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

Summary Reviewer 


A 49-year-old male enrollee has requested authorization and coverage for Crestor 20 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who was assessed with combined familial hyperlipidemia and Stevens-Johnson syndrome. The physician reviewer found that based on the records provided this patient has a history of Stevens-Johnson syndrome and he is tolerant of brand name Crestor. Medical evidence supports that in this circumstance, it would be reasonable and should be safe to transition the patient to generic rosuvastatin. Medical reviews of Stevens-Johnson syndrome associate the condition with active ingredients of certain medications. However, there is a lack of evidence to show that Stevens-Johnson syndrome is associated with any inactive ingredients that may be present in the generic medication but not present in the brand medication, Crestor. In this patients case, the submitted documentation does not show that this patient is intolerant to the generic rosuvastatin. In addition, generic medications, by law, must be bioequivalent with respect to efficacy when compared to brand medication. Based on the documentation provided and the medical literature, Crestor is not medically necessary for treatment of this patient. Therefore, for the reasons stated above, 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 57-year-old male enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees severe, persistent asthma. The physician reviewer found that in the peer-reviewed medical literature, Torrego and colleagues found that bronchial thermoplasty for patients with moderate to severe asthma provides a modest clinical benefit in quality of life and lower rates of asthma exacerbation, but no significant difference in asthma control scores. Weschler and colleagues noted that the long-term safety and effectiveness in patients with severe persistent asthma showed at five years durability of benefits of bronchial thermoplasty in regards to asthma control and safety persisted. However, in this case, the record fails to demonstrate any recent severe exacerbations or emergency department visits. The most recent notes state that the patients disease is stable. All told, the requested bronchial thermoplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure 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 2


A 57-year-old male enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees severe, persistent asthma. The physician reviewer found that Bronchial thermoplasty refers to a technique of applying heat to the airways during bronchoscopy, reducing the increased mass of airway smooth muscle associated with asthma. The U.S. Food and Drug Administration (FDA) has approved marketing of bronchial thermoplasty for the treatment of adults with severe persistent asthma not well-controlled with inhaled glucocorticoids and long-acting beta agonists with frequent exacerbation. Based on the records provided for review, this patient meets the criteria for bronchial thermoplasty with evidence of the need for oral glucocorticoids, maximal inhaled corticosteroid treatment, a forced expiratory volume in one second (FEV-1) of 50% of predicted, and he has not had a life-threatening exacerbation in the past. Since this patient has exhausted maximal available treatments and remains symptomatic, the requested bronchial thermoplasty is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 57-year-old male enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees severe, persistent asthma. The physician reviewer found that Bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway. There are three bronchoscopic procedures. The first treats the right lower lobe, the second the left lower lobe and the third bronchoscopic procedure is for both upper lobes. Thomson and colleagues reported on the safety of the procedure but noted that there was no difference in forced expiratory volume in one second (FEV-1), emergency department visits, or hospital admissions between the bronchial thermoplasty group and the control group. This patients provider states that the patient has a progressive decrease in the quality of life. However, there is no documentation that the use bronchial thermoplasty would improve the long-term functional outcome of the patients condition. Thus, the requested bronchial thermoplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure 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 Upheld

