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

Summary Reviewer 3


A 54-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma.   The physician reviewer found with regard to this patient, however, there is no indication as to why the patient is not maintained on a combination inhaler or a leukotriene receptor antagonist, both of which are standard of care in asthma and are recommended by current guidelines. The providers notes indicate the patient had been placed on these agents but there is no documentation as to duration and reason for discontinuation. Further, there is no assessment of any associated conditions such as allergic disease, reflux or sinus disease. Further, there is a diagnosis of aspergillosis, a variety of which can worsen asthma control, alluded to in a consult document from April 2016, but nothing more regarding treatment or resolution. There are no records of an eosinophil count or IgE level as well as consideration of using omalizumab or another biologic for control. Given the lack of documentation supporting the requested procedure, the bronchial thermoplasty 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 16-year-old male enrollee has requested reimbursement for the residential treatment services provided from 4/28/14 through 6/21/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees anxiety and attention deficit hyperactivity disorder (ADHD). The physician reviewer found that the records provided for review do not support the medical necessity of the residential treatment services provided from 4/28/14 through 6/21/14. The patient did not demonstrate behaviors concerning for him to place himself or other at imminent risk of harm. Psychiatric issues prompting his admission including depression and irritability could have been safely and adequately treated at a less intensive setting. There were no acute impairments, behaviors, or issues with cognition that interfered with the patients ability to perform activities of daily living. Further, psychosocial and environmental problems were not likely to undermine treatment at a less intensive level of care, such as outpatient care. Throughout the admission, he was motivated by earning the reward of a home visit and there was no evidence he required residential care for treatment of his symptoms. All told, the documentation does not indicate the residential treatment services were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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 59-year-old male enrollee has requested reimbursement for substance abuse residential detoxification and rehabilitation services provided from 5/5/16 through 6/1/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse. The physician reviewer found that this patient was on a potentially life threatening detoxification from phenobarbital. Phenobarbital has a rather low LD50, and the patient demonstrated that he was unable to refrain from overuse of this and other substances, suggesting that he was at high risk for overdose if detoxification was not conducted in a controlled environment. As such, medically conducted detoxification was appropriate until the doses of his phenobarbital were brought down to minimal levels. The records indicate the patients phenobarbital levels were safely at minimal levels by 5/11/16. Thus, by 5/12/16 he could have been stepped down to chemical dependency partial hospitalization program (CD-PHP) treatment. For these reasons, the substance abuse residential detoxification and rehabilitation services provided from 5/5/16 through 5/11/16 were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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 

