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

Summary Reviewer 


The parent of an 18-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy provided from 1/1/15 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 autism spectrum disorder (ASD). The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. A letter from the patients ABA provider recommends a number of goals designed to decrease the patients aggression. However, the patient has already been treated with extensive ABA therapy and still continues to exhibit aggressive behavior. In addition, the patient was taken out of public school because of his aggression, which may be problematic if therapy is attempted within a community setting. The additional tests and recommendations submitted for review do not support the medical necessity of the services at issue. This patient has a full scale IQ of 74 which would suggest he does have the intellect to learn from therapeutic sessions. However, his retention is limited and he has regressed to baseline at the completion of his prior ABA treatments. In addition, there is a lack of support in the medical literature for the additional testing performed. For the reasons provided, 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 57-year-old female enrollee has requested reimbursement for tumor necrosis factor antagonist testing performed on 4/04/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found it is not standard of care to measure tumor necrosis factor drug levels and their antibodies in patients failing on a biologic. The Anser tests for both infliximab and adalimumab have been available for several years, and their role in clinical management continues to be defined.  There is a lack of evidence from prospective controlled trials demonstrating superiority over standard clinical management.  Patients with inflammatory bowel disease experience disease refractory symptoms for a number of reasons unrelated to tumor necrosis levels.  All told, tumor necrosis factor antagonist testing performed on 4/04/15 was not likely to have been superior over 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 Upheld

Summary Reviewer 2


A 57-year-old female enrollee has requested reimbursement for tumor necrosis factor antagonist testing performed on 4/04/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the superior effectiveness of the services at issue.  The testing in dispute was ordered to determine the etiology for possible loss of response to Humira.  The use of Anser ADA has not been clinically proven in controlled studies to improve patient clinical outcomes or to be more effective than conventional courses.  Patients treated with Humira may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear.  Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. Clinical guidelines for management of inflammatory bowel disease do not recommend testing for anti-drug antibody during clinical management.  Therefore, tumor necrosis factor antagonist testing performed on 4/04/15 was not likely to have been of greater benefit than other modalities for 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 Upheld

Summary Reviewer 3


A 57-year-old female enrollee has requested reimbursement for tumor necrosis factor antagonist testing performed on 4/04/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the submitted records fail to demonstrate the superior efficacy of the services at issue.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or adalimumab or the presence of infliximab or adalimumab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  While there have been testimonials, 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.  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. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  Thus, tumor necrosis factor antagonist testing performed on 4/04/15 was not 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 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 1

A 51-year-old female has requested reimbursement for genetic testing performed on 4/13/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. 

 The physician reviewer found that the patient is a 51-year-old female who was diagnosed with melanoma of the right medial distal pretibial region. Pathology report from 6/06/16 showed a malignant melanoma, superficial spreading type, Clarks level IV. There was no ulceration, necrosis or regression. DecisionDx-Melanoma testing was performed on 4/13/18. The patient has requested reimbursement for genetic testing performed on 4/13/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. This patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. Therefore, genetic testing performed on 4/13/18 was not likely to have been superior over 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 Upheld

Summary Reviewer 2

A 51-year-old female has requested reimbursement for genetic testing performed on 4/13/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. 

 The physician reviewer found that the patient is a 51-year-old female who was diagnosed with a cutaneous melanoma in June 2016. At that time, she was found to have a superficial spreading melanoma, 0.8 mm in thickness, with no ulceration. DecisionDx-Melanoma testing was performed on 4/13/18. The patient has requested reimbursement for genetic testing performed on 4/13/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. The prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between DecisionDx-Melanoma classification and prognosis, in patients who had undergone sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it not clear that the DecisionDx-Melanoma classification can be used to make clinical decisions. In sum, genetic testing performed on 4/13/18 was not 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 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 51-year-old female has requested reimbursement for genetic testing performed on 4/13/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. 

