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

Summary Reviewer 1

A 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/9/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination. The physician reviewer found that there is evidence based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to have been more effective than had her examination been performed using two dimensional imaging alone. 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 Overturned

Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/9/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination. The physician reviewer found that the medical literature supports breast tomosynthesis in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed on 8/9/16 was likely to have been superior to other methods of 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 Overturned

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/9/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination. The physician reviewer found that the Breast 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.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  In this clinical setting, a routine mammogram would have been sufficient.  Digital breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality. Therefore, breast tomosynthesis performed on 8/9/16 was not likely to have been of greater benefit than other modalities for evaluating this patient. Based upon the information set forth above, the service at issue was not likely to have been 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 patient is a 44-year-old female with a history of dense breasts on mammography and calculated lifetime risk of breast cancer at 20.8%. She had magnetic resonance imaging (MRI) of the breasts on 9/22/17 which revealed a single lymph node requiring second look, ultrasound but no evidence of malignancy. For the MRI, computer aided detection (CAD) was also performed. The patient has requested reimbursement for the computer aided detection provided on 9/22/17. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary. The MRI of the breasts performed on 9/22/17 was indicated in light of the limitations inherent in routine mammography especially in patients with dense breasts and the calculated lifetime risk of breast cancer exceeding 20%. However, there is a lack of data demonstrating improve health outcomes with use of CAD with breast MRI. Overall, the studies suggest the use of CAD can improve the speed and throughput of the imaging, but does not support its utility in terms of superior detection of breast cancer. Thus, the CAD provided on 9/22/17 was not medically necessary for evaluation of this patients medical condition.  Based on the foregoing discussion, the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 35-year-old female enrollee has requested authorization and coverage for polysomnography. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the patient is at intermediate risk for obstructive sleep apnea, which could contribute to her depression and anxiety. Per the records, she has symptoms of sleep apnea. The patient is not a good candidate for a home sleep study, given her intermediate risk with a high possibility of a false negative study. The patient will need an in-laboratory diagnostic polysomnography (95810) or split night sleep study (95811) to accurately evaluate and treat her sleep disorder breathing. Therefore, the requested polysomnography is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a nine-year-old female. The patient has requested reimbursement for neuropsychological testing performed from 1/18/20 through 8/13/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Neuropsychological testing indicated that the patient had a complex combination of ADHD combined subtype, non-verbal learning disorders in math and reading, dysgraphia/dyspraxia, and dysthymia with symptoms of anxiety and depression. The patientas symptoms were interfering with her social, academic and family functioning. She was noted to be at risk of social isolation, peer rejection and bullying. The neuropsychological testing and school evaluations that were performed were the only means by which the patientas complex combination of conditions could be clarified, and appropriate intervention instituted. Therefore, neuropsychological testing performed from 1/18/20 through 8/13/20 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 60-year-old female enrollee has requested authorization and coverage for Botox. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees chronic migraine headaches The physician reviewer found that the submitted documentation fails to support the superior efficacy of the requested medication in this clinical setting. The available medical records indicate treatment with Botox but do not demonstrate or quantitate the specific degree of any benefit. The records provided do not specifically delineate or quantitate the frequency of the headaches in terms of days per month. The records describe a duration of two and a half months but does not describe any specific headache frequency decrease, headache intensity decrease or otherwise demonstrate any analgesic use reduction.  There was no presentation of a headache diary. Moreover, there were no other mechanism demonstrating headaches lasting four or more hours per day within 15 days or more per month.  As such, the effectiveness of Botox for treatment of this patient has not been demonstrated. Therefore, for the reasons stated above, the requested medication is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.  AND FINDINGS]
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2
A 60-year-old female enrollee has requested authorization and coverage for Botox. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees chronic migraine headaches The physician reviewer found that there is a lack of support for the requested medication in this patients case. There is no documentation provided that supports that the patient was previously having 15 headache days per month. While Botox is indicated for the treatment of chronic migraines in some patients, the medical records in this patients case do not support the claim that the patient was suffering from chronic migraines. Although it was noted that the patient was previously treated for Botox, there is no documentation to support its efficacy for continued treatment. In sum, Botox is not likely to be more effective than other available treatment options for the treatment of this patient. Therefore, for the reasons stated above, the requested medication is 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 60-year-old female enrollee has requested authorization and coverage for Botox. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees chronic migraine headaches The physician reviewer found the U.S. Food and Drug Administration (FDA) approval for Botox is indicated for the prophylaxis of headaches in adult patients with chronic migraines greater or equal to 15 days per month and with headaches lasting four hours a day or longer. There are no requirements by the FDA that patients must be refractory to oral preventives. However, in this patients case, the submitted records are insufficient to document a diagnosis of chronic migraines. As such, treatment with Botox is not likely to be more effective than standard therapy for treatment of this patient. Therefore, for the reasons stated above, the requested medication is 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 Overturned

