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

Summary Reviewer 1

A 37-year-old male enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that this patients records support a diagnosis of GERD based on pH recording. However, the documentation states that the patient benefited to a significant degree from acid suppression treatment in the past and the failure he reportedly experienced with proton pump inhibitor (PPI) agents did not specify dosage of acid suppressants currently employed. Also, implantation of LINX in this patients setting must be approached with caution given his manometrically documented dysmotility, which is considered a contraindication (Lipham, et al). As such, the requested LINX procedure 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 37-year-old male enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the requested LINX procedure is not likely to be more beneficial for treatment of this 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 3

A 37-year-old male enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. A recent study comparing the LINX procedure with laparoscopic fundoplication found that GERD patients had similar control of reflux symptoms after both LINX and fundoplication (Reynolds, et al). The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. In a group of 85 patients, augmentation of the lower esophageal sphincter (LES) with a magnetic device provided significant and sustained control of reflux, with minimal side effects or complications. No new safety risks emerged over a five-year follow-up period (Ganz, et al). This patient meets the specific criteria for LINX placement with a hiatal hernia that is only 0.2 cm larger than recommended for the procedure. All told, the requested LINX procedure 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 69-year-old female enrollee has requested authorization and coverage for Prolia 60 mg/mL syringe. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Osteoporosis is an increasingly widespread condition.  Fractures are the most dangerous aspect of osteoporosis, and this can lead to acute and chronic pain as well as increased mortality. While bisphosphonate therapy has been available for the treatment of osteoporosis for a number of years, a newer medication, denosumab (Prolia) is a fully human monoclonal antibody that has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. While both bisphosphonates and Prolia have been shown to be effective at improving bone mineral density and reducing the risk of subsequent fractures, recent data suggests that Prolia has superior efficacy, particularly in the region of the spine.  Because this patient has severe osteoporosis, with lowest bone mineral density in the region of the spine, and has sustained a fracture in the past, Prolia is medically indicated. Therefore, Prolia 60 mg/mL syringe is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 30-year-old male enrollee has requested reimbursement for residential treatment provided from 5/05/18 through 5/08/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the services at issue in this patients case. Per the records, his polysubstance use was dominating his daily routine and contributing to significant impairment across multiple domains of functionality.  He reported a family history and an early age of first use, both of which are associated with more severe cases of addictive illness. His substance use was undermining his educational pursuits and interpersonal functioning. The patient was negotiating emotional dysregulation, anxiety and depressive symptoms related to his substance use. Finally, the patient had attempted community-based programming, but was unable to maintain sobriety in his environment. Based on the records, the patient had not consolidated the treatment gains necessary to succeed in a less restrictive setting, and promptly would have relapsed, were he discharged to outpatient on 5/05/18. During the disputed timeframe, the patient was restless, on edge, moody, angry with himself and not sleeping well. However, he was actively engaged in therapeutic programming and furthering his recovery in a safe environment.  The services and setting were safe, appropriate and consistent with good practice, while nine days of residential treatment would be considered an inadequate duration of care for an illness burden of this severity. Additionally, the services provided at the time were reasonably expected to improve his condition and prevent a more serious episode of illness. In sum, residential treatment provided from 5/05/18 through 5/08/18 was medically necessary for the treatment of this patient. Therefore, the services at issue were 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 

