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

Summary Reviewer 3


A 59-year-old female enrollee has requested reimbursement for the Veracyte Afirma genetic testing provided on 12/3/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees thyroid nodule.  The physician reviewer found that as this patients initial biopsy report reported suspicious findings but the lesion was not malignant. This was a major determining factor in delineating further course of action. Genetic testing with the Veracyte Afirma was indicated in this case as standard protocol on the fine needle aspirate from this patients thyroid nodule. The findings helped the provider direct treatment and the patient was able to avoid unnecessary surgery. Given the current medical literature, the Veracyte Afirma genetic testing performed on 12/3/14 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, I have determined the services at issue were 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 Upheld

Summary Reviewer 

A 46-year-old male has requested reimbursement for air ambulance transportation provided on 9/04/19. 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 Dr. Martin Andrew Donlan, a physiatrist with the Roger C. Pearce Rehabilitation Hospital in Greenville, South Carolina, was consulted to assess the patient on 8/26/19. The Roger C. Peace Hospital Rehabilitation Center is a 53-bed unit that specializes in caring for people with traumatic brain injury and other conditions. Dr. Donlan recommended that the patient would benefit from an acute, multidisciplinary inpatient rehabilitation program. His consultation note indicated, Discussed recommendations with patient and spouse and both are in preference of going back to home state of Pennsylvania to complete inpatient rehabilitation stay. The decision to transport the patient to University of Pittsburg Medical Center in Pittsburgh, Pennsylvania, was made by the patient and his spouse in order to be closer to home. University of Pittsburg Medical Center was not the closest facility capable of providing inpatient rehabilitation services. Such services were available at the Roger C. Peace Hospital Rehabilitation Center. Further, at the time of transport, the patients condition was not life-threatening. He was medically stable for discharge from the hospital to an inpatient rehabilitation facility. Criteria for emergent air ambulance transport were not met in this case. Therefore, air ambulance transportation provided on 9/04/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 56-year-old male enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) treatment provided on 8/2/16, 8/4/16, and 8/9/16. 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 for the services at issue in this clinical setting. TMS is a novel, non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population.  A typical treatment course of TMS consists of 30-40 sessions spanning four to six weeks.  Tapering of the therapy is clinically recommended. Per Perera and colleagues, Once a determination of maximum benefit is made, the TMS treatments should be tapered  for the patient. A typical taper occurs over the course of two through three weeks and may consist of as many as six sessions. Thus, the services in dispute were reasonably expected to both improve the patients condition and consolidate the efficacy of the therapy.  The duration of service and number of sessions were consistent with community practice standards, in this patients case. The therapy itself was safe and appropriate for the treatment of this patients behavioral health condition. All told, TMS treatments provided on 8/2/16, 8/4/16 and 8/9/16 were medically necessary. Therefore, for 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 

