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

Summary Reviewer 1

A 29-year-old male enrollee has requested authorization and coverage for Subsys. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that high-dose and short-acting opiates may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Long-term opiates are more likely to cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose, opiates might induce tolerance and abnormal pain sensitivity.  All told, the requested medication Subsys is not likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested medication 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 29-year-old male enrollee has requested authorization and coverage for Subsys. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested medication in this clinical setting.   The requested medication is appropriate for breakthrough cancer pain relief.  While the patient does have documented chronic pain, he does not have a diagnosis of cancer.  The medical evidence does not support Subsys for the treatment of this patients condition.  Therefore, Subsys is not likely to be more efficacious than other treatment options.  Based upon the information set forth above, the requested medication 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 29-year-old male enrollee has requested authorization and coverage for Subsys. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the medical literature does not support the requested medication in this patients case.  The records do not document why injectable pain relievers are not an option for this patient.  The medical evidence supports the use of many treatment options for patients with spinal cord injury that have not been discussed.  Furthermore, the treatment for neuropathic pain has not been exhausted within the documentation available for review.  Thus, Subsys is not likely to be more effective than other options for the treatment of this patient.  Based upon the information set forth above, the requested medication 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of an eight-year-old male enrollee has requested reimbursement for services by JNK Assessments provided from 9/13/17 through 11/27/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Colenbrander and colleagues noted that early identification of dyslexia is crucial to ensure that children are able to maximize their educational potential. DuPaul and colleagues described that comprehensive intervention services for students with comorbid attention deficit/hyperactivity disorder and learning disability will require empirically supported treatment strategies that address both disorders and that are implemented across school and home settings. Hebert and colleagues described that children with dyslexia often have related writing difficulties. The authors found evidence of effective remedial and compensatory intervention strategies in spelling, transcription, executive function, and working memory. The medical evidence supports the services at issue in this clinical setting. Therefore, JNK Assessments provided from 9/13/17 through 11/27/17 were medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 55-year-old male enrollee has requested reimbursement for partial hospitalization program (PHP) services provided from 8/15/16 through 9/21/16. 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 the the PHP services provided from 8/15/16 through 9/21/16 were not medically necessary. Although chemical dependency treatment was clinically indicated, the record does not support the medical necessity for PHP level of care during the dates in dispute. On 8/15/16, the patient reported no depression, inattention, anxiety or suicidality. He was eating 100% of his meals, sleeping 10 hours per night and he was not prescribed psychotropic medication. He did not have psychiatric or medical co-morbidity. He was actively engaged in treatment and looking forward to being drug free. In sum, the record does not demonstrate that comprehensive, evidence-based services provided in an outpatient program would have been unsafe or inadequate to address this patients medical condition. All told, the patient could have been treated at a less restrictive setting as of 8/15/16. 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 60-year-old female enrollee has requested reimbursement for air ambulance services provided on 1/13/15. 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 air ambulance services provided on 1/13/15 were medically necessary for treatment of the patients medical condition. The patients symptoms represent a neurological emergency that warrants treatment at a hospital with expertise in treating stroke and subarachnoid hemorrhage (SAH). In both conditions, delay in treatment leads to a worse outcome. To expeditiously transfer the patient via air ambulance was a medically reasonable and appropriate action. In the case of a SAH, a quick work-up including potentially an angiogram, magnetic resonance imaging, and access to a neurosurgeon is critical and potentially lifesaving. In the case of an ischemic stroke, a delay of 40 minutes would have reduced the potential effectiveness of tissue plasminogen activator (TPA). The original treating facilities did not feel equipped to manage the case; thus a transfer was medically necessary. Transfer by ambulance would have delayed care and potentially placed the patient at risk of death or longstanding functional disability. Therefore, the services at issue were 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 45-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient presents with a history of constant severe left knee pain