An 18-year-old female enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided form 5/29/17 through 8/17/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 1. The medical records indicate that the patient was not actively or passively suicidal, and there were no reports of self-harm. In terms of functional status, the records support a score of 2. The patient had some issues with level of function due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment. With regards to comorbidity, the records support a score of 1. The patient did not have a history of past medical issues and denied substance use. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have interpersonal conflict with family members in the past, although she spoke well of her family. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment. In terms of resiliency and treatment history, the records support a score of 3. Per the records, the patient had some response to past outpatient treatment but continued to have some depression symptoms despite this treatment. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy actively, and she was cooperative with consistent engagement. In terms of acceptance and engagement of the parents, the records support a score of 2. The patients parents worked actively and constructively with staff. Thus, the patient has a composite score of 15. This score correlates with outpatient services. Therefore, residential mental health treatment for children and adolescents provided from 5/29/17 through 8/17/17 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 44-year-old female enrollee has requested reimbursement for an AmniSure test that was performed on 4/7/14. The Health Insurer has denied this request indicating that the test at issue is considered investigational for evaluation of the rupture of the fetal membrane. The physician reviewer found that AmniSure testing (placental alpha-microglobulin-1 measurement) is recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid when these tests are inconclusive. AmniSure is not recommended as a first line test. Studies examining the measurement of placental alpha-microglobulin-1 are mixed. While there is some data supporting the utility of the assay, others studies have noted false-positive rates of 1930% in patients with clinically intact membranes and symptoms of labor (ACOG Practice Bulletin).  This patients records do not document standard testing with ferning/nitrazine prior to the AmniSure testing. All told, there is insufficient evidence supporting the superior efficacy of the AmniSure test over standard testing with ferning/nitrazine.  Therefore, the AmniSure test performed on 4/7/14 was not likely to be more beneficial than the available standard for evaluating the patients medical condition. Based upon the information set forth above, the test 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 44-year-old female enrollee has requested reimbursement for an AmniSure test that was performed on 4/7/14. The Health Insurer has denied this request indicating that the test at issue is considered investigational for evaluation of the rupture of the fetal membrane. The physician reviewer found that AmniSure is recognized with generally accepted professional medical standards as being safe and effective. This test is well supported and recommended in difficult diagnostic cases.  In this case, the early gestational age of this patient makes accurate diagnosis especially important because this could pose difficult clinical decisions. Accurately diagnosing premature preterm rupture of membranes (PPROM) is crucial to the well-being of the mother and fetus. AmniSure is approved by the Food and Drug Administration (FDA) and is generally recognized as a safe and effective test for the diagnosis of PPROM.  In this patients case, the AmniSure test performed on 4/7/14 was likely to be superior for evaluation of this patient than any available standard test for PPROM. Based upon the information set forth above, the test 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 Upheld

Summary Reviewer 3


A 44-year-old female enrollee has requested reimbursement for an AmniSure test that was performed on 4/7/14. The Health Insurer has denied this request indicating that the test at issue is considered investigational for evaluation of the rupture of the fetal membrane. The physician reviewer found that at issue in this case is whether the AmniSure test was a better tool to evaluate this patients leakage of fluid than any other standard available test, such as a traditional speculum exam with PH and microscopic evaluation of the fluid. The diagnosis of rupture of membranes (ROM) is made based upon patient history and clinical exam including a speculum evaluation of the vagina and cervix. Typically, the patient history, with a description of leakage of fluid, can help to rule in or rule out the diagnosis. This coupled with a sterile speculum exam to evaluate vaginal/cervical secretions (pooling), to evaluate the PH of any secretions, and to perform a microscopic examination for cervical ferning are used to complete the exam. In this case, there was no documentation of any sterile speculum/pelvic exam. A complete speculum exam would allow for better evaluation of any vaginal fluid to help determine if vaginal pooling occurred or to gather a specimen for evaluation of cervical ferning. For these reasons, the AmniSure test used to evaluate for ROM was not likely to be more beneficial than the standard tests available. Based upon the information set forth above, the test 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 Overturned

