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

Summary Reviewer 


A 38-year-old male enrollee has requested authorization and coverage for suction assisted protein lipectomy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for treatment of the enrollees lymphedema. The physician reviewer found the patient as longstanding lymphedema of the right lower extremity that has caused significant functional impairment as his condition has progressed. He complains of pain and difficulty with normal activity, including ambulation. He has undergone extensive conservative management of his condition, including complex congestive therapy with compression, bandaging and manual lymphatic drainage. He has also undergone medical management of his pain, chiropractic treatment, acupuncture and physical therapy.  This has failed to treat his condition. The photographs are supportive of his documented enlarged right lower extremity. Liposuction is a well-known therapy for lipodystrophy and has been shown to provide possible functional improvement in lymphedema. This patient has failed nonoperative current standard of care management. Lymphedema liposuction is a procedure that can likely improve his current condition. Thus, the requested suction assisted protein lipectomy is medically necessary for the treatment of this patient. Therefore, the requested services are 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 50-year-old male enrollee has requested authorization and coverage for Korlym 300 mg tablets. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. Meningiomas are more commonly positive for progesterone receptors than for estrogen receptors. Several studies have been conducted on long-term oral therapy of unresectable meningiomas with the antiprogesterone mifepristone (RU486). In the study by Grunberg and colleagues, fourteen patients received mifepristone in daily doses of 200 mg for periods ranging from two to greater than 31 months (greater than or equal to six months in 12 patients). Five patients demonstrated signs of objective response (reduced tumor measurement on computerized tomography scan or magnetic resonance imaging, or improved visual field examination). Three patients experienced subjective improvement (improved extraocular muscle function or relief from headache). The side effects of long-term mifepristone therapy were noted to have been mild. The authors noted that long-term therapy with mifepristone may have efficacy in cases of unresectable benign meningioma. There is sufficient support for the requested medication in this clinical setting. Therefore, Korlym 300 mg tablets are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 

A 54-year-old female enrollee has requested authorization and coverage for cingulotomy. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollee, who has been diagnosed with metastatic renal cell carcinoma. The physician reviewer found that the submitted records fail to demonstrate the superior efficacy of the requested services. The patient has widespread metastatic renal cell carcinoma. Her prior treatment has included surgery, radiation therapy and chemotherapy. She has pain for which she is using large doses of MS Contin and oxycodone. The records noted widespread, non-localizing pain. The clinical notes do not document if she is a candidate for a spinal cord stimulator to treat her pain. There is a lack of large, randomized, prospective, controlled studies demonstrating the long-term efficacy and safety of cingulotomy and laser interstitial thermal therapy for chronic diffuse pain. At this time, further studies are warranted to establish the efficacy of the requested services in this clinical setting. Therefore, the requested cingulotomy is not likely to be superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 48-year-old female who has been diagnosed with ulcerative colitis status post colostomy and J-pouch, complicated by chronic pouchitis, and anemia. She has had pouchoscopy several times. The physician reviewer found that fecal calprotectin testing is supported for the management of patients with ulcerative colitis to prevent invasive interventions, such as colonoscopy. A randomized, prospective, controlled trial in ulcerative colitis performed by Lasson and colleagues showed lower relapse rate than control when using calprotectin to direct management with medications. Another prospective study by Scaioli and colleagues demonstrated the utility of calprotectin to lead decision-making in patients with ulcerative colitis. The test allowed for assessment of ulcerative colitis disease activity without colonoscopy. American College of Gastroenterology guidelines state, Fecal calprotectin (FC) can be used in patients with ulcerative colitis as a noninvasive marker of disease activity and to assess response to therapy and relapse. Additionally, the use of the test is supported by extensive literature for the reliable assessment of pouchitis and pouchitis disease activity level. In this case, the patient had ongoing symptoms and anemia despite treatment, consistent with uncontrolled disease activity. Therefore, fecal calprotectin assay performed on 4/19/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 45-year-old female enrollee has requested authorization and coverage for transforaminal epidural injection of the lumbar or sacral (CPT codes 64483 and 64484). The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees chronic low back pain.  