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

Summary Reviewer 


The parent of a 17-year-old female enrollee has requested reimbursement for residential mental health treatment provided from 1/28/15 through 3/21/15.  The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community settings optimize treatment gains.  In this patients case, she evidenced functional impairment from anxiety, mood symptoms and characterological influences.  Further complicating matters, this concerning confluence of pathology occurred in context of impulsivity and impaired family dynamics.  The patients illness burden was escalating despite outpatient services.  Based on the lack of significant clinical improvement, treatment at the time could not have reasonably been conducted in a setting less restrictive than the residential level of care while less intensive treatment would have resulted in inadequate care.  Moreover, the residential placement was recommended by a child psychiatrist following a failed attempt of outpatient treatment.  Thus, admission to the residential facility was safe, appropriate and consistent with good medical practice.  The services provided at the facility included trusted, evidence-based interventions that were indicated, such as dialectical behavior therapy, group therapy, family therapy and pharmacotherapy.  Finally, the services and setting were reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, residential mental health treatment provided from 1/28/15 through 3/21/15 was medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 48-year-old female enrollee has requested reimbursement for CPT codes 64483 and 64484 provided on 10/11/16. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollees lumbar radiculitis. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. There is no documentation of detailed neurologic physical examination, trials of physical therapy, home exercise program, chiropractic care, or other conservative therapies. Per the records, there is a lack of documentation of trial of conservative therapies. There is no documentation of the results of the first or second transforaminal epidural steroid injections, as is the standard of care.  There is a lack of support for the services at issue in this clinical setting.  All told, CPT codes 64483 and 64484 provided on 10/11/16 were not medically necessary for the treatment of this patient. 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 Upheld

Summary Reviewer 1


A 56-year-old male enrollee has requested reimbursement for the Cologuard test provided on 12/1/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that the Cologuard test provided on 12/1/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Colorectal neoplasms shed DNA in the stool from which the DNA can be isolated and tested for the presence of mutations and epigenetic changes acquired during carcinogenesis. Cologuard, which is a second generation stool DNA test combines stool DNA testing using a gene amplification technique to allow detection of low frequency mutations with increased sensitivity for advanced adenomas, for patterns of DNA methylation with testing for hemoglobin (Ahlquist, et al). Imperiale and colleagues compared stool DNA test with a fecal immunochemical test (FIT) in persons at average risk for colorectal cancer. The authors found that the sensitivity for colorectal cancer of the stool DNA and FIT tests were 92.3% and 73.8% respectively. Given the support in the peer-reviewed literature, the testing at issue has been established as 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 testing 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 Upheld

Summary Reviewer 2


A 56-year-old male enrollee has requested reimbursement for the Cologuard test provided on 12/1/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that conventional assessment of colorectal cancer risk largely involves detection of non-dysplastic adenomatous polyps. Cologuard is a stool DNA test that includes molecular assays for DNA mutation and methylation biomarkers (KRAS mutations, NDRG4, and BMP3 methylation) and a non-DNA immunochemical assay for human hemoglobin (e.g. FIT). Given the low sensitivity of Cologuard in detecting adenomas, the assay is not likely to be more beneficial for evaluation of the patients medical condition than the gold standard colonoscopy. Further, the records submitted for review do not support that the patient is contraindicated to more effective screening strategies. 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 3