Summary Reviewer 

A 64-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1b. The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. In conclusion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 53-year-old female enrollee has requested authorization and coverage for foam sclerosant/endovenous ablation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports a portion of the requested services. The records noted a plan for a large number of procedures, each performed on isolated days. No medical reason for performing each procedure on isolated days is documented. These procedures have been requested without documentation of a plan to reassess the patient after initial procedures.  However, there is documentation of symptomatology that is impacting this patients daily activities despite the use of compression stockings. There is documentation of truncal superficial venous reflux as well as absence of deep vein thrombosis in the presence of palpable pedal pulses. Therefore, the documentation supports bilateral greater saphenous vein ablation and one session of sclerotherapy per leg, although the truncal ablation and sclerotherapy for each leg should be performed on the same day. The records support a total of two days of service (one day for each leg). Anything performed after the first of service for each leg would require clear documentation of failure of the approved procedures to improve symptomatology with documentation of continued activity limiting symptoms despite the regular use of compression stockings. In sum, bilateral greater saphenous vein ablation and one session of sclerotherapy per leg are likely to be superior over other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 53-year-old female enrollee has requested authorization and coverage for foam sclerosant/endovenous ablation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for a portion of the requested services in this patients case. Providers often do not schedule patients for ablation of all of their refluxing superficial veins at once. Rather, they treat the veins most likely to help based on the ultrasound and the clinical findings and reevaluate the patient. It may not be indicated to treat all of the refluxing superficial veins if the patient is no longer symptomatic after the initial vein is treated. Thus, the treatment of the great saphenous vein or short saphenous vein first, followed by re-evaluation is appropriate. The plan to treat them all regardless of how the patient responds is not supported by the literature or guidelines. Thus, the medical evidence does not support second ablations for each leg until the patient is reevaluated following the initial treatments. Therefore, a portion of the requested foam sclerosant/endovenous ablation is likely to be more effective than other treatment options. Specifically, the superior efficacy of the second ablations for each leg has not been established.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 53-year-old female enrollee has requested authorization and coverage for foam sclerosant/endovenous ablation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is support for a portion of the services at issue. This patient has painful varicose veins bilaterally. She is status post radiofrequency ablation of left great saphenous vein and ultrasound-guided foam sclerotherapy. There is support for the requested services for the left leg. For the left leg, the veins are residual after a prior thermal ablation. She continues to be symptomatic. Thus, the requested services for the left leg are likely to be superior over other treatment options. With regards to the right leg, the varicose veins are de novo. There is no saphenofemoral junction or saphenopopliteal junction reflux. Per the medical evidence, endovenous thermal ablation is preferred to surgery and foam sclerotherapy in the treatment of small saphenous vein incompetence. In sum, the requested foam sclerosant/endovenous ablation of the left leg is likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 21-year-old male enrollee has requested reimbursement for inpatient psychiatric hospitalization from 11/20/15 through 12/13/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found inpatient psychiatric care is aimed at decompressing the acute exacerbations of episodic serious mental illness.  In this patients case, psychiatric hospitalization was initially indicated and discharge on 11/20/15 would have been premature.  However, the record does not substantiate the need for acute level of care services after 12/11/15.  On 11/18/15, the patient had thoughts of killing his grandmother.  On 11/19/15, the patient was disheveled, constricted and depressed.  On 11/20/15, the patient was depressed, apathetic and helpless.  Thereafter and through 12/11/15, the patient endured mood symptoms, impaired reality testing, paranoia, hallucinations and catatonia, along with an extrapyramidal side effect to one of the antipsychotic medications.  The inpatient team made several medication changes in an effort to optimize the psychotropic regimen, while the diagnosis was not determined until early December 2015.  Based on the illness severity, treatment at the time could not have been reasonably conducted in a less restrictive setting.  By 12/11/15, the patient was taking his medication regularly.  Both his psychotic burden and delusional thought system were markedly less impairing.  His thinking was linear.  He had no suicidal ideation or homicidal ideation.  His insight had improved, and his judgment was good.  Although still symptomatic with a need for long-term specialty services provided by behavioral health care professionals, the acute psychiatric syndrome that prompted the admission had resolved as of 12/11/15.  All told, inpatient psychiatric hospitalization from 11/20/15 through 12/11/15 were medically necessary, but not thereafter.  Therefore, a portion the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.