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

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment center services provided from 2/27/15 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 behavioral health condition. The physician reviewer found this patient has significant impulse control problems, related to his diagnoses of autism, ADHD and cerebral dysrhythmia. He has little insight into the nature of his problems and only seems reluctantly to admit that he could cause significant harm to others and even himself. The progress notes indicate that he still struggles with violent thoughts of raping women he encounters in his environment. The documentation submitted for review indicates that his symptoms are quite severe. In addition, there are few facilities that have the experience and expertise to treat such an individual.  It is unlikely that an outpatient or partial hospital program could meet his needs and also ensure the safety of others in the community. In sum, treatment in a 24-hour facility is clinically indicated for this patient.  Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 55-year-old male enrollee has requested reimbursement for epidural injections of corticosteroid preparations (e.g., Depo-Medrol) with or without added anesthetic agents on 2/02/16 and 2/18/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the patient has a history of lower back pain. Per the records, he has tried and failed conservative treatment, including physical therapy and pain medications, including Norco. The patient reported bilateral leg numbness and pain. Magnetic resonance imaging (MRI) findings showed severe central stenosis at L4-L5, with right-sided severe foraminal stenosis and moderate foraminal stenosis on the left. There was also possible mass effect on the left L4 and L5 nerve roots. The patient underwent lumbar transforaminal epidural steroid injections on 2/02/16 and 2/18/16. There is support for the services at issue in this clinical setting. Epidural steroid injections for lumbar radiculopathy and spinal stenosis is a widely accepted treatment for chronic lower back pain and radicular symptoms for patients that have failed conservative treatment options and/or patients that have undergone spine surgery and still have chronic back pain due to scar tissue and stenosis. In sum, epidural injections of corticosteroid preparations (e.g., Depo-Medrol) with or without added anesthetic agents on 2/02/16 and 2/18/16 were likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 55-year-old male enrollee has requested reimbursement for epidural injections of corticosteroid preparations (e.g., Depo-Medrol) with or without added anesthetic agents on 2/02/16 and 2/18/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports a portion of the services at issue. Specifically, interlaminar epidural steroid injections were likely to have been more beneficial than other treatment options. However, there is a lack of support for transforaminal selective nerve root blocks. The description of these blocks in the operative reports indicates that these blocks were directed towards treating the facet joint pain, which is not the standard approach to the performance of medial branch blocks.  The approach and the quantity of medication utilized would likely result in treating much more than just the medial branches, making this non-diagnostic for facet joint syndrome. Even if the medial branch blocks were done in the standard, generally-accepted fashion, combining them with an epidural steroid injection that contained 5cc of bupivacaine and steroid, would make it impossible to differentiate the results of the various injections, thus making the medial branch blocks non-diagnostic. The primary goal of medial branch blocks is to determine whether radiofrequency ablation of the nerves is likely to result in relief of facet joint pain by demonstrating substantial temporary relief of the low back pain. Therefore, interlaminar epidural steroid injections (62311) were likely to have been more beneficial than other treatment modalities. However, the superior efficacy of the remainder of the services at issue has not been established.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 28-year-old male enrollee has requested reimbursement for sTMS mini device provided on 8/06/18. The Health Insurer has denied this request and reported that the device at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that migraine is a disorder which affects approximately twelve percent of the population. Its severity varies from patient to patient from a benign to a severe debilitating disease state.  This patient has both episodic acute and chronic migraine. Although he has not responded well to Pamelor as well as triptan medications for migraine therapy, there are several other options with good evidence of effectiveness that the patient had not tried and failed in both preventative and abortive categories. While sTMS mini device has shown some effectiveness in migraine, there is a lack of evidence to suggest it is more effective than other established therapies, many of which the patient has not tried. Per the medical evidence, sTMS may be appropriate for patients who respond poorly, cannot tolerate, or have contraindications to pharmacotherapy. At this time, there is a lack of support for the device at issue in this clinical setting. Therefore, sTMS mini device provided on 8/06/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 29-year-old male enrollee has requested authorization and coverage for suction assisted lipectomy of the trunk. 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 grade I gynecomastia with tenderness. Surgery for removal of the small symptomatic breast mass has been approved by the Health Insurer. Authorization is requested for liposuction of the chest area for removal of fatty tissue. Any surrounding fatty tissue is not gynecomastia but pseudogynecomastia, and results in no pain or tenderness. Arya and colleagues noted that True gynecomastia refers to enlarged glandular tissue rather than deposition of fat tissue. Enlargement of breast due to deposition of fat in the breast area is known as pseudogynecomastia. Per the authors, The aims of surgery are: (a) To eliminate painful breast tissue; and (b) To restore the patients chest to acceptable cosmetic shape. The most commonly used technique is subcutaneous mastectomy that involves direct resection of the glandular tissue using a periareolar or transareolar approach, with or without liposuction. Bellini and colleagues stated, In pseudogynecomastia, there is an increased development of the fatty component in the male breast region. In true gynecomastia, however, there is an increase in volume of the male breast gland with a dense fibrous and vascular stroma, which makes suction more difficult. The gynecomastia liposuction treatment is usually associated to a resection under direct vision of the glandular tissue through a periareolar or transareolar incision. Liposuction of the surrounding fat tissue would be for the treatment of pseudogynecomastia and not for the treatment of gynecomastia. Liposuction would be for the purpose of improving the appearance of the chest. Liposuction of the fatty tissue on the chest would be cosmetic surgery and not medically necessary. Therefore, the requested suction-assisted lipectomy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 17-year-old female enrollee has requested reimbursement and prospective authorization and coverage for eating disorder residential treatment center (RTC) services provided from 2/19/18 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 eating disorder. The physician reviewer found that the records provided for review document that this patient presented for admission from another facility with a low BMI. The patients prior care was not adequate to stabilize her weight loss such that she had lost 20 pounds in two months while in treatment. During the beginning of her stay, the patient continued to have difficulty with gaining weight and completing her meals. She required staff supervision and one-to-one care in order to finish her meals. She also required supplementation with liquid dietary supplements and order to maintain her calorie requirements. She was noted to be depressed, withdrawn and minimally interactive with staff and peers. As her treatment has progressed, she has gained weight, but some of her mood symptoms have not resolved. Give this patients history, it is unlikely that less restrictive treatments would be effective for her eating disorder treatment. In the medical literature, Mehler noted that anorexia nervosa is a psychiatric disorder characterized by abnormal eating behaviors that results in weight loss and has serious potential medical consequences. Due to this patients history of mood symptoms, self-harm, suicide attempts, and severe eating disorder behaviors, the eating disorder residential treatment center services provided from 2/19/18 forward were and are medically necessary. Based on the foregoing discussion, the services at issue were and are 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 an eight-year-old male enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. The Health Insurer has denied this request indicating that the requested therapy is not medically for treatment of the enrollees behavioral health conditions.  The physician reviewer found that in this clinical setting, ABA therapy is not medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, a diagnosis of autism has not been established. In addition, there is a lack of peer-reviewed literature supporting ABA therapy for the treatment of generalized anxiety disorder, developmental coordination disorder or adjustment reaction. There is also a lack of research supporting ABA for treatment of behavioral regulation or self-control outside of a diagnosis of autism spectrum disorder. The standard of care for treating generalized anxiety disorder include medications and counseling (Dobson and Strawn; Mohatt, et al).  Moreover, the patient has not been evaluated for autism by a developmental and behavioral pediatrician utilizing Autism Diagnostic Observation Schedule (ADOS) and Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic criteria. Therefore, ABA therapy has not been established as medically necessary for treatment of the patients medical condition. Therefore, the requested therapy 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 Upheld