The patient is a 53-year-old male with a history of clinically localized favorable intermediate risk adenocarcinoma of his prostate gland. The patient has requested reimbursement for 17 fraction treatments of IMRT provided from 3/05/21 through 3/29/21. 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 submitted documentation supports the medical necessity of the services at issue. The 17 additional fractions of IMRT were standard of care and medically necessary in this clinical setting. While hypofractionation is proven equivalent in terms of safety/efficacy for treatment of prostate cancer, conventional fractionation (45 fractions as requested) is standard of care and continues to be widely utilized throughout the radiation oncology community. National Comprehensive Cancer Network guidelines support the use of 45 fractions of IMRT in this setting, as do numerous high-quality prospective clinical outcomes published in the peer-reviewed medical literature. Therefore, 17 fraction treatments of IMRT provided from 3/05/21 through 3/29/21 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 42-year-old female enrollee has requested authorization and coverage for destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the guideline published by International Society for the Advancement of Spine Surgery concluded that the intraosseous basivertebral nerve ablation for the treatment of chronic low back pain is a treatment option that has supporting level 1 evidence for patients with clinical and radiologic findings supporting a vertebrogenic source of back pain. The procedure has two randomized controlled trials that showed statistically significant pain scores and also functional improvements over a two-year period. This patientas clinical and radiologic findings of Modic type 1 changes at L4-5 support a vertebrogenic cause of back pain. She has not had any relief from comprehensive and multimodal treatment options and has exhausted these therapies. Chronic use of opioids is not indicated for the treatment of chronic low back pain. Radiofrequency ablation of the basivertebral nerve is the appropriate next step in the treatment algorithm and is likely to provide functional relief to the patient. Therefore, destruction of intraosseous basivertebral nerve is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 42-year-old female enrollee has requested authorization and coverage for destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. This patient has a history of chronic lower back pain refractory to conservative treatment. There is a paucity of clinical trials supporting this procedure. There is a need for more clinical randomized, double-blind, placebo trials. The procedure is relatively new and has not been proven to make a difference or benefit in enough clinical trials. Thus, destruction of intraosseous basivertebral nerve is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 42-year-old female enrollee has requested authorization and coverage for destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that Fischgrund and colleagues performed a randomized controlled trial regarding the two-year clinical outcomes for chronic low back pain patients treated with radiofrequency ablation of the basivertebral nerve. The authors noted, aBasivertebral nerve ablation appears to be a safe, durable, minimally invasive treatment for the relief of chronic low back pain in a patient population that typically has few effective treatment options.a Lorio and colleagues concluded, aThe procedure is supported by level 1 evidence including two randomized controlled trials demonstrating a statistically significant decrease in pain and an improvement in function with outcomes sustained to at least 24 months in a limited number of studies.a In this case, the patient has had a history of chronic low back pain that has persisted for several years, which has been refractory to multiple modes of standard care. Based on the available medical records for review and the current studies, the requested services are likely to be superior over other treatment options. Thus, destruction of intraosseous basivertebral nerve is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 51-year-old male enrollee has requested reimbursement for a coronary computed tomography (CT) calcium scan provided on 3/15/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees hyperlipidemia. The physician reviewer found that use of the coronary CT calcium score has not been recommended as Class I indication by the American College of Cardiology (ACC). The ACC guidelines state that for asymptomatic patients, coronary calcium score is reasonable in the intermediate risk group but it has not achieved class I recommendation supporting routine use for all patients regardless of risk factors. Currently, the standard approach for risk stratification does not include coronary CT calcium scan in this clinical setting. Thus, the coronary CT calcium scan provided on 3/15/18 was not medically necessary for evaluation of this patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The parent of seven-year-old female enrollee has requested reimbursement for individual psychophysiological therapy incorporating feedback training by any modality with psychotherapy services provided from 10/31/14 through 12/9/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees attention-deficit/hyperactivity disorder (ADHD).The physician reviewer found the services at issue were not likely to be more effective for this patient than any other available options. There is a lack of evidence-based research in the medical literature to support the services at issue. According to the American Academy of Child and Adolescent Psychiatry, It seems established that a pharmacological intervention for ADHD is more effective than a behavioral treatment alone. Additionally, the documentation submitted for review does not mention evidenced-based treatments tried such as parent training or social skills training. All told, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than standard treatment options. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

The parent of seven-year-old female enrollee has requested reimbursement for individual psychophysiological therapy incorporating feedback training by any modality with psychotherapy services provided from 10/31/14 through 12/9/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees attention-deficit/hyperactivity disorder (ADHD).The physician reviewer found the individual psychophysiological therapy with psychotherapy services provided from 10/31/14 through 12/9/14 was not likely to be more beneficial for treatment of the patients medical condition than other modalities. A review of the medical literature reveals a lack of clinical evidence to support the efficacy of biofeedback interventions in this clinical setting. In the absence of adequate clinical evidence in the peer-reviewed literature that supports the efficacy of neurofeedback therapy, it is not possible to conclude that neurofeedback therapy is likely to be more beneficial than standard therapies available in this setting. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

The parent of seven-year-old female enrollee has requested reimbursement for individual psychophysiological therapy incorporating feedback training by any modality with psychotherapy services provided from 10/31/14 through 12/9/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees attention-deficit/hyperactivity disorder (ADHD).The physician reviewer found the services at issue were not likely to be more beneficial for treatment of the patients medical condition than other modalities. There is a lack of medical literature supporting the services at issue in this clinical setting. According to Holtmann and colleagues neurofeedback has gained some promising empirical support in recent years from controlled studies as a treatment of core ADHD symptoms. However, a recent stringent meta-analysis of 8 randomized controlled trials published in 2013 found that the effects were stronger for unblinded measures and 3 recent subsequently published well-controlled trials found no effects for the most blinded ADHD outcome. The authors concluded that Firmer conclusions must await upcoming evidence from larger controlled studies and future meta-analyses contrasting different forms of neurofeedback and different outcome measures. In sum, neurofeedback therapy for the treatment of ADHD is not the standard of care and was 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 


