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

Summary Reviewer 


A 59-year-old male enrollee has requested authorization and coverage for cryosurgical ablation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for treatment of the enrollees thymoma. The physician reviewer found that thymoma is the most common primary tumor of the anterior mediastinum and often recurs after initial surgical resection.  In patients with recurrent disease and inability to perform further resections due to lack of pulmonary reserve or unresectability of the metastatic disease, cryotherapy may serve as a useful adjunct to chemotherapy and radiation therapy. A recent review article by Abtin and colleagues noted that percutaneous cryoablation shows promise as a safe and effective treatment modality for recurrent thymoma.  The relative rarity of this diagnosis limits the availability of large scale, prospective clinical trials.  However, current medical literature cites a high success rate for long-term tumor ablation. A recent review article by Zhang and colleagues noted that, In conclusion, cryotherapy is a safe and efficient method for the treatment of unresectable malignant thymoma. Thus, the requested cryosurgical ablation is medically necessary for 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 Upheld

Summary Reviewer 


A 51-year-old male enrollee has requested reimbursement for home healthcare services which include intravenous infusion of ceftriaxone, Benadryl, associated supplies and office visits with Miguel Gonzalez, MD from dates of service 9/11/15 through 12/09/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient has a long history of a variety of non-specific complaints.  The clinical evidence and the laboratory studies provided for review do not support a diagnosis of any tick borne diseases or Lyme disease.  The Borrelia burgdorferi serologies completed in March 2015 are negative.  In spite of this, the provider ordered intravenous ceftriaxone.  This drug is recommended for Lyme disease associated arthritis, carditis or neurological disease.  The records do not document that this patient had the rash typical of early Lyme disease, and his reported symptoms are not suggestive of this diagnosis.  In sum, home healthcare services which include intravenous infusion of ceftriaxone, Benadryl, associated supplies and office visits with Miguel Gonzalez, MD from dates of service 9/11/15 through 12/09/15 were not medically indicated 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 59-year-old male enrollee has requested authorization and coverage for Testim (testosterone gel 1%). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypogonadism. The physician reviewer found that low testosterone can lead to complications including reduced libido, erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis, depressed mood and fatigue (Dandona and Rosenberg). For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL (Nieschlag, et al). The general target level for testosterone ranges from 350 to 750 ng/dL, which is the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal and the dose of testosterone replacement therapy should be adjusted accordingly (Rivas, et al). Given these findings, the requested Testim (testosterone gel 1%) is medically necessary for treatment of this patients hypogonadism. Based on the foregoing discussion, the requested medication is 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 1


The parent of a two-year-old male enrollee has requested reimbursement for FirstStepDX Plus chromosomal microarray analysis.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that array-based comparative genomic hybridization has become standard of care to investigate children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies. Until recently, it was a diagnostic test that was employed when the first-line investigation of karyotype (chromosome analysis) returned normal; over the last several years it has emerged as a first-line investigation.  This test has become an important and mainstream tool in the practice of clinical genetics. Its diagnostic utility had been convincingly demonstrated.  Data have now emerged showing that actionable findings from chromosomal microarray justify its use. In sum, FirstStepDX Plus chromosomal microarray analysis was likely to have been of greater benefit than other methods of evaluating this patient.  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