A 21-year-old female enrollee has requested reimbursement for partial hospitalization program level of care provided form 4/12/19 through 4/26/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to an overall good functional level with appropriate activities of daily living. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability with controlled diabetes and no active substance use. With regards to level of stress of the recovery environment, the records support a score of 2 due to no mention of a stressful recovery environment. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 2 due to success in the treatment program with a good level of cooperation and stabilization of symptoms. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Thus, the patient has a composite score of 13. This score correlates with low intensity, community-based services.  Therefore, the patient did not meet criteria for partial hospitalization program level of care during the disputed timeframe. In sum, partial hospitalization program level of care provided from 4/12/19 through 4/26/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 51-year-old female enrollee has requested authorization and coverage for placement of graft to hold open nasal valves, repair of nasal fracture and transfer tissue on a pedicle. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient has a long history of nasal obstruction. She has daytime somnolence and has an RERA index of 40.4 events per hour. Her examination shows septal deviation, turbinate hypertrophy, and internal and external valve collapse. After decongestion, her nasal breathing still did not improve, indicating significant nasal valve obstruction. Her provider has recommended cartilage graft to repair nasal valves and temporalis fascia graft. Internal and external valve repair of the nose are standard procedures for the improvement of nasal airway. Assessment and treatment of these in conjunction with the nasal septum and turbinates is important in improving nasal function. Per the submitted documentation, the denied procedure codes are 30465, 21335, 20912, 20902, 20910, 21235 and 15570. In this patients case, the following services are medically necessary: 30520 (septoplasty), 30140-50 (inferior turbinate submucous resection), 30465 (vestibular stenosis repair), 21335 (open treatment of nasal fracture), and 20912 (cartilage graft septum). There is no documentation to support the need for a tubular flap, bone graft, temporalis fascia graft, or ear cartilage. Therefore, a portion of the requested services is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 55-year-old male enrollee has requested authorization and coverage for esketamine (Spravato) nasal spray (code C9399), 68-84 mg intranasal for one month, then up to two times weekly. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the records indicate that the patient has a history of depression as well as anxiety. Progress notes indicate that the patient has had unsuccessful trials of electroconvulsive therapy and transcranial magnetic stimulation. The progress notes indicate the patient has had a long history of treatment-resistant depression, which appears to be an area where ketamine has been clinically indicated. Andrade noted that although big data on ketamine are presently unavailable, the drug holds promise in the treatment of depression, especially refractory depression. The progress notes indicate that the patient has had a positive response from esketamine in the recent past. Overall, the literature shows some mixed results with regards to ketamine treatment as well as a lack of long-term outcomes data and safety data. However, the patient has failed evidence-based treatments for treatment-resistant depression, including multiple medication trials, medication augmentation strategies, transcranial magnetic stimulation, electroconvulsive therapy and psychotherapy. There is sufficient support for the requested medication in this clinical setting. Therefore, esketamine (Spravato) nasal spray (code C9399), 68-84 mg intranasal for one month, then up to two times weekly is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 43-year-old male enrollee has requested authorization and coverage for Sovaldi 400 mg, Daklinza 60 mg and Ribavirin 600 mg for 24 weeks. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollee's hepatitis C virus. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to nonliver-related comorbid conditions. Per the guidelines, patients with cirrhosis are high priority for therapy, and patients with diabetes mellitus are at risk for fast progression of fibrosis. This patient is interferon-ineligible due to anxiety. The guidelines recommend that cirrhotic interferon-ineligible patients with genotype 2 hepatitis C who have failed Sovaldi/Ribavirin regimens should be treated with Sovaldi/Daklinza and Ribavirin for 24 weeks. This is based partially on the results of two clinical trials (Sulkowski et al and Wyles et al). Delay in treatment may result in decreased survival (Jezequel et al).  For these reasons, the requested treatment with Sovaldi 400 mg, Daklinza 60 mg, and Ribavirin 600 mg for 24 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Therefore, I have determined the requested medications are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 51-year-old female enrollee has requested reimbursement for hyperthermia (77605 and 77600) provided from 11/03/15 through 12/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees breast cancer. The physician reviewer found the superior efficacy of the services at issue has not been established. Hyperthermia is generally reserved for treatment of recurrent breast cancer to the chest wall after mastectomy. Whether the addition of hyperthermia to conventional external beam radiation therapy is of clinical benefit is unknown. At least six randomized trials have compared radiation therapy with and without hyperthermia in the setting of measurable breast cancer where local therapy was indicated and surgery not feasible. Most have not been published, and the trials had a number of weaknesses, including the fact that at least two were stopped before reaching target accrual, the eligibility requirements of all of the trials varied markedly, and the primary endpoint was complete local response rather than survival. Per the medical evidence, hyperthermia (77605 and 77600) provided from 11/03/15 through 12/15/15 was not likely to have been more efficacious than other treatment options.  Based upon the information set forth above, the services at issue were 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 51-year-old female enrollee has requested reimbursement for hyperthermia (77605 and 77600) provided from 11/03/15 through 12/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees breast cancer. The physician reviewer found that hyperthermia is the use of heat to kill cancer cells, which are purportedly more sensitive to high heat than normal cells. It has had some usefulness, when combined with radiation therapy, in the treatment of chest wall recurrences of breast cancer.  However, there is a lack of data that it can be used as primary therapy, without radiation, of breast cancer, as has been done in this patient. Hyperthermia alone is not beneficial in this clinical setting. Therefore, hyperthermia (77605 and 77600) provided from 11/03/15 through 12/15/15 was not likely to have been of greater benefit than other treatment alternatives. Based upon the information set forth above, the services at issue were 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 51-year-old female enrollee has requested reimbursement for hyperthermia (77605 and 77600) provided from 11/03/15 through 12/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees breast cancer. The physician reviewer found that upon diagnosis with breast cancer, patients have two major surgical options, modified radical mastectomy or lumpectomy followed by radiation therapy.  From well-planned clinical trials with numerous patients, it is known that these two surgical approaches offer equivalent overall survival, but there are notable exceptions.  Breast conserving surgery does result in increased rates of locoregional recurrence, but this is diminished by the use of radiation therapy to the operative areas postoperatively.  However, there are absolute contraindications to lumpectomy. These contraindications include multicentric disease (two or more primaries in separate quadrants of the breast), diffuse microcalcifications, prior history of radiation therapy, pregnancy, and persistent positive margins. This is the case for this patient who had multifocal disease in the right breast. Local hyperthermia to ablate tumors or locoregional recurrence is considered standard care, but its use on a primary breast tumor before mastectomy is unusual. Thus, hyperthermia (77605 and 77600) provided from 11/03/15 through 12/15/15 was not likely to have been more efficacious than other available treatment modalities. Based upon the information set forth above, the services at issue were 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 1

