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

Summary Reviewer 3

The patient is a 63-year-old male with an elevated prostate-specific antigen (PSA) of 10. A computed tomography (CT) scan of the abdomen and pelvis dated 8/21/17 showed a large prostate, thick bladder with calculi, intermittent hematuria, large calcifications, and left low pole bladder stone of 1.5 cm. On 8/24/17, a transrectal ultrasound and magnetic resonance imaging (MRI) of the prostate, guided needle placement, prostate biopsy, and a cystolitholapaxy revealed the prostate was enlarged with a volume of 45 mL, biopsy was negative, and the bladder was moderate to severely trabeculated with multiple saccules and small diverticula with a stone of 1.5 x 2.5 cm. In a progress note dated 11/27/17, the provider reported that the patients PSA was above 10 and recommended the Uroflow procedure. The patient has requested authorization and coverage for a prostatic urethral lift implant. The Health Insurer has denied this request indicating that the requested surgical procedure is considered investigational. The UroLift procedure has been shown to be successful in treating symptomatic benign prostatic hyperplasia (BPH) without adversely affecting a patients quality of life. Based on the current literature, the prostatic urethral lift can be considered as an option for symptomatic BPH patients with small or medium size prostates defined as 80 mL or less without median lobe enlargement, who failed or are intolerant to medical therapy and wish to preserve their sexual function. However, this patient was treated for irritative urinary symptoms related to bladder stone. His symptoms have markedly improved after removal of the bladder stone and are controlled while on medication. Therefore, the requested prostatic urethral lift implant is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Based upon the information set forth above, the requested procedure is 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 39-year-old female who underwent anterior cruciate ligament (ACL) reconstruction on 4/12/21.  The patient has requested authorization and coverage for knee arthroscopy (CPT codes 29856, 29875 and 29884). 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 fails to demonstrate the medical necessity of the requested services. In this case, the treating provider is requesting arthroscopic surgery with multiple codes for the treatment of continued pain after ACL reconstruction. The examination does not demonstrate any consistent objective findings that indicate ongoing internal derangement. The MRI shows no evidence of anterior scarring, which can cause pain with full extension after ACL reconstruction. The anterior cyclops lesion is a well-known surgical indication for postoperative ACL range of motion loss; however, it is not present in this case. Anterior knee pain can be an expected complication after the reconstruction surgery in some patients. Therefore, the requested for knee arthroscopy (CPT codes 29856, 29875 and 29884) is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested reimbursement for adolescent mental health residential treatment services with New Vision Wilderness, an out-of-state wilderness program, provided from 11/01/19 through 2/10/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had serious risk of harm, due to significant impulsivity, with poor judgment and insight, and this was significantly endangering to himself or others. He had been punching walls, hitting mother and transport team member. In terms of functional status, the records support a score of 4. The patient had serious functional impairment, due to serious deterioration of interpersonal interactions, with consistent conflict as well as sporadic school attendance. With regard to comorbidity, the records support a score of 4. The patient had uncontrolled substance use that posed a serious threat to health. In terms of level of environmental stress, the records support a score of 3. The patient had a moderately stressful environment, due to estrangement from his father, conflict with his mother, and school difficulties. With regard to level of support of the recovery environment, the records support a score of 2. The patients mother was involved in treatment and treatment planning. In terms of resiliency and treatment history, the records support a score of 3. The patient had a lack of improvement at lower levels of care, and refused to attend intensive outpatient program treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The patient was incompletely engaged, due to minimization of the problems caused by his substance abuse, refusal to participate in intensive outpatient program, and initial resistance to being transported to the wilderness program. Therefore, the patient has a total score of 23. Due to serious risk of harm, the recommended level of care is medically monitored residence-based services. In this case, the therapeutic services offered at the wilderness program (individual and group therapy) are not different from those offered at other residential treatment programs. The fact that they took place in a wilderness milieu does not mean that they are not evidence-based. Therefore, adolescent mental health residential treatment services with New Vision Wilderness, an out-of-state wilderness program, provided from 11/01/19 through 2/10/20 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
 
