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

Summary Reviewer 

A 53-year-old male enrollee has requested reimbursement for MRI of the lumbar spine without dye performed on 3/22/19. 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 this patient had a history of low back pain for greater than two years. Neurological examination had been normal for greater than two years, and there had been no weakness, absent reflex, history of tumor or infection, or trauma to serve as a red flag to mandate immediate imaging with MRI. The patient was prescribed chiropractic manipulation and massage therapy during his visits in 2017 and 2018. Unless there is a red flag indication, the current guidelines support a six-week course of conservative therapy, including physical therapy, and then re-evaluation prior to pursuing MRI for low back pain. In this case, the course of physical therapy prescribed by the patients chiropractor and planned follow-up afterward occurred after the MRI had been done, not beforehand as required by the national guidelines for MRI of the lumbar spine. Therefore, MRI of the lumbar spine without dye provided on 3/22/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 47-year-old female enrollee has requested reimbursement for radiofrequency ablation performed on 2/21/19. 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 current medical evidence supports the services at issue in this clinical setting. Liver directed therapy has been part of oncologic surgical programs for many years. It is a safe procedure with excellent data supporting local control and cure for certain types of tumors. Microwave ablation is comparable to the old systems of radiofrequency and has improved local control, more uniform cell death and decreased ablation times with no increased morbidity. Long-term control and local recurrence is significantly better with lesions less than 3 cm. The majority of data for ablation has been reported for primary liver tumors or common metastatic tumor types (such as colorectal and neuroendocrine), but there is data to support treatment in the setting of gynecologic malignancies, with excellent local control and a survival advantage. This patient had multiple prior procedures, and each subsequent operation can be more difficult, with increased morbidity. Ablation offers excellent local control in a minimally invasion fashion. The patient recovered expeditiously and had an excellent result on post procedure MRI. She received standard of care for isolated recurrence of her ovarian cancer. Therefore, radiofrequency ablation performed on 2/21/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 16-month-old male who was born by Cesarean section at 32 weeks 3 days gestation. The patientas parent has requested reimbursement for occupational and speech therapy services provided from 7/24/20 through 8/20/20. 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 supports the medical necessity of the services at issue. The patient was born prematurely, at 32 weeks 3 days gestation. He spent four weeks in the NICU, and required a feeding tube. He has documented developmental delays, including gross motor delays, apraxia, poor emotional regulation, and feeding difficulties. Spittle and colleagues compared the effectiveness of early developmental intervention program provided post hospital discharge to prevent motor or cognitive impairment in preterm infants versus standard medical follow-up of preterm infants at infancy, preschool age, school age, and adulthood. The authors noted, aInfants born preterm are at increased risk of developing cognitive and motor impairment compared with infants born at term. Early developmental interventions have been provided in the clinical setting with the aim of improving overall functional outcomes for these infants.a Spittle and colleagues noted, aEarly intervention programs for preterm infants have a positive influence on cognitive and motor outcomes during infancy, with cognitive benefits persisting into preschool age.a Woodward and colleagues stated that infants born before 34 weeks of gestation have three times the risk of impairments in multiple developmental domains compared with term infants. Bui reported, aPreterm children should be screened regularly for developmental delay, and parents of preterm infants should be counseled about the options of early intervention programs, and their potential positive impact on development.a In an article describing the importance of physical, occupational and speech therapy for infants born prematurely, Orton and colleagues noted, aThe developmental allied health team, consisting of physical therapy, occupational therapy, and speech pathology, is crucial in early evaluation of gross motor, fine motor, feeding, and language development. Surveillance of neurodevelopment in the first year of life is essential to ensure early detection of specific developmental delays and impairments, and to ensure timely referral for early intervention. Early intervention is not only important in optimizing long-term outcomes for the child, but it also plays an important role in enhancing the parent-child relationship and parental well-being.a The medical evidence supports the services at issue in this clinical setting. Therefore, occupational and speech therapy services provided from 7/24/20 through 8/20/20 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 12-year-old male enrollee has requested authorization and coverage for Humatrope 12 mg cartridge. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency. The physician reviewer found the requested medication is medically necessary for treatment of the patients medical condition. The patient has experienced a deceleration in growth velocity from the 40th percentile to fifth percentile between 2-11 years of age. IGF-1 level was low, and provocative GH testing results were poor. Based on auxological and biochemical criteria, the patient meets generally established guidelines for GH treatment. He had a good response to one year of therapy without adverse effects, and continuation of GH therapy is medically necessary until epiphyseal fusion. Withdrawal of therapy at the age of expected puberty may result in irreversible impairment in height potential. As such, Humatrope 12 mg cartridge has been established as medically necessary for treatment of the patients medical condition. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 60-year-old male enrollee has requested authorization and coverage for Genium Ottobock X3 waterproof microprocessor knee system. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the Genium Ottobock X3 waterproof microprocessor knee system is medically necessary for treatment of the patients medical condition. Sawers and Hafner conducted a systematic review of outcomes associated with microprocessor controlled knees (MPK), such as the Genium X3, in comparison to non-microprocessor controlled knees, (NMPK), such as the Endolite hydraulic knee the patient currently has. In regards to the microprocessor controlled knees, the authors state This technology is intended to make the prosthetic knee responsive to the user's instantaneous needs (i.e., allow him or her to change cadence and walking speed) and adjust its behavior (i.e., provide more or less knee-flexion resistance) in response to extrinsic conditions, thereby mimicking the behavior of a nondisabled knee. The authors conclude that Moderate evidence exists to suggest that swing and stance MPKs are associated with increased confidence during ambulation, increased self-reported mobility, reduced self-reported cognitive demand while walking, improved self-reported well-being, and equivalent overall societal costs when compared with NMPKs. The Genium X3 provides swing and stance control and conveys these benefits. In addition, Kannenberg and colleagues performed a systematic review of MPKs in limited community ambulators, a population typically thought to be inappropriate for these devices. The authors state Clinical research, mainly conducted in the unlimited community ambulator (MFCL-3) population with low to moderate methodological quality, has demonstrated improved safety and superior function of MP-controlled prosthetic knees (MPKs) in level walking, walking on uneven terrain, walking on slopes, walking on stairs, and stumble recovery, resulting in significantly reduced numbers of stumbles and falls and improved balance than with NMPKs. In this case, the patient is beyond the K3 (MFCL-3) functional level. The patient is a K4 level ambulator. The authors conclude that, The results of this systematic review suggest that the use of MP hydraulic stance only or MP stance and swing control prosthetic knees may improve safety, function, and mobility of limited community ambulators with unilateral [transfemoral amputation] TFA. In light of these findings, it no longer appears appropriate to generally withhold this advanced prosthetic technology from MFCL-2 individuals. Given the above, the MPK Genium X3 is medically necessary for the high functioning K4 level patient who requires a waterproof knee. Thus, the requested device is medically necessary to maximize the patients function, health, and overall well-being.
Therefore, the requested device is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 67-year-old female enrollee has requested authorization and coverage for Actemra injections 80 mg/4 mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees rheumatoid arthritis. The physician reviewer found that in this case, the patient has active, moderate to severe rheumatoid arthritis. She is being treated with prednisone with a history of ongoing osteoporosis. She experienced side effects from the prednisone with multiple fractures. She has failed two different TNFi medications including Enbrel which was ineffective and Humira which caused an adverse reaction. She is noted to have been tuberculosis negative prior to previous TNFi and most recent chest x-ray on 5/11/17 was also negative for tuberculosis. She has failed two TNFi and the guidelines suggest a decreased response to a third TNFi after poor response or inability to use a second TNFi. As such, the request for Actemra injections 80 mg/4 mL is supported as medically necessary for treatment of this patients rheumatoid arthritis. Based on the foregoing, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a nine-year-old male with extreme short stature. Per the clinical notes, he has been growing below the third percentile since five years of age. The records document mild subclinical hypothyroidism and negative celiac panel. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has a height that is more than 2.25 standard deviations below the mean for age and sex. He has extreme short stature that qualifies for treatment with growth hormone therapy, based on Pediatric Endocrine Society guidelines. This patients bone age gives him an estimated adult height which is significantly below his mid-parental target height of 173 cm. He will not be able to attain the parental height without growth hormone treatment. Therefore, Norditropin FlexPro 15 mg/1.5 ml is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 54-year-old male enrollee has requested reimbursement for radiofrequency neurolysis performed on 4/08/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  In the documentation available for review, the providers plan is to perform a medial branch block first.  Furthermore, the physical examination does not demonstrate any pain coming from the left side.  It is unclear why a left side medial branch block or radiofrequency ablation would be done when physical examination does not corroborate pain coming from this area.  Based on the submitted documentation, it is possible the patient would have experienced the same relief from a steroid injection alone without also having the increased risk from the radiofrequency ablation. There is a lack of support for the services at issue in this patients case.  All told, radiofrequency neurolysis performed on 4/08/16 was not likely to have been of greater benefit than 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 Overturned