The parent of a two-year-old male enrollee has requested reimbursement for FirstStepDX Plus chromosomal microarray analysis.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the patient is a two-year-old male who was born at 38 weeks gestation following a pregnancy significant for hyperemesis requiring frequent antiemetic therapy and preterm labor at 32 weeks gestation requiring modified bed rest. He suffered an event prior to discharge characterized by choking followed by desaturation to the 20s with subsequent resuscitation efforts.  Persistent transaminitis lead to liver biopsy at eight weeks of age and a diagnosis of giant cell hepatitis.  He had difficulties with feeding, colic, and delayed achievement of usual gross motor milestones.  He currently receives physical therapy with ongoing gross motor delays.  Neurologic examination in March 2015 revealed increased deep tendon reflexes in his lower extremities, intermittent exophoria bilaterally, moderately decreased tone globally, inability to stand unassisted, and microcephaly. At that time, chromosomal microarray testing and fragile X testing were performed.  The Health Insurer has denied reimbursement for FirstStepDX Plus chromosomal microarray analysis.  Per the Health Insurer, FirstStepDX Plus chromosomal microarray analysis was investigational for the evaluation of this patient. The current medical evidence supports the services at issue in this patients case.  Use of chromosomal microarray testing now plays a central role in the evaluation and diagnosis of children with global developmental delay, cognitive delay, and autism spectrum disorders (ASD).  Use of buccal sampling is an acceptable means of obtaining material for study.  According to the literature, when coupled with a chromosomal microarray that contains single nucleotide polymorphic probes, analysis of buccal cells can maximize a clinicians opportunity to detect cytogenetic mosaicism. Based on the literature and current standard of practice, the services at issue were likely to have been superior over other methods of evaluating this patient.  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


