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

Summary Reviewer 1

The parent of a 10-year-old male enrollee has requested reimbursement for the functional neuromuscular electrical stimulator-arms therapy system provided on 4/16/20. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the device at issue in this clinical setting. The RT300 FES Therapy System has been approved by the U.S. Food and Drug Administration. The patient has permanent neurological disability after a spinal cord injury. This device has been recommended as the best treatment option by his treating physicians as part of his rehabilitation program. There is medical literature supporting the device at issue in this setting. Therefore, the functional neuromuscular electrical stimulator-arms therapy system provided on 4/16/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of a 10-year-old male enrollee has requested reimbursement for the functional neuromuscular electrical stimulator-arms therapy system provided on 4/16/20. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that regardless of the etiology for transverse myelitis, flaccid myelitis and other infectious or post-infectious etiologies for spinal cord injury (SCI), the impact on activities of daily living are profound. These include, but are not limited to, loss of muscle mass, decreased bone density in affected limbs, abnormal blood flow and injuries incurred because of weakness and abnormal sensory input. While there is no currently available therapy to repair or replace affected spinal cord neurons, functional electrical stimulation provides trophic and functional support to muscles and limbs affected by SCI. Furthermore, this type of stimulation and therapy may preserve cortical representations of complex motor activity programs. While functional electrical stimulation cannot replace irrevocably injured or apoptotic spinal cord neurons, it can restore function below the level of injury. Hence, this represents best medical practice to restore/maintain this member's level of neurologic function. Therefore, the functional neuromuscular electrical stimulator-arms therapy system provided on 4/16/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The parent of a 10-year-old male enrollee has requested reimbursement for the functional neuromuscular electrical stimulator-arms therapy system provided on 4/16/20. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the superior efficacy of the device at issue in this clinical setting. Murphy and colleagues noted, Following the acute phase of acute flaccid myelitis (AFM), patients typically have substantial residual disability and unique long-term rehabilitation needs." Per the authors, Patients engaged in multimodal rehabilitation can achieve functional improvements for years even after recovery of motor strength plateaus. The authors describe that potential long-term sequelae from AFM include musculoskeletal problems and psychological sequelae, such as anxiety and depression. Melicosta and colleagues reported on the rehabilitation outcomes of a cohort of 31 children with AFM who received Activity Based Restorative Therapy (ABRT), including functional electrical stimulation. The authors concluded, Children with flaccid paralysis due to AFM undergoing structured, comprehensive rehabilitation interventions, even when these are initiated long after paralysis onset, can make significant neurologic and functional gains. Recovery of function and prevention of comorbidities are the main therapeutic targets for interventions in this population. Therefore, the functional neuromuscular electrical stimulator-arms therapy system provided on 4/16/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 57-year-old female enrollee has requested reimbursement for anesthesia services provided on 2/06/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who underwent colonoscopy. The physician reviewer found that according to the American Society of Anesthesiologists guideline for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in patients with a history of failed moderate sedation, which applies to this case of a patient with a seizure after moderate sedation in the past. According to other published criteria, allergies to sedation medications are a reason for use of monitored anesthesia care. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, monitored anesthesia care is recommended for previously anticipated intolerance to standard sedatives, as in this case of a seizure after midazolam. Thus, anesthesia services provided on 2/06/18 were 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 