 The physician reviewer found that the patient is a 51-year-old female with malignant melanoma. She had a pigmented lesion removed from her right pre-tibial region. The final pathology showed this was superficial spreading malignant melanoma of Breslow depth of 0.8 mm, Clark level IV, and without ulceration. A tumor sample was submitted for DecisionDx-Melanoma testing. The patient has requested reimbursement for genetic testing performed on 4/13/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, genetic testing performed on 4/13/18 was not likely to have been more efficacious 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 27-year-old male enrollee has requested reimbursement for acute inpatient mental health treatment for adults provided from 4/25/16 through 6/5/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the clinical record does not support the medical necessity of service delivery at the acute inpatient level of care as of 5/20/16. On 4/24/16, the test results from the psychosis work-up had not yet returned. The patient remained guarded and isolative. He had no insight regarding his mental illness. Further, he was refusing psychotropic medication. The treatment team did provide thoughtful patient-centric care at a slow-pace to help build the rapport and trust necessary for meaningful therapeutic gains. For example, on 4/27/16, the psychologist did not confront the patients denial, rather the concepts of self-perception and idealism were introduced. As the therapeutic path was being forged, the patient continued with the diagnostic work-up. Aside from a slightly elevated cholesterol level, his laboratory studies were unremarkable. On 5/4/16, the electroencephalogram finding was normal. On 5/6/16, the neuropsychology report was published while the magnetic resonance imaging (MRI) of the brain was normal. On 5/10/16, the patient elected to start an antipsychotic medication. On 5/13/16, the patient was described as reserved and polite and noted to have no side effect from the medication. On 5/17/16, the patient was slowly feeling better. On 5/19/16, the patient agreed to step-down to a less restrictive setting and residential placement was recommended by the psychiatrist. In sum, the admission facilitated the completion of a thorough diagnostic assessment and improved the patients clinical condition. During the course of the admission, the patient had not voiced any new complaints or expressed any suicidal ideation, homicidal ideation or aggressive behavior. He was illogical at times, but neither disruptive nor disrespectful.  Based on his past behaviors and the severity of his illness, a structured and supervised setting remained indicated to consolidate the therapeutic gains, but there was no indication that residential placement would have been unsafe or inadequate as of 5/20/16.   Thus, the services at the acute inpatient level of care were medically necessary from 4/25/16 through 5/19/16, but not thereafter. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
 
A 22-year-old male enrollee has requested reimbursement for substance use outpatient services provided from 10/25/16 through 11/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is sufficient support in the medical literature for the services at issue in this clinical setting. Routine outpatient treatment is standard of care for patients with amphetamine use disorder. From 10/25/16 through 11/10/16, the patient was treated using EMDR therapy. EMDR is evidenced based practice in treating past psychological trauma which is a common comorbid condition for those with substance use disorders. Treatment with EMDR therapy in an outpatient setting is one of the least restrictive methods of delivering psychiatric care. This patient required treatment for his amphetamine disorder. As such, the documentation provided as well as the medical literature, support the services at issue. Therefore, in this patients case, substance use outpatient services provided from 10/25/16 through 11/10/16 were medically necessary for the treatment of this patient.  Based on the reasons stated above, 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 