The parent of a two-year-old male enrollee has requested reimbursement for FirstStepDX Plus chromosomal microarray analysis.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that CMA is increasingly utilized for genetic testing of individuals with unexplained developmental delay/intellectual disability, autism spectrum disorders, or multiple congenital anomalies.  CMA offers a much higher diagnostic yield for genetic testing of patients with unexplained developmental delay/intellectual disability, autism spectrum disorder, or multiple congenital anomalies than the previous standard testing with G-banded karyotype, primarily because of its higher sensitivity for submicroscopic deletions and duplications.  Available evidence strongly supports the use of CMA in place of G-banded karyotyping as the first-tier cytogenetic diagnostic test for patients with developmental delay/intellectual disability, autism spectrum disorders, or multiple congenital anomalies.  Given that the standard of care is now CMA, the FirstStepDx Plus chromosomal microarray was likely to have been of greater benefit than other methods of evaluation.  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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 42-year-old female enrollee has requested authorization and coverage for Remodulin (treprostinil) injections. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees pulmonary arterial hypertension. The physician reviewer found that there is support in the medical literature and guidelines for the requested medication in this clinical setting. Remodulin (treprostinil) belongs to the Prostacyclin analog drug class. Based on recommendations from the 2015 European Society of Cardiology (ESC)/ European Society of Cardiology (ERS) guidelines for the diagnosis and treatment of pulmonary hypertension, Prostacyclin analogues are appropriate therapy in particular combination with phosphodiesterase inhibitors and endothelin receptor antagonists. In a study by Simonneau and colleagues, the effects of treprostinil in PAH were assessed in a randomized clinical trial. These patients showed improvements in exercise capacity, hemodynamics and symptoms. Some of the evidence from combination therapy indicate a reduced risk of clinical worsening and other significant endpoints. According to the submitted record, this patient has stabilized with reductions in pulmonary artery pressures and symptoms on her current regimen of combination therapy, which includes subcutaneous infusions of treprostinil. For these reasons, Remodulin (treprostinil) injections are medically necessary for treatment of this patients medical condition. Therefore, based on the above, 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 43-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) therapy from 10/23/15 through 11/24/15. 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 that there is support for a portion of the services at issue in this clinical setting. The patient began TMS therapy on 8/21/15 with a PHQ9 of 27/27, indicating a severe level of depression. Over the course of TMS treatment, the documentation noted that her depression lifted, as reflected by her subsequent PHQ9 scores and subjective reports. By 10/23/15, she reported significant improvement with a PHQ9 of 5/27. On 10/7/15, she received TMS session #30, and on 10/28/15 she received TMS session #6 of tapering.   The documentation noted that the Health Insurer had approved 30 TMS sessions with an additional six for tapering. The sessions from 10/23/15 through 10/28/15 were medically necessary, as she showed improvement while in active treatment. However, the services from 10/29/15 through 11/24/15 were not medically necessary for treatment. There is a lack of evidence, in the body of literature, to support the medical necessity of continued long term TMS treatment, in this patients case. As such, the TMS sessions from 10/23/15 through 10/28/15 were medically necessary but not thereafter. Therefore, for the reasons stated above, 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 39-year-old female enrollee has requested authorization and coverage for Simponi injections 100 mg/ml.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriatic arthropathy. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records document a history of psoriasis and psoriatic arthritis.  In this case, the recent notes indicate that the patient was not currently taking methotrexate as prescribed since at least November 2016.  Per the records, she had responded to methotrexate and Otezla in the past and had stopped Simponi at that time. There is currently a lack of guidelines or large randomized controlled trials which recommend the use of a tumor necrosis factor inhibitor, like Simponi, in combination with Otezla.  The records fail to demonstrate that she has failed treatment with a tumor necrosis factor inhibitor in combination therapy with methotrexate, or Otezla with methotrexate. As such, the request for Simponi in combination with Otezla is not medically necessary.  Thus, the requested Simponi injections 100 mg/ml are not medically indicated for the treatment of this patient.  Thus, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 65-year-old male enrollee has requested reimbursement for collagen crosslink testing performed on 7/11/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found Osteoporosis is a condition of thinning of the bones which leads to increased risk of fracture.  Bone mineral density assessment, via dual-energy x-ray absorptiometry (DEXA), is the standard for evaluation and diagnosis of osteoporosis.  However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients who are treated with antiresorptive agents.  The medical evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine.  There is sufficient support for the services at issue in this clinical setting.  All told, collagen crosslink testing was likely to have been superior over other treatment options.  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 65-year-old male enrollee has requested reimbursement for collagen crosslink testing performed on 7/11/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  The National Osteoporosis Foundation approves the use of biochemical markers of bone turnover as a tool to investigate causes of osteoporosis and then as a follow-up test to monitor response and compliance with antiresorptive therapy.  This test may be done to assess response to therapy sooner than the one- to two-year follow-up dual-energy x-ray absorptiometry (DEXA) scan study that quantifies response in bone density measurements.  In this case, the test provided information regarding the response to Prolia therapy. The significant reduction of the C-telopeptide level is consistent with excellent response to antiresorptive therapy with Prolia.  In sum, collagen crosslink testing performed on 7/11/15 was likely to have been of greater benefit than other methods of evaluating this patient.  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 65-year-old male enrollee has requested reimbursement for collagen crosslink testing performed on 7/11/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  This patient has received Prolia.  In this clinical setting, a dual-energy x-ray absorptiometry (DEXA) scan is appropriate to monitor therapy.  The value of monitoring therapy with the use of biochemical markers of bone turnover is controversial.  This is a test that can be variable and subject to timing, dietary intake and lack of assay standardization.  In sum, collagen crosslink testing performed on 7/11/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 61-year-old man with low back pain and radiating symptoms.  The patient has requested authorization and coverage for spinal surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. In this case, the patient has mechanical low back pain with radiating symptoms to the thighs. Although his examination was normal, imaging showed significant spondylolisthesis. The medical literature indicates that patients with mechanical back pain associated with spondylolisthesis have superior outcomes when treated with lumbar fusion. Therefore, the requested spinal surgery is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a three-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient mental health treatment for children and adolescents provided from 12/31/18 through 6/29/19. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 2 due to the patients history of impulsive behaviors. In terms of functional status, the records support a score of 2. The patient has had deterioration in expected level of functioning in relationships with peers, adults and family, and he is struggling with serious daily behavioral issues. In terms of comorbidity, the records support a score of 1. The patient does not have medical problems or substance use. With regards to level of stress of the recovery environment, the records support a score of 3. The patient has problematic issues with family relationships. In terms of level of support of the recovery environment, the records support a score of 2. The patients family actively participates in treatment, although their relationship appears to be strained. With regards to resiliency and treatment history, the records support a score of 3 due to recent minimal progress in the intensive outpatient program. In terms of acceptance and engagement of the child, the records support a score of 3. The patient participates minimally. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 18. The score correlates with intensive outpatient program services. Therefore, intensive outpatient mental health treatment for children and adolescents provided from 12/31/18 through 6/29/19 was and is medically necessary for the treatment of this patient.