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

Summary Reviewer 




A 67-year-old male enrollee has requested authorization and coverage for Praluent Pen injections. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees diabetes, dyspnea, and a positive coronary calcium score. The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved Praluent as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease, who require additional lowering of LDL cholesterol. However, this patients documented level of cholesterol is not high enough to suspect familial heterozygous hypercholesterolemia, which is diagnosed with LDL over 190. In addition, there is no evidence of clinical atherosclerotic cardiovascular disease (CAD). There are coronary calcifications on CT scan but a normal stress nuclear imaging study, showing no ischemia. Since there is no documented contraindication to treatment with Repatha, which has been authorized by the Health Insurer, the requested Praluent Pen injections are not supported as medically necessary for treatment of this patients hyperlipidemia. Based on the foregoing discussion, 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


A 39-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 9/6/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees breast examination. The physician reviewer found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 9/6/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 39-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 9/6/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees breast examination. The physician reviewer found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed on 9/6/16 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 39-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 9/6/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees breast examination. The physician reviewer found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, while the presence of a nipple discharge is concerning, statistically it is more commonly either physiologic or secondary to a benign etiology. As noted by Patel and colleagues, the cause of nipple discharge is usually benign, so the primary goal of evaluation and management is separation of patients with pathologic causes of discharge from those with benign or physiologic causes. For this reason, tomosynthesis is warranted. This is especially true considering the heterogeneously dense nature of her breasts. It is specifically this type of patient with dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis provided on 9/6/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 7/8/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found the breast tomosynthesis performed on 7/8/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The advantage of tomosynthesis relates to the ability it allows radiologists to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. For this reason the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the exam been done with two-dimensional technique alone.
Based upon the information set forth above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 7/8/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found the digital breast tomosynthesis performed on 7/8/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). Given the support above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 7/8/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found the digital breast tomosynthesis performed on 7/8/16 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two-dimensional (2D) and three-dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the support in the medical literature, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 21-year-old male enrollee has requested reimbursement for a PET scan performed on 7/23/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the records document the rare situation of a high grade soft tissue sarcoma of the heart in a young patient. There is a lack of specific guidelines as to the best way to follow him to detect recurrence. However, there is some literature concerning the use of positron emission tomography (PET) scanning in the follow-up of high grade sarcomas in general. Pastorini and colleagues concluded that PET scan is indeed useful, although Roberge and colleagues cast some doubt on the routine use of PET. Thus, it remains somewhat controversial. However, in this rare circumstance of a very high grade sarcoma in a young patient, PET was likely to have been of benefit to detect and/or rule out recurrent disease. Therefore, PET scan performed on 7/23/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 21-year-old male enrollee has requested reimbursement for a PET scan performed on 7/23/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the current guidelines generally recommend surveillance scans using computed tomography (CT) or magnetic resonance imaging (MRI) every three to six months based on risk of recurrence, and more frequently within the first two years when risk of recurrence is highest (around 80%). As asymptomatic lung metastases can be resected for curative intent, surveillance imaging is recommended. Synovial tumors, such as in this patient, can recur as late as 10 years. Positron emission tomography (PET) scans have been useful in prognosis if done after neoadjuvant chemotherapy, but there is a lack of support for the use of PET scans for surveillance. PET scan for surveillance is unlikely to be more beneficial than standard imaging in patients with soft tissue sarcoma. In sum, PET scan performed on 7/23/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 21-year-old male enrollee has requested reimbursement for a PET scan performed on 7/23/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has a history of synovial sarcoma. According to the National Comprehensive Cancer Network (NCCN) guidelines for soft tissue sarcoma, Positron emission tomography (PET) may be useful to clarify if computed tomography (CT) or magnetic resonance imaging (MRI) are ambiguous. In light of the areas of involvement for this patient, such as the left ventricle, a PET scan was indeed useful. Three months had elapsed since the previous scan. The timing was also appropriate according to the NCCN guidelines. The medical evidence supports the services at issue in this clinical setting. Thus, PET scan performed on 7/23/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 61-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. Non-cirrhotic patients with a viral load below six million IU/mL can be treated with Harvoni for eight weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, Harvoni should be approved as medically necessary based on national guidelines. For the reasons provided, 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 Upheld