A 55-year-old male enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that transcranial Magnetic Stimulation (TMS) is a noninvasive brain stimulating procedure utilized in the treatment of major depressive disorder. The procedure is approved by the United States Food and Drug Administration. TMS tends to be very well tolerated with fewer barriers than electroconvulsive therapy. Further, subsequent to the FDA recommendation, the American Psychiatric Association (APA), investigated this treatment and the available literature.  The outcome of the investigation in 2010 was APA endorsement of TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  The standard of care does not require multiple medication trials and pharmacologic augmentation prior to TMS therapy. Likewise, even though this patient more than likely meets criteria for severe depression as he has most of the symptoms. He has an observable disability, in his case, the inability to work. The treatment is not limited to a certain specifying characterization of the depressive episode.  The APAs endorsement for TMS therapy is a compelling determination supporting its use for treatment of major depressive disorder. 
In this particular case, the patients affective illness is not disputed.  He has pursued, but not exhausted, other standard therapies used to combat depression.  Thus, common alternatives may also be considered medically necessary as defined by the Health Insurer.  However, considering the medical records, endorsement from the APA and the expanding peer reviewed literature base, TMS represents a safe, appropriate treatment consistent with good medical practice that is reasonably expected to improve the patients condition and prevent a more serious episode of illness.  As such, TMS is medically necessary for the treatment of this patients behavioral health condition. 
Therefore, for the reasons stated above, 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 53-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient had an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Newer prognostic molecular techniques should not replace standard staging procedures per the National Comprehensive Cancer Network guidelines. In addition, 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, either as a standard of care or as part of clinical trials. Therefore, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 53-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index is believed to add a bit to these prognostics. DecisionDx-Melanoma gene expression testing is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the risk of recurrence at five years. Gerami and colleagues reported on 217 cases, with good correlation between DecisionDx-Melanoma classification and prognosis in patients undergoing sentinel node biopsy. At this time, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. It is also not clear if the DecisionDx-Melanoma assay can be used to make clinical decisions. All told, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 53-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma assay has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. The test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 34-year-old male enrollee has requested authorization and coverage for intensity modulated radiation therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that in this case, due to the tumor location in the high pelvis and lower abdomen, the area that requires treatment is surrounded by a large amount of small bowel. Intensity modulated radiation therapy can be utilized in these cases to improve sparing of the small bowel compared to standard three-dimensional treatment planning. In this case, the provider has submitted comparison planning, which showed the bowel receiving an unacceptably high dose with the standard three-dimensional planning. The bowel dose is significantly reduced with the intensity modulated radiation therapy planning. The delivery of standard three-dimensional planning in this case is likely to result in an unacceptably high risk of complications. The medical evidence supports the use of intensity modulated radiation therapy in this clinical setting to mitigate toxicities from treatment. Therefore, intensity modulated radiation therapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a seven-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavior analysis (ABA) (36 hours of 97153 and 6 hours of 97155) provided from 3/03/20 forward. 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 the patient meets all medical necessity criteria defined by Papatola and Lustig. The authors noted that medical necessity is defined as health-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. The Health Insurer has indicated that the services at issue were not and are not medically necessary because they are educational in nature. While the services are provided in an educational setting (which the BACB encourages), the patient is working on goals related to his autism diagnosis, not goals that are intended to improve their academic performance. These goals include maladaptive behavior, receptive/expressive language, pragmatic language, social skills, self-help, and safety, all of which are associated with autism spectrum disorder. All of the goals highlight developing independence in association with the patients specific autism symptoms. Therefore, ABA services (36 hours of 97153 and 6 hours of 97155) provided from 3/03/20 forward were and are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 58-year-old female enrollee has requested reimbursement and prospective authorization for Forteo 20 mcg from 1/15/16 forward.  The Health Insurer has denied this request indicating that the medication at issue was not and is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for the medication at issue in this clinical setting.  Osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis. They can lead to acute and chronic pain as well as increased mortality.  Until recently, pharmacological options for the treatment of osteoporosis have been limited to anti-resorptive agents, including bisphosphonates.  Newer treatment agents have become available over the past few years, including teriparatide (Forteo).  Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone.  In contrast to anti-resorptive agents, such as bisphosphonates and Prolia, recent data also demonstrates that Forteo may aid in the healing of fractures and non-unions in osteoporotic patients.  Therefore, Forteo 20 mcg from 1/15/16 forward was and is medically indicated for the treatment of this patient.  Therefore, the medication at issue was and is 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

The parent of a 15-year-old male enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 5/13/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that the patient is a 15-year-old male with fistulizing Crohns disease with perianal involvement.  On 10/27/15, colonoscopy revealed granulomas in the colon and terminal ileum.  Remicade therapy was recommended and induced at 5.5 mg/kg.  Laboratory work on 2/05/16 with the patients second Remicade infusion showed normal comprehensive metabolic panel, normal C-reactive protein, and normal sedimentation rate.  The patients parent has requested reimbursement for Prometheus Anser IFX testing performed on 5/13/16.  Per the Health Insurer, the services at issue were investigational for the evaluation of this patient. The Prometheus Anser IFX test is a quantitative measurement of serum infliximab and anti-infliximab antibodies.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, while there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results.  Limited retrospective evidence describes changes in management after measurement of anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has yet to be established whether the use of threshold infliximab levels aid in the discrimination of treatment response, nor the optimal timing of when to measure antibody levels.  Therefore, Prometheus Anser IFX testing performed on 5/13/16 was not likely to have been more effective than other options for 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


The parent of a 15-year-old male enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 5/13/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that the patient is a 15-year-old male with Crohns disease.  The patient presented with bloody diarrhea and the presence of perianal fistulous disease.  Colonoscopy revealed discontinuous ulcers in the rectum and sigmoid.  After initially starting Flagyl, the patient ultimately was placed on Remicade.  He experienced healing of the fistulas with resolution of hematochezia.  The patients parent has requested reimbursement for Prometheus Anser IFX testing performed on 5/13/16.  Per the Health Insurer, the services at issue were investigational for the evaluation of this patient. The current medical evidence has not established the superior efficacy of the services at issue in this clinical setting.  The patient appeared to be responding, and there is no mention of an infusion-related adverse event.  Antibodies in low titer can be transient and not of biologic significance.  The provider increased the dose based on the testing.  There is a lack of prospective, controlled data showing that this leads to improved outcomes.  In summary, while targeted dosing of biologics may be an attractive concept, there is a lack of data demonstrating that this approach actually benefits patients.  Thus, Prometheus Anser IFX testing performed on 5/13/16 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.