The physician reviewer found that based on the presented clinical records submitted for review, transforaminal epidural injection of the lumbar or sacral (CPT codes 64483 and 64484) is medically necessary for treatment of the patients medical condition. There is sufficient peer-reviewed literature supporting the requested service in this clinical setting. Manchikanti and colleagues show good evidence with the use of transforaminal epidural injections in managing disc herniation and radiculitis. According to the documentation submitted for review, a repeat transforaminal epidural steroid injection of the lumbar spine is clinically indicated due to the patients return of pain which was identical to the pain prior to the previous injection. In addition, the provider has documented appropriate patient response to the previous injections with more than 80% pain relief of symptoms and leg pain lasting for over 10 months. After the previous injections the patient did not require pain medications and has had adequate conservative treatment including physical therapy. For the reasons provided, the requested service has been established as medically necessary for treatment of the patients medical condition. Therefore, the requested service 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 43-year-old female enrollee has requested authorization and coverage for left arthroscopy, hip surgical with femoroplasty (treatment of cam lesion), left arthroscopy, hip surgical with acetabuloplasty (treatment of pincer lesion). The Health Insurer has denied this request and reported that the requested services are not medically necessary for treatment of the enrollees hip pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this clinical setting. Harris and colleagues concluded that the outcomes of operative treatment of femoroacetabular impingement are significantly better than nonsurgical management. Surgical treatment significantly improves outcomes, with no consistent significant differences exhibited between open and arthroscopic techniques. In this case, the patient presents with an approximate one-year history of constant and progressively worsening left hip and groin pain. Significant functional limitations are noted in activities of daily living. Clinical examination findings have been consistent with radiographic and imaging evidence of a left hip femoroacetabular impingement with cam and pincer lesions. She has failed over six months of conservative treatment, including activity modification, anti-inflammatory medications, and physical therapy. X-rays findings document no signs of joint space narrowing, and are reportedly consistent with Tonnis grade 0. Current evidence-based medical guidelines and peer-reviewed literature support surgical management of femoroacetabular impingement syndrome when non-surgical treatment methods fail and specific criteria have been met. The medical evidence supports the requested services in this clinical setting. All told, the requested left arthroscopy, hip surgical with femoroplasty (treatment of cam lesion), left arthroscopy, hip surgical with acetabuloplasty (treatment of pincer lesion) are medically necessary for the treatment of this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 61-year-old male enrollee has requested reimbursement for physical therapy services performed from 8/27/15 through 12/5/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of low back pain, knee pain and bilateral arm numbness. The physician reviewer found that the medical evidence has not demonstrated the superior efficacy of the services at issue in this clinical setting.  Huang and colleagues noted that cupping therapy is promising for pain control and may improve the quality of life but the research shows that that cupping in the treatment of low back pain requires further research. In a meta-analysis by Yuan and colleagues, they were unable to draw definitive conclusions as to the superior efficacy of gua sha, and other forms of Chinese manipulations in treating disability associated with chronic neck pain or chronic back pain. In addition, their study could not substantiate the efficacy of tui na and moxibustion over other forms of therapy. Moreover, there was a lack of sustained, significant, objective, functional improvement or quantifiable response to the physical therapy services in this patients case. In sum, the physical therapy services provided between 8/27/15 and 12/5/15 were not likely to have been superior to other forms of therapy for the treatment of this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 2


A 61-year-old male enrollee has requested reimbursement for physical therapy services performed from 8/27/15 through 12/5/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of low back pain, knee pain and bilateral arm numbness. The physician reviewer found that there is sufficient support in the efficacy for the treatment modalities in this clinical setting. The care provided was reported as leading to functional improvement, not as a single application of one modality (cupping), but as being complementary to manual therapy, massage and myofascial release therapies. The providers choice to include cupping in the treatment plan was to increase blood flow, soften scarring and improve circulation leading to reduced pain and to increased function was an appropriate plan of care given the reported chronicity of the patients condition and the addressed functional deficits found upon clinical evaluation. All told, the physical therapy services provided between 8/27/15 and 12/5/15 were likely to have been more effective than the other standard options for treatment of this patient. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 61-year-old male enrollee has requested reimbursement for physical therapy services performed from 8/27/15 through 12/5/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of low back pain, knee pain and bilateral arm numbness. The physician reviewer found that there is a lack of medical studies to show the efficacy of the services at issue in this clinical setting. A review by Yuan and colleagues provided some evidence to show that acupuncture, acupressure, and cupping could be efficacious but they could not draw definite conclusions. Their study consisted of over seventy five randomized controlled trials with over 11,000 patients evaluated. Another study also showed cupping could be promising for pain control and improvement of quality of life, and minimizes the potential risks of treatment (Huang, et al). However, further studies were recommended in order to analyze the potential role of cupping therapy in the treatment of low back pain. In a study by Arguisuelas and colleagues, they could not determine if myofascial treatment showed any clinical significance. In addition, this patient has had extensive treatment of acupuncture with ancillary therapies but the records do not indicate a clear improvement of functional benefit. Although the services at issue show some promise as treatment modalities for pain, more studies are recommended. As such, the physical