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

Summary Reviewer 

The patient is a 51-year-old male who presented to his provider on 5/11/21 for evaluation of chronic low back pain with associated acute bilateral L5-S1 radiculopathy. The patient has requested authorization and coverage for MRI of the lumbar spine. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. According to the American College of Radiology, if lower back pain persists after four to six weeks of conservative management, and the patient is a surgical or intervention candidate, then MRI of the lumbar spine is the usually appropriate next exam. This patient presented with low back pain with associated radiculopathy symptoms. He failed conservative management in the past per the patientas provider, including physical therapy. Therefore, MRI of the lumbar spine is an appropriate exam and could change the patientas management, which may include surgical intervention or interventions such as pain management. Therefore, the requested MRI of the lumbar spine is medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 35-year-old female enrollee has requested reimbursement for homocysteine testing provided on 6/05/18 and 7/16/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who had a history of miscarriage. The physician reviewer found that Homocysteine testing is not recommended as part of the investigation for pregnancy loss.  In order to initiate an investigation for pregnancy loss, there should be a demonstration of recurrence. This patient has not had recurrent pregnancy loss. Even in the case of recurrent pregnancy loss, checking the level of homocysteine is not recommended.  There is no clinical utility to this evaluation.  All woman are advised to take adequate folate in the form of diet or supplement. The homocysteine level would not impact this recommendation. Therefore, homocysteine testing provided on 6/05/18 and 7/16/18 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 35-year-old female enrollee has requested reimbursement for homocysteine testing provided on 6/05/18 and 7/16/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who had a history of miscarriage. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The American College of Obstetricians and Gynecologists noted that testing for inherited thrombophilias in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence. Although there may be an association in these cases, there is insufficient clinical evidence that antepartum prophylaxis with unfractionated heparin or low molecular weight heparin prevents recurrence in these patients. The only superseding issue would be if the patient had a personal history of venous thromboembolism or a first-degree relative with a history of high-risk thrombophilia. No such history is presented in this case. In sum, homocysteine testing provided on 6/05/18 and 7/16/18 was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 35-year-old female enrollee has requested reimbursement for homocysteine testing provided on 6/05/18 and 7/16/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who had a history of miscarriage. The physician reviewer found that the current medical evidence does not support the services at issue in this patients case. Recurrent miscarriage is defined as three or more consecutive miscarriages. In this patients case, the records document one miscarriage. Even if she had such a history, this testing is not recommended. According to the American College of Obstetricians and Gynecologists Practice Bulletin Number 197, because of the lack of association between either heterozygosity or homozygosity for the MTHFR C677T polymorphism and any negative pregnancy outcomes, including any increased risk of venous thromboembolism, screening with either MTHFR mutation analyses or fasting homocysteine levels is not recommended. The American College of Obstetricians and Gynecologists does not recommend homocysteine testing in non-pregnant or pregnant women. Thus, homocysteine testing provided on 6/05/18 and 7/16/18 was not likely to have been of greater efficacy than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 36-year-old male enrollee has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request indicating that the device at issue was considered investigational for evaluation of the enrollee, who reported palpitations. The physician reviewer found that the patient is a 36-year-old male who reported palpitations. He was evaluated with a 30-day event monitor which demonstrated an episode of atrial fibrillation lasting 30 seconds. The patients provider recommended an implantable loop recorder to assist with treatment planning given the risks of bleeding if anticoagulation was initiated. The patient has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request and reported that the device at issue was investigational for the evaluation of this patient. There is a lack of support for the device at issue in this patients case. The medical evidence does not support an implantable loop recorder for monitoring for atrial fibrillation burden in this clinical setting. The use of an implantable loop recorder is supported if the patient has had cryptogenic stroke or recurrent syncope and has had negative results of external electrocardiogram monitoring. This patient was shown to have a 30-second episode of atrial fibrillation on the initial event monitor performed. In sum, the implantable ambulatory event monitor provided on 12/28/17 was not likely to have been superior over other available methods of evaluating this patient. Based upon the information set forth above, the device 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 17-year-old transgender female enrollee has requested reimbursement for gender reaffirming surgery performed on 7/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The records document a history of gender dysphoria. The Health Insurer denied reimbursement for gender affirming surgery performed on 7/26/18. The Health Insurer noted that coverage is provided for this procedure for patients who are 18 years of age or older, and this patient was 17 years of age at the time of surgery. World Professional Association for Transgender Health (WPATH) recommendations are flexible, taking into account the best interests of the patient. There has been considerable experience with transgender youth having vaginoplasties under age 18. In fact, it is often a better time, while the child is still living with parents, who can care for her in the perioperative period. This patient has a long history of stable transgender identity, and the experts caring for her felt that she had the maturity to make the decision to have vaginoplasty, and that it was in her best interests to have the surgery at age 17 rather than waiting until 18. Thus, gender reaffirming surgery performed on 7/26/18 was 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 Overturned