Summary Reviewer 


A 48-year-old female enrollee has requested reimbursement for residential substance use disorders treatment provided from 5/4/15 through 5/19/15. 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 due to the lengthy history of drinking and increased yet inconsistent reports of consumption, a residentially based detoxification and preliminary introduction to chemical dependency treatment was safe, appropriate and consistent with good medical practice. However, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting as of 5/4/15. There is no evidence of the emergence of any late alcohol withdrawal symptomatologies. It appears that benzodiazepine medication, a common treatment for alcohol withdrawal, was last administered on 4/24/15.  Laboratory analysis revealed mild elevation of hepatic enzymes and a slightly elevated mean corpuscular volume on 4/26/15. Such findings of transaminitis and macrocytosis are not uncommon in drinkers and often resolve rather promptly with sobriety, which is what occurred in this case. Despite the diagnoses of gastroesophageal reflux disease and seasonal/environmental allergies, the patient had an unremarkable physical examination on 4/27/15.  The presence of depression, and anxiety dating back to childhood, were significant but not generating a psychiatric syndrome that warranted treatment in a residential setting. In addition, the patient participated in therapeutic programming which helped erode her treatment ambivalence. On 5/4/15, she had a willingness to participate fully in treatment. Finally, the patient had a safe residence. Her family was described as supportive. She identified two close friendships during her psychosocial assessment. She was motivated for care. Despite the diagnoses of depression anxiety, the patient had no safety concerns. She had no prior history of chemical dependency treatment in a less restrictive setting such as anti-craving medication, community programming, outpatient specialty care, intensive outpatient services or partial hospitalization. There was no evidence to suggest that a less restrictive treatment setting would have been insufficient. Thus, the residential rehabilitation services at issue were not medically necessary for treatment of the patients medical condition. Therefore, 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 Overturned

