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

Summary Reviewer

The patient is a 15-year-old male with a history of short stature. Per the submitted documentation, he underwent growth hormone stimulation testing in 2010, which showed that he was sufficient in growth hormone production. In March 2016, the predicted adult height was calculated to be 62.5 with the chronological age of 12 years and bone age of 12 years 6 months. The mid-parental height is 68.5. The records noted pretreatment growth velocity of 4.8 cm per year, which was low.  He was started on growth hormone therapy on 5/11/16 due to growth failure or low growth velocity and poor height prediction. The patients parent has requested coverage for Nutropin AQ. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The submitted documentation supports the medical necessity of the requested medication. The U.S. Food and Drug Administration has approved the use of growth hormone therapy for idiopathic short stature or non-growth hormone-deficient short stature defined as height standard deviation less than or equal to -2.25 or less than or equal to 1.2nd percentile for age and gender. This patient had improvement in growth velocity to 7.6 cm per year. This patient meets the criteria for idiopathic short stature. He was prescribed growth hormone therapy and has shown good response to growth hormone treatment with adequate monitoring and minimal side effects. The medical evidence supports the requested medication in this clinical setting. Thus, Nutropin AQ is medically necessary for the treatment of this patient. Therefore, 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 38-year-old female enrollee has requested reimbursement for oral device/appliance provided on 11/27/17. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollee, who has been diagnosed with sleep disordered breathing, periodic limb movement disorder, and insomnia with sleep apnea. The physician reviewer found that the submitted documentation supports the medical necessity of the device at issue. The patient was noted to have a diagnosis of obstructive sleep apnea. She opted for an oral appliance as a first-line therapy for her condition. The published joint practice guidelines of the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) noted we recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy.  Okuno and colleagues performed a systematic review and meta-analysis of five studies assessing the effectiveness of an oral appliance for the treatment of obstructive sleep apnea.  The authors found that an oral appliance decreased the apnea-hypopnea index as compared with a sham device. In this setting, given that a diagnosis of obstructive sleep apnea has been established, the use of an oral appliance was medically appropriate. Thus, the oral device/appliance provided on 11/27/17 was medically necessary for the treatment of this patient. Therefore, the device at issue was 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 38-year-old male enrollee has requested reimbursement for Truvada 200/300 mg, 30 tablets for 30 days, provided on 10/03/17. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollee, who had a potential exposure to human immunodeficiency virus (HIV). The physician reviewer found that the current medical evidence supports a portion of the medication at issue. The records document that the patient was exposed to HIV infected blood. Recommendations from Centers for Disease Control and Prevention and the U.S. Public Health Service note 28 days of treatment is recommended in this setting.  Thus, Truvada 200/300 mg, 28 tablets was medically indicated. There is a lack of support for the quantity provided in this patients case. In sum, Truvada 200/300 mg, 28 tablets, was medically necessary for the treatment of this patient. Therefore, a portion of the medication at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


The parent of a 13-year-old female enrollee has requested reimbursement for homocysteine testing performed on 12/31/15. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees behavioral health condition. The physician reviewer found the testing at issue was not likely to be more beneficial than any standard therapy available. There has been some research in non-traditional treatment of ADHD utilizing standard randomized double-blinded studies; however, research studies that have correlated the role of homocysteine levels to the diagnosis and treatment of ADHD or treatment of anger issues are lacking. A study by Kim and Lee looked at whether homocysteine has been associated with cognitive impairment and various psychiatric symptoms; however, the authors, did not discuss homocysteine testing and its benefit in managing either ADHD or anger. All told, the homocysteine test was not likely to be more beneficial for evaluating the patients ADHD or anger issues than any available standard therapy. Based upon the information set forth above, the testing 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