A 57-year-old female enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI) performed on 7/21/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  The literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  MRI studies of the breast are highly sensitive, but have a relatively low level of specificity.  It is common for an MRI to suggest a significant lesion, at which point the patient is often subjected to ultimately unnecessary biopsies.  The medical evidence supports routine physical examinations as well as routine screening mammography as the best means to detect recurrence.  Moy and colleagues specifically addressed the issue of how to monitor patients with newly diagnosed stage 1 breast cancer.  The authors noted women newly diagnosed with stage 1 breast cancer have an early-stage disease that can be effectively treated.  Evidence provides little justification for performing imaging to exclude metastasis in asymptomatic women with stage 1 breast cancer.  No differences have been found in survival or quality of life in women regardless of whether they underwent initial workup for metastatic disease.  Moy and colleagues noted, American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines state that annual mammography is the only imaging examination that should be performed to detect a localized breast recurrence in asymptomatic patients. Additional imaging may be needed if the patient has locoregional symptoms.  In this patients case, there were apparently no clinical or imaging signs of recurrent tumor.  Routine surveillance mammography and possibly breast tomosynthesis should be sufficient in this clinical setting.  All told, bilateral breast MRI performed on 7/21/15 was not medically indicated for the evaluation of this patient.  Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 55-year-old female enrollee has requested authorization and coverage for arthrodesis of sacroiliac (SI) joint (27279). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees SI joint pain. The physician reviewer found that the International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive SI joint fusion provide specific indications for surgery. ISASS criteria includes: significant SI joint pain or significant limitations in activities of daily living because of SI joint pain; SI joint pain confirmed by at least three positive SI joint provocative tests; confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period; failure to respond to at least six months of non-surgical treatment including medications, rest, physical therapy, and SI joint steroid injection or rhizotomy; and, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been clearly considered, investigated and ruled out. In this case, the patient presents with chronic left SI joint pain. Functional limitations are noted in activities of daily living and ambulatory ability. The records document up to three positive provocative SI joint tests on clinical examination. The provider reports a 75% reduction in pain with diagnostic injections, but the patient reports no benefit with any treatment attempted. Conservative treatment has included medications, activity modification, massage, acupuncture, and physical therapy. She has been diagnosed with a painful left SI joint condition but there is no imaging evidence consistent with SI joint spondyloarthropathy, degenerative sacroiliitis, or SI joint disruption. In addition, there is concern for lumbar spine and left hip pain generation. Therefore, the requested arthrodesis of SI joint (CPT code 27279) 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 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 55-year-old female enrollee has requested authorization and coverage for arthrodesis of sacroiliac (SI) joint (27279). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees SI joint pain. The physician reviewer found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. SI joint syndrome can cause various symptoms and may be a reason for persistent low back pain, especially in patients with prior spinal fusions. If conservative treatments fail to improve symptoms, arthrodesis surgery can be considered. Minimally invasive approaches provide a good alternative to conventional methods. A triangular implant system can be used without bone grafting or screw fixation to achieve an optimal fusion of the SI joint.  Minimally invasive surgical arthrodesis of the SI joint is known to result in significant improvement in pain and function. In this case, the left SI joint has been demonstrated to be the pain generator. This was confirmed with a SI joint injection with associated pain relief. For the reasons provided, the proposed minimally invasive surgical arthrodesis of SI joint (27279) 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 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 Upheld

Summary Reviewer 3

A 55-year-old female enrollee has requested authorization and coverage for arthrodesis of sacroiliac (SI) joint (27279). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees SI joint pain. The physician reviewer found the request for arthrodesis of SI joint (27279) is not likely to be beneficial for this patient. The reliance of steroid local injection into the SI joint as an indicator for identification of a specific pain generator is not sufficient to localize pain generation from the SI joint in the face of multifactorial chronic pain. Local anesthetic injection is questionable since the SI joint is large and irregular and only acceptable to needle intervention in portions of the joint. In sum, it is not likely to be beneficial for this patient to undergo SI instrumentation and fusion as a treatment method for her condition of chronic pain. 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.