Summary Reviewer 1


A 38-year-old male enrollee has requested authorization and coverage for cervical disc prosthesis.  The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition.  The physician reviewer found the current medical evidence supports the requested services in this clinical setting.  Davis and colleagues performed a prospective, randomized, controlled multicenter clinical trial on two-level symptomatic degenerative disc disease. Their findings supported the use of cervical arthroplasty at two contiguous levels and demonstrated advantages over two-level anterior cervical discectomy and fusion.  This patient presents with persistent severe neck pain radiating into the left upper extremity consistent with a C6 radiculopathy.  His symptoms are consistent with imaging and electrodiagnostic evidence of radiculopathy at C5-6 and C6-7 with plausible neural compromise.  The use of two-level artificial disc replacement will allow for motion preservation in this case.  All told, the requested cervical disc prosthesis is likely to be superior over other treatment options.  Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 38-year-old male enrollee has requested authorization and coverage for cervical disc prosthesis.  The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition.  The physician reviewer found there is sufficient support for the requested services in this patients case.  The medical literature indicates an initial advantage to cervical disc replacement compared to anterior cervical discectomy and fusion.  However, long-term results appear to demonstrate a slight advantage to total disc arthroplasty.  In their study published in 2015, Davis and colleagues evaluated the safety and effectiveness of two-level total disc replacement using a Mobi-C cervical artificial disc at 48 months follow-up.  The conclusions were that this study continues to support total disc replacement as a safe, effective, and statistically superior alternative to anterior cervical discectomy and fusion for the treatment of degenerative disc disease at two contiguous cervical levels.  Thus, the requested cervical disc prosthesis is likely to be more efficacious than other treatment options.  Therefore, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 38-year-old male enrollee has requested authorization and coverage for cervical disc prosthesis.  The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition.  The physician reviewer found the submitted records fail to demonstrate the superior effectiveness of the requested services.  There are concerns regarding short-term and long-term potential complications of cervical total disc arthroplasty.  The potential long-term complications of cervical total disc arthroplasty include a lack of predictability of individual autoimmune response to metal and methyl methacrylate debris.  If revision is needed after total disc arthroplasty, there may be added difficulty when the devices are removed with resultant large defects requiring complex bone graft procedures.  Revision procedures will have to be performed through tissue which has undergone a fibrotic response with increased risks incurred during the surgical exposures. This patients relatively young age contributes to an increased likelihood of negative effects and long-term complications.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 35-year-old male enrollee has requested authorization and coverage for spine fusion extra segment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the patient is a 35-year-old male with a history of low back pain.  On 2/09/15, the medical records noted pain radiating down right lower extremity of three months duration.  The documentation indicated a history of right L5-S1 microdiscectomy in September 2013.  The provider noted that magnetic resonance imaging (MRI) of the lumbar spine performed in December 2014 showed recurrent disc herniation at L5-S1 with narrowing of right lateral recess.  The patient reported that two epidural steroid injections did not improve his symptoms.  He has requested coverage for spine fusion extra segment.  The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient. The submitted records fail to demonstrate the superior efficacy of the requested services.  A multilevel fusion for degenerative disc disease is not likely to be beneficial in this patients case.  In the absence of instability, for the management of failed spinal surgery syndrome, the medical evidence supports a combination of physical therapies and cognitive therapies rather than a surgical intervention.  All told, the requested spine fusion extra segment is not likely to be superior over other treatment options.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 35-year-old male enrollee has requested authorization and coverage for spine fusion extra segment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the patient is a 35-year-old male with a history of low back pain.  On 2/09/15, the patient reported low back pain radiating to the right lower extremity of three months duration.  He was status post right L5-S1 microdiscectomy in September 2013. The provider noted that magnetic resonance imaging (MRI) from December 2014 showed a recurrent disc herniation at L5-S1 with narrowing of the right lateral recess.  He was going to physical therapy, which was not helping.  Examination revealed antalgic gait with use of a cane, 5/5 strength to the lower extremities, sensation intact and deep tendon reflexes were 2+ and symmetric.  The patients diagnoses included right S1 radiculopathy and recurrent L5-S1 disc herniation.  On 2/19/15, computed tomography (CT) scan of the lumbar spine demonstrated right L5-S1 herniated disc similar to what might be anticipated from the MRI of December 2014. There was mild annular bulge at L4-5 without focal herniation, spinal stenosis or significant foraminal stenosis.  The provider reports that due to evidence of significant degenerative changes and signs of potential instability at L4-5, the L4-5 would be included in the fusion construct.  Previously, single level fusion at L5-S1 with intervertebral body space was approved by the Health Insurer.  The patient has requested coverage for spine fusion extra segment.  The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient. The medical records do not support revision lumbar surgery including decompression and fusion L4 through S1.  In 2013, this patient underwent L5-S1 decompressive surgery and now has a recurrent disc and radicular complaints both subjectively and objectively.  There is evidence on MRI of recurrent disc herniation.  The current medical evidence does not support extending the fusion through L4 or L5 levels as there is no disc pathology at those levels other than disc desiccation.  There is no evidence of flexion/extension instability.  Thus, the superior efficacy of the requested spine fusion extra segment has not been established.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.