with associated swelling, buckling and instability. Significant functional limitations are documented in mobility and activities of daily living. She has a history of multiple dislocations and multiple surgical attempts to correct her patellar instability. She underwent left knee arthroscopy, debridement, chondroplasty, chondral biopsy, synovectomy and removal of loose bodies on 7/27/18. Operative findings documented a 2.0 x 2.0 cm (4.0 cm2) chondral defect of the lateral facet of the patella, and lateral tilt and subluxation of the knee cap. She also had a 1.5 x 1.5 cm chondral defect of the anterolateral trochlea. She had failed extensive long-term operative and non-operative treatment, including activity modification, bracing, ice, medications, and ambulatory assistive devices. The treating provider has opined that she was not a candidate for standard operative therapy including microfracture, osteochondral autograft or allograft transplant (OATS), or total knee arthroplasty given her age and lesion size. Under consideration is a request for matrix associated chondrocyte implantation (MACI) for the left knee. There is current evidence-based medical literature support for the use of autologous chondrocyte implantation in patellar defects as safe and effective with documented long-term outcomes. There is evidence that MACI offers a more efficacious alternative than microfracture with a similar safety profile for the treatment of symptomatic articular cartilage defects of the knee. Osteochondral allograft and autograft transplantation is limited to defects measuring 2.5 cm2 or less. Therefore, the requested autologous chondrocyte implantation of the knee is likely to be more beneficial for treatment of the patients medical condition that available standard therapy. Based upon the information set forth above, the requested services are 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 2

A 45-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain. The physician reviewer found that the surfaces of the bones in the knee are covered with hyaline articular cartilage, a very smooth, frictionless surface allowing movement in the joint and acting as a shock absorber. In this case, the documentation shows significant loss of the articular cartilage of the patellofemoral joint. Articular cartilage has very little capacity for self-repair, so damage may be permanent. Various methods have been used to try to repair cartilage. Autologous chondrocyte implantation involves laboratory culture of cartilage-producing cells from the knee and then implanting them into the defect. Studies have revealed that the results with autologous chondrocyte implantation are superior to microfracture. When combined with a patellofemoral stabilization procedure, it is effective in relieving pain and promoting healing of articular defects of the patellofemoral joint. The medical evidence supports the requested services in this clinical setting. In sum, autologous chondrocyte implantation of the knee is likely to be more effective than other treatment options. Based upon the information set forth above, the requested services are 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 45-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain. The physician reviewer found that surgical implantation of healthy cartilage cells (autologous chondrocyte implantation) is an alternative option for the treatment of large articular cartilage defects. Autologous chondrocyte implantation is primarily used to treat full-thickness cartilaginous defects of the distal femur by arthroscopically extracting healthy chondrocyte cells from the patients knee, culturing the cells, and implanting them back into an articular defect via an open surgical procedure. In general, autologous chondrocyte implantation is recommended as a second-line surgical option either after failure of initial arthroscopic repair or when a full-thickness articular cartilage defect is very large (2.5 cm2 or greater).  Autologous chondrocyte implantation should also be avoided in obese patients who have been shown to have no sustained improvement at two years. Worse outcomes have been reported in females with autologous chondrocyte implantation, especially in patients with patellar defects. Weak evidence has suggested some success with patellar autologous chondrocyte implantation, which remains off-label, but quality randomized controlled trials are lacking. In this patients case, the records noted a bipolar chondral lesion of the patellofemoral joint, which is a contraindication for autologous chondrocyte implantation. The failure rate of this procedure is high in this location. Thus, autologous chondrocyte implantation of the knee is not likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested services are 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 47-year-old female who presented to her primary care provider on 7/25/19 for establishment of care. The patient has requested reimbursement for vitamin D testing performed on 7/30/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that the clinical manifestations of vitamin D deficiency depend upon the severity and duration of the deficiency. The majority of patients with moderate to mild vitamin D deficiency are asymptomatic. With severe vitamin D deficiency, there can be hypocalcemia, which leads to bone disorders.   