The patient is a 33-year-old female who has a history of a motor vehicle accident in April 2018. The patient has requested reimbursement for physical therapy provided from 4/30/20 through 6/26/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the management of chronic benign musculoskeletal pains affecting body regions such as the neck, shoulders and back can include pharmacological agents, rehabilitation, psychological treatment, complementary/alternative medicine and invasive approaches. The aim of rehabilitation is to reduce pain, reduce impairment/disability, and improve quality of life. Formal rehabilitative interventions are rendered, in conjunction with education, towards a goal of self-management, independent exercise and remaining active. Exercise and physical activity have low risk for adverse effects and are generally encouraged in the setting of these types of chronic pains. The benefit of prolonged exercise and formal modalities in a formal therapy setting, however, is not established in the medical literature. There is no proven marginal benefit of prolonged formal therapy in the chronic pain clinical setting over independently pursued exercises and independently rendered interventions, such as self-massage (e.g., using foam rollers, massage balls, etc.) and topical treatments, such as ice or heat. In this case, the patient experienced some major life stressors in early 2020 and reported exacerbations in her chronic symptomatology. She did not, however, have any documented impairments that would have precluded her from performing an appropriate independent exercise program, including stretching and strengthening, as well as independent soft-tissue and palliative interventions, e.g., self-massage using foam rollers or massage balls, and topical treatments such as ice or heat, during the time period under review. Although the patient had been making some subjective and nominal progress with therapy, there would have been no expectation of a marginally significant difference in clinical course or outcomes with the formal therapy in question over an appropriate independent program and the passage of time. She would have been expected to have had some persistent and fluctuating symptomatology, just as she did despite receiving the therapy services during this time period. Therefore, physical therapy provided from 4/30/20 through 6/26/20 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 60-year-old female who has a history of pain and pressure around her left ear. Per the notes provided, she has seen otolaryngology specialists, and her symptoms were felt to be secondary to temporomandibular joint disorder. The physician reviewer found that the current well-accepted test to identify the presence or absence of temporomandibular joint disorder or one of its subcategories is a comprehensive evaluation of the patientas history and clinical examination and, when indicated, select temporomandibular joint imaging. The panoramic radiograph is the initial study of choice for evaluation of the temporomandibular joint. CT scan is indicated when bony pathology is suspected and can better delineate bony anatomy and demonstrate any degenerative changes. Given the patientas clinical findings, which included crepitus of her temporomandibular joint, a CT scan was appropriate to evaluate her temporomandibular joint for any degenerative changes. Therefore, CT scan performed on 10/28/20 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 46-year-old female with a history of anxiety and depression and eating disorder. The patient has been prescribed bupropion (Wellbutrin) since at least 1997. She has been doing well with brand name Wellbutrin. A trial of generic bupropion reportedly lacked efficacy and tolerability, and required treatment with diphenhydramine for a possible allergic reaction. The patient has been treated with other psychotropic medications including venlafaxine, fluoxetine, trazodone, aripiprazole and buspirone without substantial improvement. The provider has ordered continuing therapy with brand name Wellbutrin XL. The patient has requested reimbursement and prospective authorization and coverage for brand name Wellbutrin XL from 3/9/17 forward. The Health Insurer has denied this request indicating that the medication at issue was not and is not medically necessary. Bupropion is a dual-acting medication that enhances both noradrenergic and dopaminergic tone in the central nervous system that was approved by the U.S. Food and Drug Administration (FDA) for treatment of depression in 1989. An extended release (XL) formulation was approved in 2003. In the medical literature, Sadock and colleagues noted that the possibility exists that differences in potency may underlie adverse changes in clinical status, when a brand name medicine is substituted with a generic, or even if there is a switch between specific generic manufacturers. This patient has been clinically stable on an evidence based antidepressant medication endorsed by current practice guidelines and community standards. The patient previously failed treatment with various medications as well as a trial of generic bupropion. All told, the brand name Wellbutrin XL provided from 3/9/17 forward, was and is medically necessary as it is reasonably expected to maintain the patients clinical stability and prevent an exacerbation of illness. Based on the available documentation, the medication at issue was and 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 25-year-old enrollee has requested reimbursement for bilateral nipple/areola reconstruction associated with gender reassignment surgery performed on 10/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the medical necessity of the services at issue. The Health Insurer is incorrect in its understanding of the nature of the most common chest surgery for transmasculine patients. As noted by Schechter and Schechter, patients with small non-ptotic breasts can often be treated with periareolar incisions but most patients require double incision surgery with free nipple grafts, as sought by this patient. The authors noted generally, free nipple-areola grafts, as opposed to maintenance of the nipple-areola complex on the dermoglandular pedicle are the preferred techniques for nipple transposition. Olson-Kennedy and colleagues demonstrated that for transmasculine individuals, this surgical intervention positively affected both minors and young adults. In sum, bilateral nipple/areola reconstruction associated with gender reassignment surgery provided on 10/30/18 was medically necessary for the treatment of this patient.