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

Summary Reviewer 1

A 61-year-old female enrollee has requested authorization and coverage for endoscopic anti-reflux procedure (LINX). The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that there is sufficient support for the requested services in this patients case.  The U.S. Food and Drug Administration has approved the LINX reflux management system for lower esophageal sphincter augmentation. Appropriate candidates for the procedure include patients with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. This patient meets those specific criteria and in addition has a documented episode of aspiration pneumonia perhaps from a severe reflux event. As such, the medical evidence supports the efficacy of the requested procedure in this clinical setting.  Accordingly, the requested endoscopic anti-reflux procedure (LINX) is likely to be more effective than the standard options for treatment of this patients medical condition. Therefore, for the reasons stated above, the requested procedure is 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 2

A 61-year-old female enrollee has requested authorization and coverage for endoscopic anti-reflux procedure (LINX). The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that the documentation provided supports that this patient has GERD as based on pH recording when off Nexium. However, while it appears on pH testing her symptom correlation with reflux was limited, she has reportedly benefited to a significant degree from acid suppression treatment. Her record documents that symptoms worsened off proton pump inhibitor therapy. As such, she cannot be considered medically refractory to acid blocker drugs. In addition, implantation of LINX in this patients setting must be approached with caution given her documented intestinal metaplasia on esophageal biopsy. Moreover, there is a lack of medical studies in the setting of Barretts esophagus. Accordingly, the requested endoscopic anti-reflux procedure (LINX) is not likely to be more efficacious than the standard methods of treating this patients medical condition.
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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 61-year-old female enrollee has requested authorization and coverage for endoscopic anti-reflux procedure (LINX). The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. Sheu and colleagues in Current Opinion in Gastroenterology, concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration approval (Bauer, et al). One peer reviewed journal published a letter stating that there are 11 reports of endoscopically confirmed LINX erosion through the esophagus in the publicly-accessible U.S. Food and Drug Administration (FDA) Adverse Events database (Bielefeldt, et al). Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al in Surgical Endoscopy). The currently available peer reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment, surgical fundoplication. The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). All told, the requested endoscopic anti-reflux procedure (LINX) is not likely to be more beneficial than the standard methods of treating this patients medical condition. Therefore, for the reasons stated 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 Overturned

Summary Reviewer 


A 19-year-old female enrollee has requested reimbursement for mental health inpatient services provided from 3/23/15 through 8/24/15. 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 considering this patients formidable psychiatric history, significant affective symptoms with psychosis, suicidality and drug use, a conservative hospitalization was reasonably expected to improve her condition and prevent a more serious episode of illness.  However, based on the medical records, services at the acute level of care were only necessary through 5/9/15. Discharge on 3/22/15 would have been premature and more than likely would have resulted in undue morbidity and prompt readmission. The patient was reported to be isolative, hallucinating and picking at her self-inflicted wounds. Her medications were not yet optimized and her disposition was uncertain. Thereafter, the patient struggled with apprehension, anxiety, depression, auditory hallucinations and suicidal ideation. By late-April, a trend of sustained mood improvement began to emerge.  On 4/22/15, her mood was okay with no behavioral dysregulation or skin picking. It was the first day she was described as pleasant rather than depressed. On 4/24/15, the patient was less irritable and not as angry. She was consolidating the notion of conservatorship, taking her medication without issue and participating in all unit activities. In the days that followed she was described as bright and playful. On 4/20/15, placement was pending, suggestive that the illness burden was approaching appropriateness for an alternative setting. By 5/9/15, the prolonged disposition process had declared itself as the primary source of the patients frustration and apprehension.  She was eating well and sleeping well, and maintaining her activities of daily living. She had unimpaired cognitive faculties. Her mood was euthymic. She had not been suicidal or psychotic in nearly three weeks, while her depression had lifted as well. She was adherent with medications which were well tolerated. Although the patients chronicity warranted ongoing treatment, she was no longer suffering from an acute psychiatric syndrome.  Based on the documentation provided, safe, appropriate and adequate treatment could have reasonably been conducted at a less restrictive setting, such as a residential treatment facility, as of 5/10/15.  Thus, mental health inpatient services provided from 3/23/15 through 5/9/15 were medically necessary, but not thereafter. Therefore, 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 


