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

Summary Reviewer 1

The patient is a 57-year-old male with a history of obstructive sleep apnea and prior smoking.  A clinic note dated 5/15/17 documented longstanding but increasing frequency of rapid palpitations relieved with Valsalva maneuver including several episodes in the last year.  There is reference to ambulatory electrocardiographic monitoring that did not capture an arrhythmia. There is no documented history of syncope. A comprehensive invasive diagnostic electrophysiology study was performed on 9/20/17 and reported a dual atrioventricular nodal physiology but there was no inducible sustained dysrhythmia.  An implantable loop recorder was then inserted. The patient has requested reimbursement for implantable event recorder inserted on 9/20/17. The Health Insurer has denied this request and reported that the procedure at issue was investigational for the treatment of this patients medical condition. The patient has a history of increasing frequency of palpitations without syncope, occurring several times in the last year. In this circumstance, prolonged outpatient self-activated event recording should be sufficient in documenting heart rhythm during symptoms and is less invasive than an implantable event recorder. Moreover, there is less risk for infection when compared to placement of an implantable loop recorder. The medical studies do not recommend an implantable loop recorder as an initial test for heart rhythm monitoring in patients with occasional symptoms such as this patient.  Implantable loop recorders can be useful for patients with very infrequent symptoms that are potentially injurious (syncope, for example) or when searching for asymptomatic occult episodes of atrial fibrillation, such as following a cryptogenic stroke. As such, the implantable event recorder inserted on 9/20/17 was not likely to have been of greater benefit than the standard method of managing this patients medical condition. Based upon the information set forth above, the procedure at issue was 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 Overturned

Summary Reviewer 2

The patient is a 57-year-old male who has a history of infrequent brief episodes of tachycardia usually controlled by Valsalva maneuver. The record indicated that episodes were occurring more frequently with the last one occurring approximately one month prior to his cardiology evaluation. An electrophysiology (EP) study failed to reproduce his clinical arrhythmia and the provider recommended and placed an implantable loop recorder. The patient has requested reimbursement for implantable event recorder inserted on 9/20/17. The Health Insurer has denied this request on the basis that the procedure at issue was investigational for treating this patients medical condition. The patient did not have a diagnosis to reproduce the clinical arrhythmias despite EP testing. His symptoms were infrequent and brief but of increased frequency. The guidelines support the use of the implantable loop recorder in this clinical setting.  Given the unusual situation with a difficult diagnosis of the arrhythmia in this patients case, the use of the implantable loop recorder was an effective treatment option. In this case, this is more likely than standard therapy to be beneficial in this individual's treatment. In sum, the implantable event recorder inserted on 9/20/17 was likely to have been more beneficial than the standard therapy for the treatment of this patients medical condition. Based upon the information set forth above, the procedure at issue was 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 Overturned