A 42-year-old female enrollee has requested authorization and coverage for substance use inpatient detoxification provided from 10/03/18 through 10/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Society of Addiction Medicine (ASAM) criteria for level of placement can be applied to the patients presentation to help determine the appropriate level of care. The patient did not meet the criteria for dimension 1) acute intoxication and/or withdrawal potential. Additionally, the patient did not meet the criteria for dimension 2) biomedical condition and complications. According to the ASAM criteria, all six dimensions must be met for placement in this level of care. Therefore, substance use inpatient detoxification from 10/03/18 through 10/08/18 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 56-year-old male who has been diagnosed with cannabis use disorder, alcohol use disorder, and cocaine use disorder. The patient began smoking marijuana at age 14, drinking alcohol at age 17 and using cocaine at 25 years of age. Prior to admission, the patient was smoking cannabis, drinking 48 ounces of beer and snorting 1 gram of cocaine on a daily basis. The patient was treated previously with chemical dependency outpatient services for two to three weeks in 2016. He also participated in Alcoholics Anonymous and was prescribed escitalopram and amitriptyline. Due to the sequelae of substance use including deceptiveness, isolative behavior and relationship stress, the patient was admitted for detoxification on 1/28/17.  He successfully completed a phenobarbital taper and was directly transitioned to a residential treatment program.  The Health Insurer has denied reimbursement for inpatient residential treatment from 2/02/17 through 3/08/17.  Per the Health Insurer, 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 submitted documentation fails to demonstrate the medical necessity of the services at issue. The medical records do not demonstrate the necessity of residential level of care following detoxification. Upon admission, the patient had a normal mental status examination. He had no acute psychiatric issues or medical comorbidity aside from hyperlipidemia. He desired balance and happiness. He was employed and valued spirituality.  He received his last phenobarbital on 2/01/17, at which time his vital signs were stable, and he had no tremor.  Aside from a brief course of outpatient services a year prior, during the episode of illness the patient had not engaged standard therapies such as anti-craving medications, sober living environments, intensive outpatient programming or partial hospitalization. This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been unsafe or inadequate at the time. Thus, inpatient residential treatment from 2/02/17 through 3/08/17 was not medically necessary for the treatment of this patient. 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 56-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 7/29/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that there is a lack of peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in the peer-reviewed medical literature. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 7/29/16 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 service 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 Overturned

Summary Reviewer 2


A 56-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 7/29/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. This particular patient has breasts that have been described as being heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 7/29/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 56-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 7/29/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 7/29/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 23-year-old female enrollee has requested reimbursement for mental health partial hospitalization program (PHP) services provided from 7/27/15 through 9/22/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees obsessive compulsive disorder and major depressive disorder. The physician reviewer found that this case incorporates elements of the biopsychosocial model of conceptualization and represented a patient burdened with a profoundly debilitating anxiety disorder, with comorbid depression, that impaired multiple domains of functionality. The patients fear of contamination and incessant washing consumed hours of the day and resulted in dermatologic sequelae, intrapsychic distress, occupational problems and interpersonal discord. In accordance with modern psychiatric practice, the patient had first pursued treatment in the outpatient setting. Her illness burden prevented consideration of psychotropic medication and she failed to respond to non-pharmacologic interventions. Thus, she pursued a higher level of care. Such progression is common for patients with severe OCD and consistent with the American Psychiatric Association treatment guidelines. Thus, for the duration of treatment, the patient could not have reasonably been conducted at a less restrictive setting and less intensive treatment would have resulted in inadequate care. While in the program, the patient received gold-standard therapies for OCD, cognitive behavioral therapy and exposure response prevention. Additionally, she was able to defeat her irrational fear and begin a serotonergic medication, which is a first-line intervention for both mood disorders and OCD. The programmatic services provided were for active treatment. The treatment was evidence-based, and reasonably expected to improve her condition and prevent a more serious episode of illness. Further, the duration of services afforded the consolidation of treatment gains while remaining consistent with community practice standards. In sum, the PHP services provided from 7/27/15 through 9/22/15 were medically necessary for treatment of the patients medical condition.  Based on the foregoing discussion, 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 Overturned