A 21-year-old male enrollee has requested authorization and coverage of Humira pen psoriasis-uveitis 40 mg/0.8 mL pen injector kit. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees plaque psoriasis.
 The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. The records indicate that this patient is a poor candidate for systemic treatments. He not a candidate for treatment with methotrexate as he drinks alcohol and may be trying to conceive a child. He should also avoid a systemic retinoid like Soriatane as he has elevated triglycerides and Soriatane has the side effect of raising triglyceride levels. Cyclosporine is not recommended since this patients medical condition is a chronic disease and there are long term risks with use of cyclosporine. On the other hand, Humira has been shown effective as a treatment option and it has strong safety ratings. Additionally per available data, Humira has better efficacy than methotrexate or cyclosporine in this clinical setting. According to the American Academy of Dermatology and the medical literature, Humira is a standard treatment option for treatment of chronic plaque psoriasis. Humira is also U.S. Food and Drug Administration approved. As such, Humira pen psoriasis-uveitis 40 mg/0.8 mL pen injector kit is medically necessary for the treatment of this patients medical condition. Therefore, based on the information noted above, the requested medication is 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 63-year-old male enrollee has requested authorization and coverage for left total knee replacement. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees knee pain. The physician reviewer found the records document that this patient has clinical and radiographic evidence of osteoarthritis of the left knee with a history of failed conservative treatment for over three years. The surgical criteria include pain, functional alteration, objective findings of deformity, loss of motion, radiological findings of osteoarthritis involving at least two compartments, and failure of conservative treatment. All of these indications have been well documented in this case. As such, the requested left total knee arthroplasty is medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested surgery is 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 patient is a 49-year-old male with a history of lumbar stenosis without neurogenic claudication, lumbar degenerative disc, right sciatica and lumbosacral herniated disc. The patient has requested authorization and coverage for laminotomy with decompression of nerve, including partial facetectomy, foraminotomy and/or excision of herniated disc. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that Held and colleagues concluded that there was strong evidence that surgical treatment is superior to non-operative treatment for elderly patients with degenerative lumbar spinal stenosis. Weinstein and colleagues found that patients with symptomatic spinal stenosis treated surgically maintain substantially greater improvement in pain and function through four years compared to those treated nonoperatively. Jarrett and colleagues reported that their systematic review of the recent literature demonstrates that decompressive surgery is more effective than land-based exercise in the management of lumbar spinal stenosis. However, given the conditions slowly progressive nature and the potential for known surgical complications, they recommended that a trial of conservative management with land-based exercise be considered prior to consideration of surgical intervention. Kovacs and colleagues concluded that decompressive surgery, with or without fusion, was more effective for patients with symptomatic lumbar spinal stenosis than continued conservative treatment when the latter had failed for three to six months. In this case, the records document continued complaints of worsening low back and right lower extremity pain. He has had severe numbness and tingling. There is a grossly positive straight leg raise producing low back pain. MRI documents right paracentral/foraminal disc herniation at L5-S1 measuring 18 x 4 mm, resulting in severe right lateral recess stenosis with compression of the right S1 nerve root. Provided documentation demonstrates subjective and objective deficits that are corroborated by imaging studies. Trial and failure of conservative treatment modalities has been documented. The current medical evidence supports the requested services in this clinical setting. Therefore, laminotomy with decompression of nerve, including partial facetectomy, foraminotomy and/or excision of herniated disc is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 55-year-old female enrollee has requested authorization and coverage for Cambia 50 mg powder packet. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees migraine without aura. The physician reviewer found that Cambia is a powdered form of diclofenac which has been shown to be effective in treating acute migraine. This patients provider states that the patient is unable to use tablets due to nausea. However, Cambia must also be taken orally and is not a parenteral treatment. When nausea is present, then parenteral medication such as sumatriptan nasal spray, zolmitriptan nasal spray, sumatriptan injection, or use of an anti-nausea agent with antimigraine properties such as prochlorperazine are likely to be effective. Overall, the patients records do not document that the patient has used other approved standard therapies. Therefore, the requested Cambia 50 mg powder packet is not medically necessary for treatment of this patients medical condition. Based on the available documentation, the requested medication is 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