Summary Reviewer 

The parent of a six-year-old male enrollee has requested reimbursement and prospective authorization and coverage for mental health applied behavioral analysis from 1/13/19 through 7/13/19 (30 hour per week one-to-one therapy and H0031, 6 hours per month). The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The treatment authorization request included over 35 goals, most being social in nature. The purpose of supporting the patient in the educational settings is to provide training on social interactions with typical/same aged peers in a more naturalistic setting. The Behavior Analyst Certification Board (BACB) highlights that services are provided in multiple locations, including school settings, to promote generalization and maintenance of treatment gains. Further, the number of goals identified necessitates the treatment intensity described. The medical evidence supports the services at issue in this clinical setting. Therefore, mental health applied behavioral analysis from 1/13/19 through 7/13/19 (30 hours per week one-to-one therapy and H0031, six hours per month) was and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 58-year-old female enrollee has requested reimbursement for the anesthesia services provided on 11/1/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees gastritis.   The physician reviewer found that the patient is an ASA status II, non-emergent patient who underwent evaluation with an upper endoscopy with MAC services. The records provided for review document the patients medical history includes low blood pressure. Sohn and Ryu concluded that many procedures in and outside of the operating room, including eye surgery, otolaryngologic surgery, cardiovascular procedures, pain procedures, and endoscopy are performed with MAC to increase patient and operator satisfaction. However, a history of low blood pressure is not a medically indicated condition to warrant MAC for an upper endoscopy. All told, the anesthesia services provided on 11/1/16 were not medically necessary for evaluation of this patients gastritis.  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

A 59-year-old female enrollee has requested reimbursement for the computed tomography (CT) scan performed on 11/17/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees risk of coronary artery disease. The physician reviewer found that although there is ample data demonstrating how coronary calcium scoring can provide incremental risk stratification, to date there is a lack of data which assess the benefit of this technology in terms of interventional outcomes. Given that this patient is currently treated with a statin as well as antihypertensive therapy, it is unlikely that coronary calcium scoring would provide meaningful benefit or significant alteration in medical management. Therefore, the CT scan performed on 11/17/16 has not been established as 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 diagnostic procedure 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 Upheld

Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for the computed tomography (CT) scan performed on 11/17/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees risk of coronary artery disease. The physician reviewer found that although there is some research showing an association of coronary artery calcium with risk of heart disease, the American College of Cardiology (ACC) has not endorsed this as a Class I recommendation for screening for heart disease. The ACC guidelines emphasize standard risk assessment formulations such as the Framingham score and the fasting lipid panel. According to the American Heart Association recommendations for screening in women The role that novel [cardiovascular disease] CVD risk biomarkers (e.g., [high-sensitivity C-reactive protein] hsCRP or advanced lipid testing) and imaging technologies (e.g., coronary calcium scoring assessment) should play in risk assessment and in delineation of appropriate preventive interventions is not yet well defined. For these reasons, the CT scan performed on 11/17/16 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 diagnostic procedure 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 Upheld

