistic-like behaviors but high intelligence). Males with fragile X will have significant developmental concerns, which this patient does not have. Psychiatric illness alone is not caused by fragile X full mutations or pre-mutations. While his sisters infertility may be an indication for testing her if she has premature ovarian failure, testing this patient was not indicated. Therefore, laboratory services (81243, 88230, 88262 and 88289) provided on 10/19/18 were not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 57-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine without contrast. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollees bilateral upper extremity pain and numbness. The physician reviewer found that the American College of Radiology (ACR) criteria recommends a plain x-ray for evaluated of patients with chronic neck pain. The ACR criteria suggest that for patients with radiographic evidence of degenerative changes and positive neurologic symptoms, the most appropriate test is an MRI of the cervical spine. This patients numbness and diminished reflexes are considered neurologic signs. Although this patients records do not document conservative therapy in addition to chiropractic care, the provider noted concern that continuing chiropractic manipulation may cause further damage without properly ruling out a significant herniation or stenosis. For these reasons, the requested MRI of the cervical spine without contrast is medically necessary for evaluation of this patients chronic neck pain. Based on the foregoing discussion, the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. 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 doxycycline capsules delayed release 40 mg received on 5/22/18. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollee, who has a history of hypersensitivity reaction affecting the periocular area. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue. The records document a hypersensitivity reaction affecting the periocular area. Per the Health Insurer, the medication at issue cannot be approved unless the patient carries a diagnosis of rosacea and has already failed a one-month course of immediate-release 50 mg doxycycline. The medication at issue, doxycycline capsules delayed release 40 mg, is not considered to be superior or more efficacious than the preferred, generic immediate-release formula of doxycycline 50 mg. In fact, given the degree of inflammation, higher doses of doxycycline would be preferred for treatment of this eruption. Thus, doxycycline capsules delayed release 40 mg received on 5/22/18 were not medically necessary for the treatment of this patient. Therefore, the medication at issue was 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 46-year-old female enrollee has requested authorization and coverage for Duavee 0.45-20 mg tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who is status post hysterectomy. The physician reviewer found that in this patients case, her menopausal symptoms included occasional hot flashes and vaginal dryness. There is no mention of other management options, including whether the patient has tried any other medicinal (hormonal or non-hormonal) and nonmedicinal forms of therapy and what the response to that therapy was, other than a prescription for Duavee. The benefit of Duavee is that it is selectively designed and marketed as a hormone replacement therapy that is more protective of the endometrium of the uterus than other progestins that are coupled with estrogens. This is not an issue for this patient. As she is status post hysterectomy, this patient does not need protection of her uterine endometrium. In this case, there are other reasonable estrogen only treatment options that would be more prudent for this patient. If the risks associated with estrogens and their potential relationship to breast/reproductive cancers is driving management, then the use of non-hormonal management, such as Paxil, may be a better option. The medical evidence does not support the requested medication in this patients case. Thus, Duavee 0.45-20 mg tablets are not medically necessary for the treatment of this patient. 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 Upheld

Summary Reviewer 1


A 49-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of atrial septal defect. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that based on the records provided, the patient is a 49-year-old male with a history of a cryptogenic renal infarction in 2015, migraine headaches and a patent foramen ovale.  Although there is an association with patent foramen ovale and both cryptogenic strokes and migraines, it is not clear that this patient's renal infarction was due to paradoxical embolization (no deep vein thrombosis identified) and current literature does not consistently demonstrate improved outcomes with patent foramen ovale closure compared to medical therapy.  A randomized prospective trial by Furlan and colleagues did not demonstrate relative benefit of patent foramen ovale closure compared to standard medical therapy. Therefore, at this time the use of percutaneous closure devices for treatment of a patent foramen ovale in the setting of a documented transient ischemic attack or cryptogenic stroke has not been established, except in specific circumstances where alternative therapies, such as when aspirin or warfarin are not tolerated, alternative therapies are contraindicated, alternative therapies have failed, or in a clinical trial. Given the medical literature cited above and the documentation submitted for review, the requested services are not likely to be more beneficial than any standard treatments for this patient medical condition. 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.