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

Summary Reviewer 

The patient is a 56-year-old male with a history of trauma to the left elbow resulting from a fall while bicycling during his vacation in Costa Rica. The patient has requested reimbursement for hospital services provided from 12/26/19 through 12/28/19. 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 this was a complicated situation with an angulated comminuted intra-articular fracture of the proximal ulna and a concomitant fracture of the radial head. The orthopedic surgeon in Liberia did not wish to handle this and transferred the patient to San Jose where, after appropriate workup and preparation, open reduction and internal fixation of the proximal ulna was performed in the early hours of the morning, achieving rigid fixation of the fracture, and stabilizing the elbow joint. This was medically necessary as noted in the literature referenced here. The initial splinting and transportation by ambulance to the appropriate facility was necessary. Surgery was performed in the early hours of the morning at the receiving facility after preparation as noted. The patient stayed in the hospital until the next morning, which was appropriate for pain control and observation because of the location of the facility in Costa Rica. Therefore, hospital services provided from 12/26/19 through 12/28/19 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 41-year-old female enrollee has requested reimbursement for monitored anesthesia care (MAC) services provided on 2/12/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees risk for colon cancer. The physician reviewer found that The American Society of Anesthesiologist (ASA) noted that MAC with sedation may be necessary to improve patient cooperation, decreased movement, and reduce discomfort during endoscopy procedures in patients with significant psychiatric disorders, cognitive dysfunction and movement disorders. The ASA also noted that MAC is necessary for patients in situations of extreme procedure anxiety. The records indicate that this patient has a history of extreme anxiety and panic attacks. Thus, the MAC services were appropriate and medically necessary during the colonoscopy performed on 2/12/15 for evaluation of this patients medical condition. Based on the foregoing discussion, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 53-year-old female enrollee has requested reimbursement for the ColonSentry testing performed on 1/20/15. The Health Insurer has denied this request indicating that the diagnostic testing at issue is considered investigational for evaluation of the enrollees risk for colorectal cancer.  The physician reviewer found that review of the submitted documentation and relevant literature fails to support the services at issue in this clinical setting. ColonSentry is a seven-gene panel test that determines a patients risk of colon cancer. It is not a substitute for colon cancer screening such as with routine colonoscopy. With no family history of colon cancer this patient is considered an average risk patient and ColonSentry testing is not recommended by any of the major published guidelines cited above as appropriate screening for average risk patients. Based on the lack of support in the peer-reviewed literature, the ColonSentry testing performed on 1/20/15 was not likely to be more beneficial for evaluation of the patients medical condition than other modalities. 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 53-year-old female enrollee has requested reimbursement for the ColonSentry testing performed on 1/20/15. The Health Insurer has denied this request indicating that the diagnostic testing at issue is considered investigational for evaluation of the enrollees risk for colorectal cancer.  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines for screening for colon cancer do not include ColonSentry, or similar, testing for average or above average risk individuals. The NCCN recommendations are for either colonoscopy, stool based testing with high sensitivity guaiac based or immunochemical based testing or flexible sigmoidoscopy. There is a lack of medical literature to support the use of ColonSentry for colorectal cancer screening. All told, 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 53-year-old female enrollee has requested reimbursement for the ColonSentry testing performed on 1/20/15. The Health Insurer has denied this request indicating that the diagnostic testing at issue is considered investigational for evaluation of the enrollees risk for colorectal cancer.  The physician reviewer found that the ColonSentry test is typically performed to help patients decide on whether or not a colonoscopy may be indicated. The ColonSentry test does not replace colonoscopy as the gold standard for colon cancer screening. In this case, the case file does not show any contraindication to colonoscopy. As such, the ColonSentry testing performed on 1/20/15 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 46-year-old male enrollee has requested reimbursement for total disc arthroplasty to cervical vertebral level: C5/6 using Globus Secure-C device on 6/29/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition.The physician reviewer found evidence-based medical peer reviewed literature and guidelines do not support single-level artificial disc replacement in the setting of multilevel cervical degenerative disc disease. This patient presented with significant neck pain radiating into the right upper extremity with severe functional disability. Physical examination