Summary Reviewer 


A 52-year-old male enrollee has requested reimbursement for sleep study (CPT 95810) performed on 7/16/16. The Health Plan has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees possible obstructive sleep apnea.  The physician reviewer found that based on the medical literature and the presented clinical records submitted for review, the sleep study (CPT 95810) performed on 7/16/16 was medically necessary for evaluation of the patients medical condition. In this case the patient was suspected of having obstructive sleep apnea due to reports of snoring and daytime sleepiness. The sleep study performed is in accordance with the current standards of practice by the American Academy of Sleep Medicine (AASM). It is also generally accepted that a sleep technologist is not to initiate a split-night study unless the laboratory criteria for the performance of a split-night study is met which prevents the initiation of continuous passive airway pressure (CPAP) for patients who do not or may not require therapy. A technologist is then to run the study as a diagnostic sleep test (Robertson, et al). The patients sleep study did not demonstrate that the patient had a frequency of respiratory events in the early part of the study that would have met the threshold for initiation of a split-night study. The study was continued as a diagnostic polysomnography. Thus, the use of split-night study was not clinically appropriate. All told, the service at issue has been established as medically necessary for evaluation of the patients medical condition. 
Therefore, the service at issue was 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 parent of a 15-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health intensive outpatient program treatment provided from 9/22/15 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 behavioral health condition. The physician reviewer found that mental health intensive outpatient program treatment provided from 9/22/15 forward was and is medically necessary for treatment of the patients medical condition. According to the American Psychiatric Association guidelines services available for the treatment of eating disorders can range from intensive inpatient settings to residential and partial hospitalization programs to varying levels of outpatient care. In this case, the patient has been diagnosed with major depressive disorder, recurrent, generalized anxiety disorder, bulimia nervosa in partial remission and obsessive compulsive disorder and has completed a month long residential DBT program due to the long history of self-injurious behavior and suicide attempts. She engaged in the treatment however she still continues to have significant symptoms of depression and anxiety. Per the therapy note dated 9/28/15 the patient reported feeling an increase of anxiety due to multiple transitions over the last year. Based on the documentation submitted for review, the request for intensive outpatient program treatment provided from 9/22/15 forward was and is medically necessary as this patient continues to have significant symptoms of depression and anxiety. Therefore, the services at issue were and are 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 68-year-old male who has requested reimbursement for DecisionDx-Melanoma testing. The patient has requested reimbursement for DecisionDx-Melanoma testing performed on 11/23/20. 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 use of gene expression profiling (GEP) testing according to specific melanoma stage (either before or after sentinel lymph node biopsy) requires rather prospective investigation in large, contemporary datasets of unselected patients. Prognostic GEP testing to differentiate melanomas at low versus high risk for metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive result, GEP testing should not guide clinical decision making in this group. Commercially available GEPs, such as DecisionDx-Melanoma, are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular, to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Therefore, DecisionDx-Melanoma testing performed on 11/23/20 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 51-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 9/29/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the Guardant360 test is a liquid biopsy that analyzes patient plasma for mutations in a panel of 70 genes. In most instances of visceral disease or lymph node involvement, testing can be performed on the excised tissue, but in certain cases, this tumor tissue is inaccessible. For example, for bone metastases, the decalcification process makes the material unsuitable for gene sequencing. Thus, liquid biopsy is specifically mentioned in the National Comprehensive Cancer Network (NCCN) guidelines in these instances. Mutational testing by this method or by direct tumor sequencing offers a rational selection of the next regimen. When Guardant360 testing was ordered, the patient had a mixed response to fulvestrant and alpelisib. Whereas most tumor lesions were stable, one liver lesion had increased in size. The oncologist requested a Guardant360 serum analysis of mutations. This was an effort to verify the HER2-point mutation that was found previously by Foundation One analysis of the liver specimen and to use HER2-directed therapy. Finding this mutation in the plasma just indicates that one of the metastatic sites has the mutation. The test does not verify whether the liver lesion is the source of the mutation. Since this liver lesion in segment 2 of the liver was the area of progression, one would need mutational testing done on it to help direct therapy. Therefore, Guardant360 testing performed on 9/29/20 was not likely to have been more beneficial than other available standard therapy.