therapy services provided between 8/27/15 and 12/5/15 were not likely to have been more effective than the available standard treatment options for this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 45-year-old female who had been trying to conceive for greater than six months, without success. Her work-up was suggestive of diminished ovarian reserve. The patient has requested reimbursement for infertility services provided from 2/08/19 through 2/11/19. The physician reviewer found that infertility is defined as a condition in an individual who is unable to conceive or produce conception during a period of six months in a female over the age of 35 years. In this case, in vitro fertilization would not be considered medically necessary due to its low likelihood to achieve pregnancy in a then 44-year-old patient. Increasing maternal age negatively impacts the live birth rate after embryo transfer when the patients own eggs are used. This effect is particularly pronounced for women age 40 and greater. After age 43, the Centers for Disease Control and Prevention indicates that the probability of live birth is 5.7 percent. Thus, many clinics will not provide in vitro fertilization to women using autologous oocytes after the 44th birthday when the live birth rate declines further to 4.6 percent. Thus, infertility services provided from 2/08/19 through 2/11/19 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 55-year-old female enrollee has requested authorization and coverage for bariatric surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees morbid obesity. The physician reviewer found that submitted documentation supports the medical necessity of the requested services in this patients case. This patient meets the standard criteria for bariatric surgery, including the American Society for Metabolic and Bariatric Surgery criteria. The patient has a body mass index which is greater than 35 kg/m2. Specifically, the records documented a body mass index of 60.53 kg/m2. The patient has more than one comorbid condition related to obesity. The patient has completed a multidisciplinary evaluation that did not reveal any obvious dietary or behavioral barriers. Medical clearance, support and attestation of prior failed weight loss efforts were provided. The medical evidence supports the requested services in this clinical setting. Thus, the requested bariatric surgery is medically necessary for the treatment of this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 54-year-old female enrollee has requested reimbursement for the shingles vaccine performed on 2/06/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of rheumatoid arthritis. The physician reviewer found the herpes zoster vaccine is recommended for people age 60 years and older by the Centers for Disease Control. Patients with a diagnosis of rheumatoid arthritis who are on methotrexate, steroids, azathioprine or 6-mercaptopurine or are expected to receive high level immunosuppressive therapy are eligible to receive the vaccine if they are greater than 50 years of age. This patient does not qualify under these criteria. The diagnosis of rheumatoid arthritis or lichen planus in itself is not an indication for vaccination.  In sum, the shingles vaccine performed on 2/06/17 was not likely to have been superior over other treatment options in this patients case.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 54-year-old female enrollee has requested reimbursement for the shingles vaccine performed on 2/06/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of rheumatoid arthritis. The physician reviewer found the varicella-zoster virus causes two clinically distinct forms of infection.  Herpes zoster is related to reactivation of varicella-zoster virus infection and is characterized by a painful, unilateral vesicular eruption in a dermatomal distribution. The herpes zoster vaccination can decrease the risk of developing herpes zoster and post-herpetic neuralgia associated with infection.  The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of all patients 60 years of age or older, including patients who report a previous episode of zoster and patients with chronic medical conditions (such as chronic renal failure, diabetes mellitus, rheumatoid arthritis, chronic pulmonary disease), unless those conditions are contraindications. In clinical practice, the vaccine is recommended for patients between 50 and 59 who are receiving low-level immunosuppressive therapy or are expected to receive high-level immunosuppressive therapy or for patients that would have difficulty tolerating a zoster infection. In this case, the patient has multiple skin conditions including lichen planus, herpes simplex virus, and atopy, and she has been diagnosed with rheumatoid arthritis. Rheumatoid arthritis is treated with immunosuppressive medications that would leave the patient vulnerable to infections. Given this patients rheumatoid arthritis and skin conditions, it was appropriate to vaccinate this patient. Therefore, the shingles vaccine performed on 2/06/17 was likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 54-year-old female enrollee has requested reimbursement for the shingles vaccine performed on 2/06/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of rheumatoid arthritis. The physician reviewer found that although the shingles vaccine is approved for adults over the age of 50, it is generally not recommended until over the age of 60 due to concerns regarding long-term effectiveness. There is some advice regarding earlier administration in patients who would not be expected to tolerate a shingles outbreak, such as patients with a chronic skin condition or chronic pain. This patient is not in this category. In addition, it is recommended for patients over the age of 50 who are receiving immunosuppressive therapy. In this patients case, the medical records do not indicate she is receiving immunosuppressive therapies for the treatment of her rheumatoid arthritis. The current guidelines do not suggest earlier administration of the vaccine on the basis of rheumatoid arthritis. Thus, the shingles vaccine performed on 2/06/17 was not likely to have been more efficacious than other available treatments. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.