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for the computed tomography (CT) scan performed on 11/17/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees risk of coronary artery disease. The physician reviewer found that based on the records provided for review, the patient is a 59-year-old female with increased coronary risk but no documented symptoms or objective findings concerning for coronary ischemia. In this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including screening coronary CT scanning. Treatment change or addition based on the results of screening with coronary CT scanning has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Therefore, the CT scan performed on 11/17/16 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 diagnostic procedure 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 54-year-old female enrollee has requested reimbursement for monitored anesthesia care provided on 10/6/14. 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 review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the services at issue. According to the American Society of Anesthesiologists (ASA), monitored anesthesia care is a planned procedure during which the patient undergoes local anesthesia together with sedation and analgesia. When there is documentation in the patients medical record that specific risk factors or significant medical conditions are present, monitored anesthesia care is clinically indicated. Some factors or significant medical conditions may include patients with potential for difficult intubation and/or ventilation with a mask, at risk for airway obstruction, increased risk for complication due to severe co-morbidity, American Society of Anesthesiologists (ASA) class III physical status or greater, history of myocardial infarction, history of stroke, insulin dependent diabetes, poorly controlled disorders, asthma, psychiatric disorders, dysrhythmias, patients with chronic degenerative neurologic diseases which may cause difficulty swallowing or pose a risk for muscle weakness and respiratory failure, morbid obesity or extremes of age such as older than 70 years or younger than 18 years of age. In this case, the patient had no significant past medical history to indicate that monitored anesthesia care was medically necessary. During a screening colonoscopy for a healthy adult, the standard of practice is for the endoscopy nurse, under the guidance and supervision of the gastroenterologist, to monitor vital signs and pulse oximetry and administer sedation/analgesia, with medications such as midazolam and fentanyl. For the reasons provided, 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 Upheld

Summary Reviewer 1

A 36-year-old female enrollee has requested reimbursement for AmnioMatrix or BioDMatrix injectable, 1 cc provided on 2/01/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who underwent open reduction and internal fixation. The physician reviewer found that the operative note dated 2/01/18 advises that a 10 mm and 12 mm 2.0 Synthes screw was utilized to fixate the fracture. The operative note indicated that excellent fixation and anatomic reduction was achieved. No other pathology was noted in the operative note that would require additional measures to improve healing. Furthermore, amniotic membranes and other graphs similar to this are authorized for the use of ulcerations of the skin. In this particular case, it was utilized in between a deep and superficial closure after a fracture fixation. While the literature on amniotic grafts do demonstrate promise when utilized for skin ulceration closure, there is a lack of support for the services at issue in this clinical setting. Therefore, AmnioMatrix or BioDMatrix injectable, 1 cc provided on 2/01/18 was not likely to have been more effective 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 36-year-old female enrollee has requested reimbursement for AmnioMatrix or BioDMatrix injectable, 1 cc provided on 2/01/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who underwent open reduction and internal fixation. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The medical evidence has not demonstrated that AmnioFix graft was likely to be more effective than any other available standard therapy.  Further study is warranted to fully understand the efficacy of this treatment method. In sum, AmnioMatrix or BioDMatrix injectable, 1 cc provided on 2/01/18 was not likely to be of greater benefit than other available 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 3

A 36-year-old female enrollee has requested reimbursement for AmnioMatrix or BioDMatrix injectable, 1 cc provided on 2/01/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who underwent open reduction and internal fixation. The physician reviewer found that the superior effectiveness of the services at issue has not been established. There is a paucity of substantive research supporting the use of AmnioFix graft in this setting. The medical evidence has not demonstrated that the use of AmnioFix is more efficacious than standard techniques. The use of these types of products is poorly researched at this time. Thus, AmnioMatrix or BioDMatrix injectable, 1 cc provided on 2/01/18 was not likely to have been more effective than other 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 41-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/02/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the current medical evidence does not support the services at issue in this clinical setting.  The records do not demonstrate the clinical rationale for this testing.  The patient has been exposed to other biologics in the same class.  Anser IFX testing is not standard of care in this clinical setting.  All told, Anser IFX testing performed on 4/02/15 was not likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.