Summary Reviewer 3

The patient is a 57-year-old male with a history of recurrent palpitations over  approximately an eight year period. The episodes are infrequent but typically are relieved with a Valsalva maneuver. He has had approximately four or five episodes over the  previous year when he was seen in April 2017. Per the medical record provided, the patient had ambulatory electrocardiogram (ECG) monitoring, which was unsuccessful in diagnosing the clinical arrhythmia. An echocardiogram performed on 4/14/17 demonstrated normal left ventricular function, no gross valvular abnormalities and mild mitral regurgitation by Doppler. On 9/20/17, a comprehensive electrophysiological study was performed, which demonstrated a dual abnormal atrioventricular (AV) node physiology, induction of non-sustained AV node reentrant tachycardia, inducible non-sustained atrial tachycardia and no inducible ventricular tachyarrhythmias.  However, the patients clinical arrhythmia could not be induced. An implantable loop monitor was inserted following the electrophysiology study. The patient has requested reimbursement for implantable event recorder inserted on 9/20/17. The Health Insurer has denied this request for reimbursement. Per the Health Insurer, the procedure at issue was investigational for treating this patients medical condition. In the study by Giada and colleagues, patients with symptoms of palpitations and without severe structural heart disease, a diagnosis of the clinical arrhythmia was significantly more likely with the use of an implantable loop monitor than with a conventional strategy. The patient has had recurrent significant palpitations suggestive of a supraventricular tachycardia with associated lightheadedness over several years. Conventional ambulatory monitoring did not yield a diagnosis. The treatment strategy in this case involved identifying the specific arrhythmia followed by treatment with radiofrequency ablation. In this patients case, the use of an implantable loop monitor allowed the best opportunity for a definitive diagnosis. As such, the implantable event recorder inserted on 9/20/17 was likely to have been more effective than the conventional diagnostic strategy for the evaluation of this patients medical condition. Based upon the information set forth above, the procedure at issue was 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 48-year-old female enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation from 11/23/15 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 behavioral health conditions. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  First, the clinical record indicates diagnoses of posttraumatic stress disorder and bipolar disorder.  Transcranial magnetic stimulation is not indicated for these conditions.  Additionally, for those with unilateral depressive illness, the safety and utility of long-term and/or maintenance treatment with transcranial magnetic stimulation has not yet been established by the scientific community.  Although the American Psychiatric Association Practice Guideline for depression endorses transcranial magnetic stimulation for the acute phase treatment of major depressive disorder, it has not yet been endorsed for maintenance treatment or long-term therapy.  There are a few small studies which demonstrate positivism for maintenance therapy.  However, the statistical power and study designs render the findings inadequate to define definitive recommendations regarding the long-term use of the intervention at this time.  All told, transcranial magnetic stimulation from 11/23/15 forward was not and is not medically indicated for the treatment of this patient.  Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested authorization and coverage for Humatrope 24 mg cartridge. 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 fails to demonstrate the medical necessity of the requested medication. Based on the growth chart provided, significant linear deceleration before the age of 14 is not confirmed. A growth velocity of 3.8 cm per year can be normal for a child who is not in puberty. Based on the testosterone level, the patient was probably pre-pubertal. There is a significant family history of delayed puberty in both parents, which also supports the diagnosis of constitutional delay of growth along with a history of multiple bone age studies with 1.5 years bone age delay. This patient has a mid-parental height that is 57, which is between the 10th and 25th percentile. Based on the last bone age and height from March 2019, and using an average bone age prediction, his estimated predicted adult height is 173 cm, which is within normal limits for an adult male. The patient had a bone age which was 15 years 6 months in March 2019. His bone age is likely closer to 16 years of age as of November 2019. This patient is not likely to benefit from growth hormone therapy at this time. Therefore, Humatrope 24 mg cartridge is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 46-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees neck pain and bilateral upper extremity pain. The physician reviewer found that conventional radiographs are the first step in the evaluation of neck pain, particularly to diagnose post-surgical complications, degenerative disease, spinal stenosis or malalignment. After radiographs are obtained, a subset of patients may benefit from further imaging utilizing MRI or computed tomography (CT). According to the American College of Radiology appropriateness criteria for the evaluation of chronic neck pain in a patient with prior surgery and neurologic symptoms, MRI may be appropriate for further evaluation. MRI is the optimal examination for the evaluation of intervertebral discs, facet arthropathy, foraminal stenosis, nerve root compression and spinal stenosis. It can also demonstrate abnormalities present within the spinal cord, which may be the cause of neck or extremity pain. These findings are suboptimally or not at all visualized on initial radiographs, and would alter the patients management. In this case, in the setting of prior cervical fusion with neurologic symptoms, MRI is indicated for further evaluation/surgical planning. This patient already had radiographs which did not demonstrate a cause for the chronic pain. The current medical evidence supports the requested services in this clinical setting. Thus, the requested MRI of the cervical spine is medically necessary for the evaluation of this patient. Therefore, the requested services are medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 40-year-old female enrollee has requested authorization and coverage for Otezla 30 mg tablets, 60 per 30 days. 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 Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-TNF drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. Otezla (apremilast) provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. ESTEEM 1 is the first phase III study confirming the efficacy of apremilast in psoriasis. Apremilast demonstrated significant improvements in mean percentage change in psoriasis area and severity index (PASI) score and in pruritus. PASI response was maintained over 52 weeks with continued apremilast treatment. In addition, apremilast demonstrated improvements in nail and scalp psoriasis, both difficult-to-treat forms of psoriasis. This patient has chronic plaque psoriasis that requires systemic treatment. The immunosuppressors and anti-TNF drugs can increase the risk for infection and malignancy. Otezla has been approved by the U.S. Food and Drug Administration (FDA) for treatments of such patients. Therefore, Otezla, which does not increase the risk of malignancy and infection, is medically appropriate in this case. Thus, Otezla 30 mg tablets, 60 per 30 days, are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for mental health residential treatment center (RTC) services provided from 2/4/15 through 4/24/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bipolar disorder, parent-child relational problem, and cannabis abuse. The physician reviewer found that based on the records provided for review, the criteria for RTC services from 2/4/15 through 4/24/15 have not been met. The patient did not have any suicidal or homicidal ideations, there was no evidence of psychosis, and she had no self-injurious impulses during the course of treatment documented. Additionally, no medication changes were made during the course of admission that required 24-hour supervision. The records suggest the patient could have been treated safely and effectively in a less intrusive, less invasive level of care such as outpatient medication management and outpatient therapy during this period of time. Accordingly, the RTC services provided from 2/4/15 through 4/24/15 were not medically necessary. Based on the foregoing discussion, 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 