The parent of a 13-year-old female enrollee has requested reimbursement for homocysteine testing performed on 12/31/15. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees behavioral health condition. The physician reviewer found the homocysteine testing has been used to assess vitamin B12 deficiency, lack of folic acid in the diet, hypothyroidism, certain cancers and Alzheimers disease.  In this clinical setting, the patients parent and her provider requested the test to assist in the treatment plan for the patients ADHD. In order to render a diagnosis of ADHD there must be symptoms of inattention and/or hyperactivity-impulsivity that are chronic or long-lasting, impair the persons functioning, and cause the person to fall behind normal development for his or her age. Evidence based studies are lacking in correlating homocysteine levels with ADHD. Due to the lack of scientific data demonstrating or correlating homocysteine levels to ADHD and its treatment, the test at issue was not likely a better marker than available standard therapies. Based upon the information set forth above, the requested testing 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


The parent of a 13-year-old female enrollee has requested reimbursement for homocysteine testing performed on 12/31/15. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees behavioral health condition. The physician reviewer found the homocysteine testing is not a standard therapy recognized for treatment of ADHD. While a study by Karababa and colleagues was aimed at evaluating the homocysteine levels and oxidative stress parameter in patients with ADHD, that study only involved 32 adult ADHD patients. Moreover, the study concluded that oxidative balance is not impaired in adult ADHD patients and homocysteine levels were found to be lower (Karababa et al).  Due to the lack of peer-reviewed literature to support the use of this test in evaluating and treating the patients ADHD symptoms, the test at issue was not likely to be more beneficial than available standard therapies. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 59-year-old female who has requested reimbursement for a cold cap for chemotherapy provided from 1/02/19 through 12/31/19.  The patient has requested reimbursement for a cold cap for chemotherapy. The Health Insurer has denied this request and reported that the device at issue was not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.The physician reviewer found that there is sufficient support for the device at issue in this clinical setting. Chemotherapy-induced alopecia is a symptom that results from the treatment of cancer. It is what many cancer patients state makes them feel like they have cancer and affects quality of life. In this patients case, use of the cold cap was supported by her provider. There are no other acceptable alternatives. U.S. Food and Drug Administration (FDA) clearance of scalp cooling devices has been extended to cover patients with all solid tumors, and extensive data exists to support this use. More than 60 percent of patients receiving taxanes will develop grade 1 alopecia. Scalp hypothermia has been used in more than 30 countries to prevent or reduce chemotherapy-induced alopecia, with variable success reported depending on the specific cooling device and type of chemotherapy. However, use with taxanes has been efficacious. Scalp cooling is now listed as an option for alopecia prevention in the National Comprehensive Cancer Network (NCCN) guidelines for breast cancer. Therefore, the cold cap for chemotherapy was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 16-year-old transgender male enrollee has requested reimbursement for mental health residential treatment services provided from 9/15/14 through 10/10/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees depression, anxiety and gender dysphoria. The physician reviewer found that this patient has required various inpatient and residential treatment placements but continued to deteriorate once he was transitioned to a lower level of care. It appears that he had experienced such deterioration prior to the RTC admission at issue. The patient was dealing with complicated issues that included disclosing to his family that he was transgendered and then developing coping strategies to address his gender dysphoria. To appropriately address this patients issues and prevent relapse, continued treatment through discharge on 10/10/14 was indicated. Overall, the summary of treatment provided by the attending physician and therapist indicate that the patient was receiving appropriate medical and psychiatric treatment, and that he was benefiting from this treatment and improving. For these reasons, the mental health RTC services provided from 9/15/14 through 10/10/14 were medically necessary for treatment of this patients medical condition. In summary, 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 51-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 10/16/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy. The current medical evidence does not support the services at issue in this clinical setting. Therefore, DecisionDx-Melanoma assay performed on 10/16/18 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 33-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation (64568 and 0466T). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has obstructive sleep apnea, and he is status post septoplasty. Drug-induced sleep endoscopy showed no concentric collapse at velum. The patient has not been able to tolerate continuous positive airway pressure (CPAP) therapy. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. This patient is a candidate for the Inspire device as he has failed CPAP therapy, and his body mass index and apnea-hypopnea index are within the range of pivotal FDA studies. Therefore, the requested hypoglossal nerve stimulation (64568 and 0466T) is likely to be more effective than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 33-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation (64568 and 0466T). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. The records do not document what measures were used to make continuous positive airway pressure (CPAP) usage tolerable. There is no record of compliance studies to demonstrate the effectiveness of his CPAP usage. Further guidance and follow-up has been shown to be successful in helping patients adhere to CPAP therapy. The patient also may be a candidate for an oral appliance. Oral appliances have been shown to be highly successful for the treatment of patients with mild and moderate obstructive sleep apnea. In sum, the requested hypoglossal nerve stimulation (64568 and 0466T) is not likely to be superior over other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 33-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation (64568 and 0466T). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the requested services in this patients case. The records document an apnea-hypopnea index of 22.3. The patient has been unable to tolerate continuous positive airway pressure. Clinical studies of the use of hypoglossal nerve stimulation indicate that patients benefit from this device when they have a body mass index (BMI) less than 32. This patient has a BMI of 21.3. Per the medical evidence, selective upper airway stimulation is a safe and effective therapy for patients with obstructive sleep apnea and represents a powerful option for its surgical treatment. Woodson and colleagues noted long-term improvements and demonstrated that adverse events were uncommon. Thus, the requested hypoglossal nerve stimulation (64568 and 0466T) is likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 33-year-old female who had preconception genetic carrier screening with her spouse.Both were found to be carriers of a cystic fibrosis (CF) gene mutation. The physician reviewer found that the basis of screening patients pre-conception for CF among other conditions is to provide actionable information to avoid having an affected child. This was done in this case, and provided the impetus to pursue what is currently the best option to avoid having a child with CF. In vitro fertilization with prenatal genetic screening essentially avoids the risk of having to terminate an affected pregnancy, or having a child with a serious lifelong and ultimately fatal condition. The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion on pregnancy counseling notes, Couples at risk of having children with specific genetic diseases can be counseled about the disease inheritance and course and offered referral for potential interventions, such as preimplantation genetic testing. It recommends screening of all women who are planning a pregnancy for this reason. The ACOG Committee Opinion on Identification and Referral of Maternal Genetic Conditions in Pregnancy states, Patients with established causative mutations for a genetic condition, and who desire prenatal genetic testing, should be offered preimplantation genetic testing with in vitro fertilization by a reproductive endocrinologist. There is sufficient support for the requested services in this clinical setting. Therefore, the requested embryo transfer is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 47-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 12/15/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees melanoma. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines states while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of this testing was not likely to have altered treatment and surveillance recommendations. Thus, DecisionDx-Melanoma assay performed on 12/15/17 was not medically necessary for the evaluation of this patient. Therefore, 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 46-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 1/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found the addition of digital breast tomosynthesis to screening diagnostic mammograms has gained wide acceptance by providers. This is due to the tomographic features of this particular technique allowing providers to eliminate overlapping tissue and gain a clearer picture of the breast parenchyma which in turn has led to increased detection of small cancers and a decrease in callbacks. For this reason the addition of the technique to the mammographic views is likely to be of more benefit to the patients than digital mammography alone. As such, the services at issue were likely to be more beneficial than standard modalities.Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 46-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 1/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found there is a lack of evidence in the peer-reviewed literature that supports the use of breast tomosynthesis compared to currently available techniques. Although digital breast tomosynthesis is a promising technology, there is a lack of peer-reviewed literature supporting its use in this clinical setting. Therefore, the breast tomosynthesis performed on 1/21/15 was not likely to be more beneficial than standard modalities. 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 46-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 1/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found the breast tomosynthesis performed on 1/21/15 was not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The study by Howard and colleagues states Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase reassurance in ruling out malignancy. In this case, the patients routine imaging studies as well as the sonogram was negative. Her breasts were described as having scattered fibroglandular elements, and were not dense. In addition, her studies were unchanged when compared to prior mammograms. In addition, breast pain is rarely associated with breast cancer, especially without a recognizable mass. If there had been a recognizable mass seen on the mammogram or sonogram, there may have been an indication for tomosynthesis. For the reasons provided, in this clinical setting the breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities.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.