Summary Reviewer 

A 41-year-old male enrollee has requested authorization and coverage for rituximab injections 100 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees pretibial myxedema. The physician reviewer found that the use of rituximab for ocular related findings associated with Graves disease is supported by peer-reviewed medical literature. However, there is a paucity of large, controlled studies demonstrating the safety and efficacy of rituximab for treatment of pretibial myxedema (Heyes, et al; Ferreira-Hermosillo, et al). As this patient does not have any documented ocular related findings associated with Graves disease, the requested rituximab injections 100 mg are not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication 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 92-year-old male who has a history of a stroke in June 2015, attributed to atrial fibrillation. The patient has requested reimbursement and prospective authorization and coverage for home health care services from 5/08/20 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  The physician reviewer found that the patient returned home in May 2020 after inpatient rehabilitation following a hospitalization for pneumonia with placement of a gastrostomy tube due to dysphagia. At that point, he was no longer new to gastrostomy tube feeds, and an enteral nutrition therapy and medication administration plan should have been established in the rehabilitation facility for transition to the community environment, which is a routine practice. There were no indications that he was not tolerating administration of his feeds and medications through this route. His bolus tube feeds were spread out, which is the typical manner in which bolus tube feeds are administered. This level of care did not require a registered nurse or licensed practical nurse to perform on a long-term, routine basis in the community setting. There was one documented instance when the feeding tube was not working (e.g., 5/19/20), but he could have been taken to an emergency room by a caregiver or other custodial level provider, just as the nurse did, for further evaluation and care. The patient did not have wound care or other needs that required skilled nursing services during the time period in question, based on the available documentation, outside of the two periods when he was being administered medications parenterally for infections (i.e., from 8/12/20 through 8/22/20 and 9/06/20 through 9/20/20). Gauze placed at the gastrostomy stoma site is not a skilled nursing need. Patients can develop stoma site issues, such as infections, whether or not this routine stoma care is provided by a skilled provider. In this case, despite the provision of this service by a skilled provider, the patient developed an ESBL infection at his stoma site. He was otherwise largely performing his self-care on his own. Any assistance that he received with respect to routine self-care, e.g., related to incontinence, would have been custodial. Chronic lymphedema can be managed with compression stockings and intermittent pneumatic boot therapy, but routine application of these appliances can be performed by individuals/caregivers and is not a skilled nursing need. Therefore, a portion of the home health care services from 5/08/20 forward was medically necessary. Specifically, home skilled nursing services from 8/12/20 through 8/22/20 and 9/06/20 through 9/20/20 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 43-year-old female enrollee has requested reimbursement for services (HCPCS codes L0637, L0456 and L3030) provided on 3/2/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees back pain. The physician reviewer found that this patient received a lumbar brace on 3/02/18, foot orthotics on 3/13/18, and thoracic brace on 3/20/18. In this case, the progress notes on 3/02/18 indicated that the patient already achieved 20 to 25% improvement in her low back pain. She was given a back brace without explanation of medical necessity. On 3/20/18, the patient reported a 50 to 55% improvement in her mid-back pain, and the records do not demonstrate the need for a thoracic supporting brace. Back support has not been found to reduce lower back pain or help prevent lower back pain in this setting. The treatment note dated 3/13/18 indicated that the patients back and hip condition had improved approximately 40 to 45%, and the patient received a pair of foot orthotics. There is no documentation of foot symptoms or gait dysfunction warranting foot orthotics. Therefore, HCPCS codes L0637, L0456 and L3030 provided on 3/02/18, 3/13/18 and 3/20/18 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 15-year-old female enrollee has requested authorization and coverage for an insulin pump (T-Slim). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation establishes the medical necessity of the requested services. In this case, the patient has a history of widely fluctuating blood glucose levels before meals, glycemic control that is suboptimal on a multi-dose insulin injection regimen, and variations in her daily activity schedule and eating plan such that a multiple dose injection regimen is unlikely to be adequate to maintain glycemic control and prevent severe hypoglycemia. Several studies in the peer-reviewed literature have shown that insulin pump therapy is safe and effective in children and adolescents with type 1 diabetes. Compared with conventional insulin treatment, continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain, reduces the frequency of hypoglycemic events, and results in overall improved satisfaction in patients and their parents (Battelino; Plotnick, et al; Saha, et al). Finally, this patients caregivers have demonstrated that they possess the necessary tools to carry out an effective treatment and follow-up plan on insulin pump therapy. Specifically, the patient and her family have adhered to frequent blood glucose monitoring, have kept appointments with the patients various health care providers, and have attempted to comply with dietary recommendations. Pump therapy is medically necessary for treatment of this patients diabetes. Furthermore, the patients previously prescribed OmniPod pump was never fully functional. Although there was no mechanical failure of the OmniPod and it is not out of warranty, in effect, the OmniPod malfunctioned in