documented upper extremity motor and sensory deficits and reflex changes. There was imaging evidence of multilevel severe spinal canal and neuroforaminal narrowing at the C3/4, C4/5, and C5/6 levels. The North American Spine Society evidence-based clinical guidelines for cervical artificial disc replacement (ADR) state that cervical ADR may be indicated for patients with radiculopathy related to single level degenerative disease (either herniated disc or spondylotic osteophyte) from C3/4 to C6/7 with or without neck pain that has been refractory to conservative treatment. Guidelines state that cervical ADR is not indicated in symptomatic multilevel disease (two or more levels) that would require multiple level artificial disc replacement. In this patients case, there was no compelling evidence presented to support the medical necessity of C5/6 artificial disc replacement over the standard anterior cervical discectomy and fusion. Moreover, there was a lack of evidence that the patients symptoms were limited to the C5/6 level. As such, the total disc arthroplasty to cervical vertebral level: C5/6 using Globus Secure-C device on 6/29/16was not medically necessary for treatment of this patient. Therefore, for the reasons stated above, 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 patient is a 38-year-old male with a history of low back and radicular leg pain associated with clinical and imaging evidence of a lumbar disc herniation. The patient has requested authorization and coverage for laminotomy surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the patient has a history of lumbar disc herniation associated with radiculopathy and leg pain greater than back pain. There is documentation of conservative treatment, including four weeks of physical therapy, in addition to chiropractic care and medications. Although many patients  improve with nonsurgical management, Lorio and colleagues noted, aResults from randomized controlled trials have shown that 35% to 54% of patients assigned to continued nonsurgical care undergo discectomy within six months due to persistent or aggravating symptoms.a Other randomized controlled trials show that discectomy provides faster and/or greater pain relief, and functional recovery as well as patient satisfaction compared to continued nonsurgical care. A review of the recent medical literature indicates that this patient is a good candidate for the requested surgical procedure. Therefore, the requested laminotomy surgery is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 54-year-old female enrollee has requested reimbursement for emergency services provided on 1/26/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found the issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented for removal of scalp sutures due to a laceration nine days prior to her visit. She admitted to a lingering hangover feeling, but had no specific complaints of headache, vomiting, dizziness, blurry vision, or other symptoms of acute head injury. She denied any symptoms of wound infection. Moreover, the patient was not experiencing the sudden onset of acute symptoms. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided on 1/26/16 did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 66-year-old female enrollee has requested reimbursement for the computed tomography (CT) of the chest with contrast and CT of the abdomen and pelvis with contrast provided on 10/19/17.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees uterine cancer. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines support the preoperative use of CT of the chest, abdomen and pelvis for evaluation of possible metastases in patients with serous uterine cancer. In addition, the use of CT scans every six months for a course of two years are suggested per NCCN guidelines. The evaluation is designed to detect distant or local metastatic disease at the earliest possible stage in order to provide optimal treatment. All told, the CT of the chest with contrast and CT of the abdomen and pelvis with contrast provided on 10/19/17 were medically necessary for evaluation of this patients medical condition. Based on the foregoing discussion, the services at issue were 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 

The patient is a 33-year-old male who was noted to have a 6.1 cm mass in the right lower lobe of his lung on 5/18/18. On 6/08/18, a diagnosis of adenocarcinoma was made. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The National Comprehensive Cancer Network (NCCN) recommends obtaining a brain MRI before proceeding with additional chemotherapy after diagnosing advanced metastatic non-small cell lung cancer (NSCLC). Pechoux and colleagues noted, In patients with more advanced (stage IIIA/N2) NSCLC who underwent surgical resection, those who had adenocarcinoma histology and