Summary Reviewer 2


A 54-year-old male enrollee has requested reimbursement for radiofrequency neurolysis performed on 4/08/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case.  The majority of peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected.  In reviewing the medical records, imaging is significant for multilevel spondylosis.  The physical examination is also significant for facet mediated pain.  Per the providers notes, the patient experienced long-term relief with previous radiofrequency facet ablation at the same level below the fusion.  In sum, radiofrequency neurolysis performed on 4/08/16 was likely to have been of greater benefit than other treatment alternatives.  Based upon the information set forth above, the services at issue were 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


A 54-year-old male enrollee has requested reimbursement for radiofrequency neurolysis performed on 4/08/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for a portion of the services at issue.  In this case, the records indicate that this patient underwent radiofrequency ablation in March 2015 prior to the repeat radiofrequency ablation on 4/08/16.  The patient previously experienced several months of pain reduction following the radiofrequency ablation in March 2015.  Based on the medical evidence, the superior efficacy of radiofrequency ablation at the cervical C7 level has been established.  However, there is a lack of support for radiofrequency ablation performed on thoracic levels T1, T2 and T3.  Boswell and colleagues noted the evidence for pain relief with radiofrequency neurotomy of cervical and lumbar medial branch nerves is moderate for short- and long-term pain relief, and indeterminate for thoracic facet neurotomy. Manchikanti and colleagues noted the evidence for therapeutic thoracic facet joint nerve blocks is fair, limited for radiofrequency neurotomy, and not available for thoracic intraarticular injections.  In sum, radiofrequency neurolysis at the C7 level performed on 4/08/16 was likely to have been more efficacious than other treatment options.  However, the superior efficacy of radiofrequency neurolysis performed on thoracic levels T1, T2 and T3 has not been established.  Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 28-year-old male enrollee has requested reimbursement for code L0456 provided on 1/13/16. The Health Insurer has denied this request and reported that the equipment at issue was not medically necessary for treatment of the enrollee, who had a history of neck pain, upper back pain, and shoulder pain. The physician reviewer found there are no indications in the records forwarded for review that the patient had a condition that required the use of a thoracolumbosacral orthosis.  There are no indications in the records, for instance, that the patient has an unstable bony spine (e.g., fracture or significant spondylolisthesis) or that he recently underwent destabilizing spinal surgery.  The records indicate that the patient had neck and upper back pain following a twisting and falling injury while putting away holiday decorations.  A lumbosacral orthosis was not appropriate for this patients condition.  There is a lack of objective evidence that it is an effective measure to treat any spinal condition in the absence of objective instability or postoperatively. There is a lack of high-grade published data that this type of intervention favorably impacts the natural history of sprain/strain/enthesopathic spinal conditions in a clinically meaningful manner.  Clinically, they are generally considered contraindicated because they can promote core weakness, which is the opposite of appropriate treatment.  All told, code L0456 provided on 1/13/16 was not medically necessary for the treatment of this patient. Therefore, the equipment at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The parent of a 16-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 12/13/13. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found the Prometheus Anser IFX diagnostic testing performed on 12/13/13 was likely to be more effective for this patient than other available treatment options. Anser IFX testing is commonly used in gastroenterology practices and has been well studied. There is sufficient peer-review literature supporting its usefulness in treating patients with irritable bowel syndrome and guiding therapy. Prometheus Anser IFX testing informs the provider if the serum levels of drug are in the range to be beneficial and effective or if they have antibodies that could potentially lead to a reaction or failure to respond. This helps guide the provider in dosing or may lead to discontinuation of the drug if the patient is not likely to benefit from the medication. All told, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of a 16-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 12/13/13. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found in general, diminished or suboptimal response to infliximab or adalimumab can be managed in several ways such as shortening the interval between doses, increasing the dose, switching to a different anti-TNF agent or switching to a non-anti-TNF agent based on clinical observation in lieu of Anser IFX testing. In this patients case, the medical records submitted for review do not support acute loss of therapeutic response nor acute disease flare. There are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. In addition, the clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. In sum, the testing at issue was not clinically indicated and 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.