Patient groups who are at risk for vitamin D insufficiency include those who have dark skin or are obese, those taking medications that accelerate the metabolism of vitamin D, hospitalized or institutionalized people or those who have limited effective sun exposure. Other people at high risk include those with osteoporosis or malabsorption, including inflammatory bowel disease and celiac disease. Screening of the general population is not recommended. Normal-risk adults do not need assessment. In this case, the patient does not have any chronic medical conditions that would cause vitamin D deficiency. She did not have any signs or symptoms of vitamin D toxicity or severe deficiency. Therefore, vitamin D testing performed on 7/30/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 52-year-old female enrollee has requested reimbursement for hospital stay from 4/17/14 through 4/19/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee who presented with chest pain. The physician reviewer found that the patient is a 52-year-old female with a history of hyperlipidemia and hypertension.   Due to chest discomfort, a chest computed tomography (CT) angiogram was performed on 4/16/14. The study reported no evidence of pericardial effusion, pulmonary embolism or aortic pathology.  A note dated 4/17/14 documented one week of chest pain, worse with inspiration. A coronary angiogram had recently been performed at another hospital and reported only 20-30% proximal left anterior descending coronary disease. She presented on 4/17/14 with persistent chest pain, a normal cardiovascular physical examination and lateral precordial ST depression and T wave inversions on electrocardiogram.  She was placed on telemetry and observation.  Both troponin I and creatine kinase (CK) were normal.  The patient was discharged on 4/19/14.  The Health Plan denied coverage for the hospital admission from 4/17/14 through 4/19/14. This denial is the subject of this appeal and determination.Based on the records, this patient presented with some coronary risk and chest pain that does not sound anginal (worse with inspiration and some foods).  An evaluation reported a normal chest CT angiogram and an essentially normal coronary angiogram (20% stenosis). In addition, initial serum cardiac biomarkers were also normal. In this circumstance of persistent nonanginal quality chest pain and a negative evaluation, the hospital admission, from 4/17/16 through 4/19/16 was not medically necessary. Further evaluation and management could have been safely provided at a lower level of care. 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 32-year-old male enrollee has requested authorization and coverage for Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 ml and Gamunex-C. The Health Insurer has denied this request and reported that the medication at issue is investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. The medical literature has noted the efficacy of intravenous immune globulin for the management of chronic inflammatory demyelinating polyneuropathy. In this patients case, other options, such as corticosteroids, would not be advisable due to greater adverse side effect profile and potential of causing steroid induced myopathy. Eftimov and colleagues showed that the benefit of intravenous immune globulin persisted for 24 and possibly 48 weeks. In the study by Hughes and colleagues, intravenous immune globulin was shown to reduce functional disability and significantly improved grip strength in patients with chronic inflammatory demyelinating polyneuropathy. Therefore, Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 mL) and Gamunex-C is likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 32-year-old male enrollee has requested authorization and coverage for Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 ml and Gamunex-C. The Health Insurer has denied this request and reported that the medication at issue is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the requested medication in this patients case. The records document peripheral motor neuropathy, which is consistent with chronic inflammatory demyelinating polyneuropathy. Chronic inflammatory demyelinating polyradiculoneuropathy is a heterogeneous disorder that includes diverse clinical presentations and immunopathological mechanisms. Intravenous immune globulin is currently the standard of care in the treatment of patients with this condition. This patient is likely to benefit from intravenous immune globulin over other treatments. In sum, Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 mL) and Gamunex-C is likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 32-year-old male enrollee has requested authorization and coverage for Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 ml and Gamunex-C. The Health Insurer has denied this request and reported that the medication at issue is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested medication. There has been a diagnosis of peripheral motor polyneuropathy. Medical records from his neurologist describes muscular atrophy and weakness, diminished distal reflexes, and no upper motor neuron signs. Headaches and autonomic dysfunction are also described. He has had treatment with Radicava, which is indicated for treatment of amyotrophic lateral sclerosis. The notes do not include electromyography/nerve conduction velocity studies or autoimmune studies. Based on the available records, the diagnosis is unclear. While motor neuropathy is commonly treated with intravenous immune globulin, there is a lack of evidence that intravenous immune globulin would be helpful for amyotrophic lateral sclerosis. Without a more distinct diagnosis, it is not possible to state that intravenous immune globulin is likely to be more effective than other therapies. Thus, Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 mL) and Gamunex-C is not likely to be more beneficial than other treatment options.