preoperative chemotherapy seem to have an increased risk of developing brain metastases (>30%). At the same time, there is literature suggesting that early detection of further metastases does not alter the course of disease. As written by McMurry, representative data provide evidence that more frequent post-surgical surveillance is not associated with improved survival. As the number of lung cancer survivors increases over the next decade, surveillance is an increasingly important major health care concern and expenditure. In this patients case, he would not have been able to participate in a clinical trial without a new brain MRI. This is common in clinical trials. In order to have an effective clinical trial, there are always strict criteria for admission. In conclusion, while one could argue that another MRI of the brain is not warranted simply prior to routine chemotherapy, the MRI dated 6/18/19 allowed the patient to participate on the trial, and hence, altered his immediate therapy. Therefore, MRI of the brain provided on 6/18/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 53-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the bilateral breasts. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollees risk of breast cancer. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested diagnostic procedure. According to Phi and colleagues, the Addition of MRI to mammography for screening BRCA1/2 mutation carriers age greater than 50 years improves screening sensitivity by a magnitude similar to that observed in younger women. Limiting screening MRI in BRCA1/2 carriers age greater than 50 years should be reconsidered. In addition, Warner and colleagues state Screening with both MRI and mammography might rule out cancerous lesions better than mammography alone in women who are known or likely to have an inherited predisposition to breast cancer. The medical literature supports the use of breast MRI for women with higher risk of breast cancer, such as women with BRCA mutation. Given that the patient is less than a month away from her annual breast MRI screening and this is also to be used for pre-surgical mastectomy evaluation, it is medically necessary for this patient to have a screening breast MRI a few weeks earlier. For the reasons provided, the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 36-year-old male enrollee has requested reimbursement for air ambulance transport provided on 2/12/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. Based on the medical records submitted for review, there is no medical reason for the patients transfer. The patient was receiving adequate care at the initial location in California. The promise of successful weaning off mechanical ventilation does not warrant the risks for transferring a patient such a long distance. In some case, patients are better off on the ventilator. In this case, there is no evidence that this patient, who has been on a ventilator since 2011 was weanable. All told, the air ambulance transport provided on 2/12/14 was not medically necessary for treatment of the patients medical condition.Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 57-year-old male enrollee has requested reimbursement for electromagnetic navigational bronchoscopy performed on 9/29/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung nodule.The physician reviewer found there is a lack of support for the services at issue in this patients case.  The medical evidence does not demonstrate that the use of the electromagnetic navigational system improves long-term health outcomes.  The services at issue were not standard of care. There are numerous ways of work-up of potential malignant lung disease, including needle biopsy under fluoroscopy, mediastinoscopy, washing, brushing, and positron emission tomography (PET) scan and/or CT scan follow-up.  Therefore, electromagnetic navigational bronchoscopy performed on 9/29/15 was not likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 57-year-old male enrollee has requested reimbursement for electromagnetic navigational bronchoscopy performed on 9/29/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung nodule. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  Electromagnetic navigational bronchoscopy is a unique tool that allows the provider to accurately guide bronchoscopic tools to predetermined points within the tracheobronchial tree.  With this system, the provider can accurately guide the steerable extended working channel to a suspicious peripheral lesion for diagnostic testing.  The alternatives to electromagnetic navigational bronchoscopy biopsy include standard/blind bronchoscopy or computed tomography (CT) guided biopsies.  While CT guided biopsies have a superior diagnostic yield of 90%, they are limited by complications, both pneumothoraces and hemoptysis.  Electromagnetic navigational bronchoscopy has a track record of excellent diagnostic yields, low complication rates and acceptance within the medical community as a useful test of the diagnosis of a peripheral lesion.  Based on the medical records, this patient was a candidate for electromagnetic navigational bronchoscopy based on the lesion size, location and shape, especially in light of his smoking history.  In sum, electromagnetic navigational bronchoscopy performed on 9/29/15 was likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were 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 57-year-old male enrollee has requested reimbursement for electromagnetic navigational bronchoscopy performed on 9/29/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung nodule. The physician reviewer found that electromagnetic navigational biopsy is a procedure which allows the provider to direct a biopsy forceps or brush with greater accuracy to sample lung nodules.  Existing techniques, like a standard bronchial brush or biopsy, have a low yield for peripheral lesions.  This patient had a peripheral lung lesion and hemoptysis.  Computed tomography (CT) guided needle biopsy involves a risk of bleeding.  The use of electromagnetic navigational localization allows the provider to sample a lesion with much more accuracy and safety than standard procedures.  In sum, electromagnetic navigational bronchoscopy performed on 9/29/15 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.