The parent of a 17-year-old female enrollee has requested authorization and coverage for external ambulatory insulin delivery system (Omnipod). The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees diabetes. The physician reviewer found that transition to the Omnipod pump is medically necessary for this patient. This patient has had malfunctioning of her Medtronic pump and adverse reactions to the site insertions while engaged in competitive swimming. She is able to successfully employ insulin pump therapy to control her diabetes and has had excellent adherence to diabetes management tasks, but she requires a different type of pump due to her active lifestyle. Treatment with the Omnipod insulin management system has been found to be associated with clinically meaningful and statistically significant improvement in glycemic control, reduction in daily insulin requirement and reduction in the frequency and severity of hypoglycemic episodes analogous to the Medtronic pump. The medical evidence supports the requested device in this patients case. All told, the requested external ambulatory insulin delivery system (Omnipod) is medically necessary for the treatment of this patient. Therefore, the requested device is 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 30-year-old female enrollee has requested reimbursement for gene expression profiling performed on 6/29/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found there is a lack of medical literature supporting the testing at issue in this clinical setting. According to the results of analysis of patients Decision Dx Melanoma testing, the tumor was classified as Class 1A with a low risk of near-term within five years, such as 96% metastasis free rate. According to the standard analysis of such risk, the lesions of 1-2 mm depth have a risk of 80-96% of recurrence. Therefore, the gene expression profiling performed on 6/29/16 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 Upheld

Summary Reviewer 2

A 30-year-old female enrollee has requested reimbursement for gene expression profiling performed on 6/29/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found the Decision Dx melanoma assay examines genes for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some accuracy in thin melanomas. However, the patients treatment would not likely change based on the results of the exam. There is a lack of medical literature to support its use in patients with thin melanomas to effect health outcomes. Given the lack of published data to support the use of gene expression profiling, the testing performed on 6/29/16 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 Upheld

Summary Reviewer 3

A 30-year-old female enrollee has requested reimbursement for gene expression profiling performed on 6/29/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found the gene expression profiling performed on 6/29/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the Decision Dx Melanoma assay should not be used outside of a clinical trial. Moreover, the testing at issue is not expected to impact the treatment or outcome of the patients melanoma. As such, the testing at issue 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 67-year-old male enrollee has requested authorization and coverage for a split night polysomnogram. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that the records indicate that this patient has a prior history of OSA and remains symptomatic. Testing would have been indicated to re-establish a diagnosis of OSA. However, provision of services in the attended setting would have exceeded the patients clinical needs. The current literature indicates that there has been a shift from the provision of services in the attended setting to the ambulatory setting (Jordan, et al). Unattended and attended testing have been shown to yield equivalent outcomes to laboratory testing in at least two randomized trials (Rosen, et al; Chai-Coetzer, et al). The performance of testing and treatment in the home setting has also been shown to produce equivalent outcomes to testing in the attended environment. There were no extenuating circumstances present in this patients case that would have warranted an attended sleep study. The patients sleep related presentation was most consistent with OSA. While he reported nocturnal limb movements, it would be more appropriate to evaluate and treat the OSA to see if the limb movements are due to respiratory related arousals. Moreover, he has no other medical conditions that are a contraindication to provision of services in the home setting. Accordingly, the requested split night polysomnogram is not medically necessary for evaluation of this patients medical condition. Based on the foregoing discussion, the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 47-year-old male with a medical history including obesity and hypertension. Per the records, he has been treated with Saxenda since March 2020. The physician reviewer found that according to the U.S. Food and Drug Administration (FDA), Saxenda is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia). The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention: a combination of diet, exercise, and behavioral modification. All patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with a BMI greater than 30kg/m2 or a BMI of 27-29.9 kg/m2 with comorbidities, such as hypertension or diabetes Mellitus, has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy
is suggested. In this case, the documentation does not support that the patient has failed treatment with counseling, calorie restriction and increased physical activity to achieve weight loss goals. Therefore, Saxenda pen injector 6 mg/mL is not medically necessary for the treatment of this patient.