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center (RTC) services provided from 11/7/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and anxiety.   The physician reviewer found the records do not demonstrate that this patient reported suicidal or homicidal ideation or demonstrated psychosis during his RTC admission from 11/7/16 forward. The patient had continued symptoms of oppositional behavior and periods of intense emotions but had not engaged in any self-harm behaviors. He was not displaying any significant or severe behavioral problems during the disputed period. Thus, although he needs treatment to further improve his social functioning, impulsive behaviors, and sexual maladaptive behaviors, as of 11/7/16, he no longer required the restrictiveness of a residential psychiatric treatment facility. The records indicate that he has stabilized over the five months of residential care at the facility to support transition to a less restrictive setting. Outpatient treatment and least restrictive options are considered first-lines of care as referenced by The American Academy of Child and Adolescent Psychiatry (AACAP), which recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports (Winters, et al). The treatment goals listed by the residential treatment center could be accomplished on an outpatient basis and are treatment goals that are typically listed for outpatient level of care. Accordingly, the psychiatric RTC services provided from 11/7/16 forward were not and are not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 46-year-old male enrollee has requested authorization and coverage for Repatha. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hyperlipidemia. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The records note a history of hyperlipidemia, intolerance to statin medications and Zetia, but no documented cardiovascular disease. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied only in patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient does not fit either of those categories. There is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. These diagnoses require not only elevated LDL levels that significantly exceed 180 mg/dL, but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a strong family history of coronary disease (younger than 50 years in second-degree relative or younger than 55 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism. PCSK9 inhibitors have not been studied in other patient populations, such as this patient. Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Thus, Repatha is not medically necessary for the treatment of this patient. Therefore, the requested medication is 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 36-year-old female enrollee has requested authorization and coverage for Flex Walk System and multiaxial rotation unit for right leg. The Health Insurer has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees bilateral transtibial amputation. The physician reviewer found that in this case, the patients functional condition is expected to increase by two categories with the addition of the new components. As noted by Armannsdottir and colleagues, following transfemoral amputation numerous changes in movement patterns during gait can occur. The authors reported that six weeks of individualized training with a microprocessor controlled prosthetic foot with active/inactive ankle dorsiflexion resulted in improved gait quality. The requested equipment is expected to allow complete independent function in all ambulatory environments. Given this support, the requested Flex Walk System and multiaxial rotation unit for right leg is supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested equipment 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 60-year-old male enrollee has requested reimbursement for Xiaflex injections performed from 6/24/15 through 8/21/15. 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 submitted documentation establishes the medical necessity of the services at issue. Xiaflex has been shown to have modest efficacy in clinical trials and is U.S. Food and Drug Administration (FDA) approved for patients with Peyronies disease with at least 30 degrees of curvature and a palpable plaque. Xiaflex is the only FDA approved drug for Peyronies disease and this patient is an appropriate candidate for Xiaflex. Therefore, the Xiaflex injections performed from 6/24/15 through 8/21/15 were medically necessary for treatment of the patients Peyronies disease. For the reasons provided, 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 23-year-old female enrollee has requested reimbursement for inpatient hospital stay from 9/06/18 through 9/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient did not meet criteria for acute inpatient admission. She could have been safely and effectively managed under an observational level of care. Patients with uncontrolled diabetes with nausea, vomiting and blood sugars in the 300s do require observation to control blood sugars.  However, acute inpatient admission is required when there is evidence of severe acidosis, evidence of end organ damage, persistent symptoms, electrolyte disturbances or altered mental status. There is no clinical evidence to support the patient meeting any of these requirements. Furthermore, there was no evidence of fetal distress or maternal hemodynamic instability to support acute inpatient admission. Therefore, inpatient hospital stay from 9/06/18 through 9/08/18 was not medically necessary for the treatment of this patient.