The parent of a 13-year-old male enrollee has requested reimbursement for balloon sinus ostial dilation performed on 10/28/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees chronic sinus problems. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  This patient had chronic sinusitis. He underwent the standard of care treatment, which is adenoidectomy. A balloon sinuplasty procedure is a clinically effective procedure for pediatric patients suffering from chronic sinusitis. This has been proven in multiple trials.  All told, balloon sinus ostial dilation performed on 10/28/15 was likely to have been superior over other treatment options.  Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of a 13-year-old male enrollee has requested reimbursement for balloon sinus ostial dilation performed on 10/28/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees chronic sinus problems. The physician reviewer found there is sufficient support for the services at issue in this patients case. The indication for balloon sinuplasty is chronic sinusitis refractory to maximal medical treatment.  Chronic rhinosinusitis was documented in this patient. There was documentation that he was treated with maximal medical therapy prior to the computed tomography (CT) scan. He has been treated with multiple courses of antibiotics and with adenoidectomy, which is the first-line treatment for sinusitis in pediatric patients. Balloon sinuplasty is an effective therapy for chronic sinusitis patients and for pediatric patients.  In sum, balloon sinus ostial dilation performed on 10/28/15 was likely to have been more efficacious than other treatment options.  Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The parent of a 13-year-old male enrollee has requested reimbursement for balloon sinus ostial dilation performed on 10/28/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees chronic sinus problems. The physician reviewer found there is a lack of support for the services at issue in this patients case.  The records noted that the patient had evidence of PANDAS.  This problem was ultimately treated with removal of tonsils and adenoids in July 2015.  The patient apparently had some evidence of nasal and sinus congestion and difficulty breathing through the nose, but there is no mention of adequate medical management of the sinus congestion prior to consideration of any surgical intervention such as inferior turbinate ablation and balloon sinus dilation technology.  Preoperative computed tomography (CT) scan demonstrated that the maxillary, ethmoid and frontal sinuses showed some degree of mild mucus congestion, but there was no evidence of any severe thickening or obstruction of the drainage pathways of the paranasal sinuses. At present, functional endoscopic sinus surgical techniques for the management of chronic rhinosinusitis refractory to medical management is still considered the surgical treatment of choice. Thus, balloon sinus ostial dilation performed on 10/28/15 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested authorization and coverage for Dupixent (dupilumab) 300/2 ml injections. 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 submitted documentation supports the requested medication in this clinical setting. The medical records document longstanding atopic dermatitis which has been recalcitrant to treatment with topical steroids, topical calcineurin inhibitors, prednisone and cyclosporine.  Dupixent has been approved by the U.S. Food and Drug Administration for the treatment of moderate to severe atopic dermatitis in patients aged 12 years and older. This patients condition has been poorly controlled with topical and systemic immunosuppressants. He has had side effects from cyclosporine, necessitating discontinuation. Therefore, Dupixent (dupilumab) injections 300/2 ml are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 27-year-old female enrollee has requested reimbursement for the DecisionDx-Melanoma Assay (CPT code 84999) provided on 3/28/17. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees cutaneous melanoma.   The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma gene assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Assay provided on 3/28/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based on the foregoing discussion, the testing at issue was 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 26-year-old male enrollee has requested authorization and coverage for the LINX reflux management system. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).   The physician reviewer found according to peer-reviewed published literature, there is only one lower esophageal sphincter (LES) augmentation device designed for the treatment of GERD at this time.  The LINX device has been approved for patients diagnosed with GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. Patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. Two post-approval studies are designed to evaluate the long-term effectiveness of the device and incidence of adverse events; however, comparative studies with other anti-reflux surgeries are still needed. While there is some medical literature in support of the use of the LINX device for patients with GERD, appropriate patient selection is crucial before anti-reflux procedures. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach. In this patients case, the records reflect that he has undergone much of this pre-operative assessment and that he has GERD based on pH recording. However, neither his radiographic studies in 2011 nor 2015 evidenced gastroesophageal reflux. As such, he cannot be considered medically refractory given the intermittency of documented reflux. Also, implantation of LINX in this clinical setting must be approached with caution given the patients charted complaint of dysphagia.  As such, the LINX procedure 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.