this patient after a trial of a few months, as the patient experienced significant adverse skin reactions at the sites of the adhesive tape, making it impossible for her to continue to wear the pump. In addition, due to the nature of her active lifestyle, the pump dislodged too often to make it a viable tool to deliver insulin, and her glycemic control worsened due to unpredictable insulin delivery. The T-Slim pump delivers insulin via a catheter inserted under the skin instead of a pod; the insertion site is much smaller and does not require as much adhesive tape to stay in place. In addition, the thin catheter in the T-Slim is less likely to dislodge with vigorous physical activity than the pod in the OmniPod system. Thus, transition to the T-Slim pump is medically necessary based on the history of adverse reaction to the OmniPod. Moreover, the T-Slim pump has been shown to have an easy-to-read screen and reduced error rates and training time compared to other insulin pumps (Schaeffer, et al). Therefore, the requested services are 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 17-year-old male who has been diagnosed with autism spectrum disorder and an intellectual disability. The parent has requested reimbursement for ABA performed from 7/01/20 through 12/31/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Papatola and Lustigas definition of medical necessity entails ahealth-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care.a This patientas request fails to meet criterion (a), as many of the goals are not linked to their autism diagnosis. Specifically, the goals of preparing food and washing dishes are tied to executive functioning, but it is unclear how exactly executive functioning is being measured and whether these specific tasks are improving executive functioning and/or ameliorating the symptoms of autism. Further, the insured fails to meet criterion (c), as many elements or missing from the treatment plan, which will be described in greater detail below. Both the Council of Autism Service Providers (CASP) and the ABA Coding Coalition outline the necessary elements of treatment plans. While the patientas treatment plan includes many of these items, several are missing, which makes it difficult to ascertain progress and necessity of the request. Specifically, the treatment authorization request fails to include dates of proposed mastery. Data on almost all goals (with the exception of minimal challenging behavior data), transition and discharge planning is lacking specific measurable criteria. The medical necessity of the goals are unclear, and there has been an overall lack of progress on most goals (at least how it can be interpreted from the lack of data provided) with no explanation of why. Given these missing elements, the lack of progress, and the emphasis on non-autism related goals, the request fails to meet medical necessity. Therefore, ABA performed from 7/01/20 through 12/31/20 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 62-year-old female enrollee has requested reimbursement for FoundationOne CDx test performed on 12/31/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition. The physician reviewer found that a Non-small cell lung cancer, particularly adenocarcinoma, should be tested for a variety of mutations, including EGFR, ALK, ROS-1, KRAS, tumor mutational burden and microsatellite instability. Each of these has therapeutic implications. Ordinarily, these genomic assays are done on the tissue biopsy done for diagnosis. FoundationOne assay is an assay of more than 300 gene mutations, including those noted above. However, beyond the specific mutations noted above, there has been a lack of convincing data that the assays for the rest are of clinical benefit. The chance of benefit from therapy guided by such a general assay is small. Therefore, FoundationOne CDx test performed on 12/31/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 62-year-old female enrollee has requested reimbursement for FoundationOne CDx test performed on 12/31/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition. The physician reviewer found that Molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC.  Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Therefore, FoundationOne CDx test performed on 12/31/19 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 62-year-old female enrollee has requested reimbursement for FoundationOne CDx test performed on 12/31/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition. The physician reviewer found that the The therapy of advanced NSCLC has been revolutionized by the finding of EGFR mutations in certain adenocarcinomas. Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of NSCLC has significantly expanded in recent years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. It is generally accepted that the panel of mutations that was analyzed in the patient in question is for mutually exclusive somatic driver mutations. Patients on targeted therapy may develop resistance to erlotinib and this too may be appreciated at the genetic level by recognition of new mutations or amplifications in parallel signal transduction pathways. BRAF mutations may suggest alternative targeted therapies that may be better than those selected empirically. There is sufficient support for the services at issue in this clinical setting. Therefore, FoundationOne CDx test performed on 12/31/19 was likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 56-year-old male enrollee has requested reimbursement for inpatient hospital stay provided from 6/23/18 through 6/25/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient was injured in an accident and presented to the emergency department with shortness of breath and chest/rib pain.  He denied loss of consciousness, and the initial imaging did not show any acute central nervous system bleeding. He was treated in the emergency department with intravenous fluids and pain medications. At the time of admission, his vital signs were stable with normal oxygen saturation.  Imaging showed a fractured rib without any significant complications.  The inpatient admission was not medically necessary for this patient. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Therefore, inpatient hospital stay from 6/23/18 through 6/25/18 was not medically necessary for the treatment of this patient.