A 56-year-old male enrollee has requested reimbursement for the Cologuard test provided on 12/1/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that the Cologuard test provided on 12/1/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Cologuard is U.S. Food and Drug Administration (FDA) approved to test for colon cancer, proved 92% sensitive for detection of colon cancer, and can detect most adenomas with high-grade dysplasia (Imperiale, et al). The limited evidence for Cologuard reports that 154 patients would have to be screened to find one cancer using colonoscopy, versus 166 patients using Cologuard, thus cancers may be missed by Cologuard (Imperiale, et al). Additionally, the evidence of the impact of this information on patient care or health outcomes is lacking. Although Cologuard is able to determine that cancer has already developed, it cannot detect or remove polyps or precancerous lesions. Health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer. In addition, there is a lack of consensus in clinical guidelines and peer-reviewed literature to support that Cologuard has a positive impact on health outcomes. Given the limited support in the peer-reviewed medical literature, Cologuard was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 66-year-old male who presented with anterior mediastinal mass measuring 3.6 cm
mass with calcifications. On 7/10/20, he underwent a computed tomography (CT) guided biopsy
of the mass which revealed no evidence of malignancy with benign thymic tissue. The physician reviewer found that the Current National Comprehensive Cancer Network (NCCN) guidelines state that thymoma should
be treated in 60-70 Gy in 1.8 Gy to 2 Gy fraction sizes. The provider has stated his intention of
treating to 70 Gy. Thus, only 35 fractions are considered medically necessary, which would treat
the patient with 2 Gy per day. There is no benefit to treating this tumor at 1.8 Gy per day which
would prolong the entire treatment course by four fractions. In cases of patients requiring doses of
70 Gy to the mediastinum or chest, it is typically standard to treat in 2 Gy fraction sizes. There is
a lack of medical literature to suggest that treatment with 1.8 Gy per day over 2.0 Gy per day is
associated with improved toxicities or improved outcomes. Consensus group guidelines also
support use of 35 fractions in this setting. Therefore, an additional four fractions (treatment
sessions) of IMRT is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 63-year-old female who presented to her provider on 4/30/20. The patient has requested authorization and coverage for surgery of the left shoulder. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that Osteoarthritis of the acromioclavicular joint is a frequent cause of shoulder pain and can result in significant disability. Although the treatment is usually conservative, surgery may be necessary if conservative treatment is not effective and there is documented severe pathology and the pain source can be confirmed. In this case, there is a history of pain, failed conservative treatment, large osteophytes on the MRI scan, clinical evidence of localized tenderness over the acromioclavicular joint, and evidence of a type 2 acromion with impingement syndrome. Conservative treatment for impingement syndrome has also not been effective. This patient meets the criteria for surgical management of the persistent acromioclavicular joint arthritis. Additionally, she also has failed conservative management of anterior shoulder impingement for six months and there is evidence of a type 2 acromion and narrowed supraspinatus outlet. Therefore, the requested surgery of the left shoulder is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 35-year-old male enrollee has requested authorization and coverage for HP Acthar Gel 80 units. The Health Insurer has denied this request indicating 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 medical necessity of the requested medication. Acthar gel has been approved by the U.S. Food and Drug Administration for multiple sclerosis relapses. In this case, the patient is unable to take traditional corticosteroids due to prior side effects. He has benefitted from Acthar gel. The medical evidence supports the requested medication in this clinical setting. Therefore, HP Acthar gel 80 unit/ml vial is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 30-year-old female enrollee has requested authorization and coverage for Butrans.  The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees pain. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. The Health Insurer has denied coverage for Butrans. The Health Insurer requires history of failure or intolerance to the step one alternative drugs. These are Belbuca, tramadol extended release, and morphine sulfate controlled release tablets. In this patients case, a trial of Belbuca is medically appropriate and reasonable.  Belbuca is the same drug as the patient is requesting, but in a form that dissolves in the buccal cavity.  It is approved by the U.S. Food and Drug Administration for treating severe pain.  Similar to Butrans, Belbuca has been shown to have efficacy and safety in chronic pain patients. Additional studies support the efficacy of Belbuca in this clinical setting.  All told, Butrans 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 21-year-old male enrollee has requested authorization and coverage for Consentyx Pen 150 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees severe plaque psoriasis.  The physician reviewer found that Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation (Marji, et al). Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus (Patel, et al). Cosentyx selectively binds to IL-17A, inhibiting its interaction with the receptor, thus inhibiting its downstream effects on keratinocytes in plaque psoriasis (Reich, et al). In addition, Cosentyx is approved by the U.S. Food and Drug Administration (FDA) for treatments of such patients (Gohil). The patient has severe, disseminated, chronic plaque psoriasis that requires systemic treatment. He has failed treatment with standard therapies including Dovonex, Taclonex, and methotrexate. Thus, the requested Cosentyx Pen 150 mg is medically necessary for treatment of this patients psoriasis. Consistent with these findings, 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 56-year-old male enrollee has requested authorization and coverage for Xiaflex. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the request for Xiaflex is medically necessary for treatment of the patients medical condition. Xiaflex has been shown to have modest efficacy in clinical trials and is U.S. food and Drug Administration (FDA) approved for use in 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. This patient has failed conservative therapy and is an appropriate candidate for treatment with Xiaflex. Given the above, the medical necessity for Xiaflex has been established for treatment of the patients Peyronies disease. 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 27-year-old female enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient psychiatric rehabilitation services provided from 9/3/15 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 schizoaffective disorder.  The physician reviewer found the patient is gravely disabled by her mental illness and has required multiple psychiatric hospitalizations. She had florid psychosis and planned to kill a family member. As such, a conservative hospitalization to improve her condition and prevent a more serious episode of illness was to be expected. Discharge prior to 9/28/15 would have been premature and more than likely would have resulted in undue morbidity, unnecessary risk to the community and prompt readmission as the illness burden that prompted the admission had not yet resolved. The patient had been described as labile, uncooperative, irritable, agitated, delusional, disorganized and homicidal. Convincing her to take medication was an arduous process. On 8/29/15, she was agitated, illogical and needed intramuscular administration of an antipsychotic medicine to address her psychosis. On 8/30/15, she was fixated on needing a vaporizer to deliver marijuana to temper her homicidality. On 8/31/15, she was refusing medication, hostile, aggressive and threatening. However, the psychiatric progress notes did reflect the emergence of durable improvement and by 9/28/15 there was no mention of medication changes, tolerability issues or non-adherence. The patients energy improved while her sedation waned. The patient consistently denied any suicidality, homicidal ideation or hallucinations. In addition, there was no report of disruptiveness on the unit. In the absence of any clinical documentation after 9/28/15, the patient had achieved a level of stability that would be conducive for ongoing specialty care in a less restrictive setting. All told, the acute inpatient psychiatric rehabilitation services provided from 9/3/15 through 9/28/15 were medically necessary for treatment of this patients medical condition, while services from 9/29/15 forward were not and are not medically necessary. In conclusion, 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 58-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 12/28/15.  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 that the breast tomosynthesis performed on 12/28/15 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The American College of Radiology (ACR) has urged the tomosynthesis be removed from the investigational category due to the advantages this tomographic technique provides radiologists interpreting mammograms. This technique often allows the radiologist to separate dense glandular elements from underlying mass/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 (2D) protocol was likely of more benefit for the patient than had her mammogram been done using 2D technique only. 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 Overturned

Summary Reviewer 2


A 58-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 12/28/15.  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 that the services at issue were 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 medical literature cited above, 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 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 Overturned

Summary Reviewer 3
A 58-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 12/28/15.  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 that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. However, in this case there were no problems to be resolved. The patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. A routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there have been no changes when compared to prior studies. All told, the breast tomosynthesis performed on 12/28/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Based upon the information set forth above, the 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.