A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient had a recent transient ischemic attack while flying on an airplane. He was evaluated and has no other reason for transient ischemic attack other than the patent foramen ovale. In addition, the development of the transient ischemic attack symptoms while flying a high altitude makes the patent foramen ovale an even more likely etiology of the symptoms as right heart pressures increase at high altitudes, and the risk of transient deep vein thrombosis is higher as well. This combination (occult deep vein thrombosis with elevated right heart pressures because of lower air pressures) makes the likelihood of paradoxical embolism from increased right to left shunting significantly higher in the setting of a large patent foramen ovale. This adds further credence to the clinical suspicion of the patent foramen ovale being the culprit pathology of the transient ischemic attack in this case. Recent data and meta-analyses suggest that patent foramen ovale closure prevents recurrent crytogenic stroke better than medical therapy alone in patients with no other suspected cause of the stroke and likely transient ischemic attacks as well. Therefore, patent foramen ovale closure is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presented with a transient ischemic attack in the setting of reported hypertensive urgency. There are no other verified transient ischemic attacks and a reportedly normal head computed tomography (CT) scan. In patients with transient ischemic attacks and patent foramen ovales, transcatheter closure has been demonstrated to be of mild benefit only in younger patients without another potential source of transient ischemic attack, such as hypertensive urgency, and mainly in patients with transient ischemic attacks despite antiplatelet medication. This patient does not fit those criteria since there is another potential source and his age is greater than 60. In sum, patent foramen ovale closure is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that based on the recent trials comparing patent foramen ovale closure to antiplatelet therapy, patent foramen ovale closure is superior to antiplatelet therapy for preventing future ischemic events. However, in each of the trials, the patients selected had evidence of definite ischemic infarcts. This patient had only clinical symptoms. Therefore, it is unknown whether antiplatelet therapy alone may be superior or equal to patent foramen ovale closure in this population. If recurrent symptoms/transient ischemic attack recur on antiplatelet therapy, then patent foramen ovale closure would be appropriate in the absence of any other etiology, such as paroxysmal atrial fibrillation. Thus, patent foramen ovale closure is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 19-year-old female enrollee has requested reimbursement for electromyography (EMG) and electroencephalogram (EEG) monitoring during spine surgery performed on 12/05/19. 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 intraoperative neurophysiologic monitoring is the standard of care for intraoperative detection of emerging iatrogenic complications of scoliosis surgery, and to prevent its progression and to possibly reverse it by making adjustments during surgery. The monitoring needs to be total, as in this case. Combined sensory and motor evoked potentials monitoring must be regarded as the least neurophysiological standard for intraoperative detection of emerging spinal cord injury during corrective spinal deformity surgery. Early detection affords the surgical team an opportunity to perform rapid intervention to prevent injury progression or possibly to reverse impending neurologic sequelae. Iatrogenic spinal cord injury is the most feared complication of scoliosis surgery. Based on the medical evidence, the monitoring in this case was medically appropriate. Therefore, EMG and EEG monitoring during spine surgery performed on 12/05/19 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2
A 19-year-old female enrollee has requested reimbursement for electromyography (EMG) and electroencephalogram (EEG) monitoring during spine surgery performed on 12/05/19. 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 comprehensive or multimodal intraoperative neurophysiological monitoring (IONM) is essential in patients undergoing major spinal correction surgery. IONM is considered a standard of care modality that is used to improve safety of surgical deformity correction. EMG provides immediate actionable information in evaluating whether pedicle screw breaches the cortex and impinges on the spinal canal and/or nerve root and also evaluates excessive mechanical spinal distraction. Nerve conduction velocity (NCV) is important in monitoring intraoperative injurious positional pressures, particularly in this case involving a long procedure while in a prone position. Intraoperative EEG changes can occur. These EEG changes can potentially detect what may become an ischemic focal decrease in cerebral blood flow resulting from hypotension in the setting of a stenotic cerebral artery, further establishing EEG modalityas critical importance in IONM. Significant alterations in cerebrospinal fluid pressures, which can occur during major corrective spinal surgery, may also be reflected in EEG waveform. Multimodal IONM also represents the standard of care for these difficult and risky spinal procedures. Therefore, EMG and EEG monitoring during spine surgery performed on 12/05/19 was likely to have been more beneficial than other available standard therapy.