Summary Reviewer 

A 64-year-old male enrollee has requested authorization and coverage for Privigen. 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 the submitted documentation supports the medical necessity of the requested medication. Patients with myasthenia gravis can have weakness of the ocular, limb, respiratory, and bulbar muscles. The nature of the pathogenesis and the anatomical target can create clinical situations that are very diverse. The clinical presentation can range from mild symptomatology with mild weakness or cosmetic changes to severe life-threatening clinical scenarios involving difficulty with breathing, ambulating, eating, and speaking. The treatment of myasthenia gravis is dependent on several factors, including the patients medical comorbidity, age, involvement of respiratory or bulbar muscles, progression and severity. IVIG is considered a safe and effective tool in the maintenance and acute management of myasthenia gravis. Therefore, Privigen is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 28-year-old male enrollee has requested reimbursement for cyanocobalamin (vitamin B-12) testing performed on 7/24/19. 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 Vitamin B12 deficiency is considered as a possible problem for patients who have associated anemia, gastrointestinal issues (which may lead to poor absorption) or neuropsychiatric problems, including irritability or cognitive decline with nerve problems. Typically, the evaluation includes a history and physical examination with abnormal dermatologic, neurologic or gastrointestinal problems. The laboratory evaluation includes B12, folate levels and a complete blood count. In this case, the documentation does not support that the patient had medical conditions or symptoms that would be consistent with vitamin B12 deficiency. Furthermore, there was no laboratory testing to include a folate level or complete blood count. Therefore, cyanocobalamin (vitamin B-12) testing performed on 7/24/19 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 63-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System, CPT code 43284. 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 LINX device has been approved for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux. Appropriate patient selection is crucial before anti-reflux procedures. This patient has gastroesophageal reflux disease based on pH recordings. Aside for situations of diet indiscretion, the patient reports appropriate benefit from acid suppression treatment, and accordingly, she cannot be considered medically refractory to acid blocker drugs. In this patients case, implantation of the LINX device must be approached with caution, particularly since there are documented complaints of difficulty swallowing and a normal lower esophageal sphincter anatomy and function that does not warrant augmentation. As such, LINX cannot be considered more beneficial for treatment of the patients condition than appropriate diet and lifestyle modification in combination with her presently effective acid suppression medications. Therefore, the LINX Reflux Management System (CPT 43284) is not likely to be more effective than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 63-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System, CPT code 43284. 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 U.S. Food and Drug Administration (FDA) has approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm. This patient meets those specific criteria. The device is a ring made up of a series of magnets that have sufficient attraction to increase the LES closure pressure, but allow for food passage with swallowing. Lipham and colleagues performed a prospective study that included 44 patients. The mean total percent time pH was less than 4 was reduced from 11.9 percent at baseline to 3.8 percent at three years. A recent study by Reynolds and colleagues compared the LINX procedure with laparoscopic fundoplication. This was a retrospective study that used propensity matching to compare groups. The authors found that gastroesophageal reflux disease patients had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. Five-year cohort data was recently published by Ganz and colleagues. In a group of 85 patients, augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux, with minimal side effects or complications. Therefore, the LINX Reflux Management System (CPT 43284) is likely to be superior over other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 63-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System, CPT code 43284. 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 there is a lack of randomized controlled trials with long-term follow-up demonstrating that 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 that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia, requiring endoscopic intervention. Sheu and Rattner concluded that the long-term safety and efficacy of LINX, both alone and in comparison to current gastroesophageal reflux disease therapies, remains to be determined. 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, surgical fundoplication. Thus, the LINX Reflux Management System (CPT 43284) is not likely to be of greater benefit than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 36year-old female with a history of low back and right lower extremity pain due to a disc herniation at L4-5.  The patient has requested reimbursement for anterior interbody fusion with cage lumbar disc L4-5 performed on 4/23/21 and two days of inpatient hospitalization. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Phan and colleagues performed a meta-analysis of seven studies, including 181 patients who underwent anterior lumbar discectomy and fusion after primary discectomy had resulted in a recurrence of low back and leg pain, as in this patients case. The authors noted that there are certain advantages to the anterior approach. Repeat posterior approach for recurrent herniations may result in trauma to the spinal nerves and paraspinal muscles that is avoided in the anterior approach. Furthermore, the authors noted that the exposure allows for a comprehensive discectomy. In these 181 patients, there was significant improvement in the Oswestry Disability Index and Visual Analogue Scale (VAS) back and leg pain scores. The average length of hospital stay was 5.28 days. This patient has requested reimbursement for the surgery and two days of inpatient hospitalization. The authors concluded that anterior lumbar interbody fusion is a feasible approach for the treatment of recurrent lumbar disc herniations and demonstrates good results, with minimal complications. As such, in the presence of a recurrent herniation with chronic low back and leg pain, and failure of conservative treatment, the services at issue were medically indicated. Therefore, the anterior interbody fusion with cage lumbar disc L4-5 performed on 4/23/21 and two days of inpatient hospitalization were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 51-year-old male enrollee has requested authorization and coverage for low back surgery to be done in two stages (stage 1, anterior lumbar fusion with one day stay followed by stage 2, posterior fusion also with one day stay). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this patients case. A review of the literature indicates moderate evidence of good outcomes from standalone lumbar fusions for chronic pain with or without instability. Degenerative disc and facet joint disease of the lumbar spine is common in individuals in this age group, and is one of the most frequent causes of pain and associated disability. Lumbar spondylosis may result in mechanical back pain, radicular pain, reduced mobility and poor quality of life. Surgical interbody fusion of degenerative levels is an effective treatment option to stabilize the painful motion segment, and may provide indirect decompression of the neural elements, restore lordosis and correct any associated deformity. The provider has suggested the fusion procedure at L4-5 in two stages due to the large size of the patient, which is reasonable, appropriate, and medically necessary in this case. Therefore, low back surgery to be done in two stages (stage 1, anterior lumbar fusion with one day stay, followed by stage 2, posterior fusion also with one day stay) is medically necessary for the treatment of this patient.