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

Summary Reviewer 2

The parent of a 14-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 10/7/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the testing at issue was likely to be more effective for this patient than other available treatment options. Monitoring of both serum drug levels of infliximab as well as antibodies to infliximab have been recognized as crucial elements in maintaining long-term success and has been shown to improve the health of patients by preserving response to infliximab. A study by Gisbert and Panes noted cumulative loss of response to infliximab in approximately 13% of patients per year. In this case, a question was raised regarding whether the patients clinical symptoms were suggestive of loss of response to infliximab or some other cause, and subsequent notation reveals that the results of the test were interpreted to the benefit of the patient by leaving the pre-test dosing schedule unchanged. In this clinical setting, drug level monitoring 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 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 Overturned

Summary Reviewer 3


The parent of a 14-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 10/7/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the medical literature indicates that measurement of infliximab levels and anti-infliximab (anti-chimeric) antibodies produces actionable data (Afif, et al; Yanai and Hanauer).  Change of dose or drug based on these results improves response to treatment, as measured by clinical response.  The study by Hoekman and colleagues demonstrates that lower infliximab troughs are associated with elevated markers of mucosal inflammation in children. Paul and colleagues demonstrate prospectively that an increase in infliximab levels leads to a decrease in those same markers. Moreover, infliximab levels and antibodies allow the providers to adjust or change biologic therapy with some objective determinants. The utility of this approach is indicated in the article by Huang and colleagues who demonstrate that knowledge of infliximab trough levels frequently leads to a change in treatment course. An alternative is to sequentially increase dose and decrease dosing frequency of infliximab, then empirically change to another medication, typically adalimumab. However, this clinical approach can be lengthy and prolong a patients symptoms as well as the likelihood of an intercurrent hospital admission. In sum, the medical literature supports the use of infliximab levels and antibody measurements in the setting of inadequate clinical response to treatment, as well as for monitoring effectiveness of dose escalation. Therefore, the Prometheus Anser IFX testing 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 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is 61-year-old male who presented for a neurology consultation on 10/21/16 for chief complaints of snoring and fatigue. The patient endorsed snoring, non-restorative sleep and daytime sleepiness. He endorsed a past history of (nocturnal) teeth grinding.  The patient was reportedly previously diagnosed with obstructive sleep apnea (OSA) but was unable to tolerate continuous positive airway pressure therapy (CPAP).  The patient reported a history of seizures, which were characterized as lapses.  He was on Keppra extended release for this condition.  Physical examination showed the patient to be 69 inches tall and weighed 181 pounds.  Physical examination was said to show a beefy tongue and narrow inlets in the nose.  The provider listed a primary diagnosis of sleep apnea.  The patient was referred for split night polysomnography.  On 11/1/16, the patient reportedly underwent a split night study where the patients apnea hypopnea index was 1.2 events per hour.  The recording technologist initiated CPAP during the study.  The final report stated that CPAP was applied but that the patient was unable to tolerate CPAP. The patient has requested reimbursement for in-laboratory sleep study performed on 11/1/16. The Health Insurer denied reimbursement and reported that the services at issue were not medically necessary for the evaluation of this patients sleep disorder. There is a lack of support in the medical literature for the medical necessity of the services at issue in this clinical setting. In this case, the patient presented with a clinical presentation that was suggestive of a sleep related breathing disorder.  He was noted to have had a prior diagnosis of OSA.  He endorsed snoring and non-restorative sleep.  He also had a history of gastroesophageal reflux disease and an enlarged tongue.  These are all potential signs of OSA (Jordan, et al; Epstein, et al 2016). Given the prior diagnosis of OSA and signs and reported symptoms, sleep testing would have been clinically appropriate (Kapur, et al). In this patient, with a reasonably high pre-test probability of OSA particularly given his prior diagnosis, testing could have been performed in the ambulatory or home setting.  As noted by Jordan and colleagues, there has been a shift from the attended to the unattended setting for such testing. A recent study by Donovan and colleagues also reported the same shift. While testing was indicated in this patients case, performance of attended sleep testing exceeded this patients clinical and diagnostic needs.  In this regard, in-laboratory sleep study performed on 11/1/16 was not medically necessary. Therefore, for the reasons stated above, the services at issue were not medically necessary for the evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 27-year-old female with a history of vitiligo affecting the facial skin. The patient has been treated with Xtrac (excimer) laser therapy. The patient has requested reimbursement for dermatology services provided from 6/10/15 through 7/29/15. The Health Insurer has denied this request as not medically necessary.  Review of the submitted documentation and relevant literature demonstrates the medical necessity for the services at issue. According to the documentation submitted for review, the patient has been treated with Xtrac laser therapy for treatment of vitiligo affecting the facial skin. Vitiligo is an autoimmune disorder resulting in destruction of melanocytes, the pigment generating cells, in the skin. Use of the Xtrac (excimer) laser is a U.S. Food and Drug Administration (FDA) approved therapy for the treatment of vitiligo. In addition, treatment of vitiligo is not considered cosmetic, as therapy is aimed at encouraging repigmentation in areas where melanocytes have been destroyed by the autoimmune process. Therefore, dermatology services provided from 6/10/15 through 7/29/15 were medically indicated for this patient.

For the reasons provided, 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 Overturned

Summary Reviewer 

A 62-year-old female enrollee has requested reimbursement for corrective footwear provided on 4/09/19. The Health Insurer has denied this request and reported that the equipment at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the records document posterior tibial tendon dysfunction and associated stage I flexible flat foot deformity. The patient also has associated pain and gait abnormality. Posterior tibialis tendon dysfunction is an acquired defect that affects 10% of the geriatric population, particularly women. The cause is degenerative changes. There are four primary stages of posterior tibialis tendon with subcategorizations that range from mild to severe. Orthotics and corrective shoes are generally used for stage I and stage II cases, along with nonsteroidal anti-inflammatory drugs (NSAIDs). In this case, the deformity was stage I flexible flatfoot. Therefore, the use of corrective footwear and orthotics was appropriate. Stage III and stage IV deformities require surgery. Thus, corrective footwear provided on 4/09/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 14-year-old female enrollee has requested reimbursement for mental health residential treatment from 9/28/15 through 10/05/15 and prospective authorization and coverage for mental health residential treatment.  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 behavioral health conditions.The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not suicidal or homicidal.  She denied self-harm urges.  She was not aggressive towards others, and her body weight was stable.  She had no medical or psychiatric conditions that would interfere with her ability to return to a lower level of care.  Her mother was supportive and actively participated in her care.  Per the medical records, the patient had improved and no longer required 24-hour medical or nursing supervision.  Therefore, mental health residential treatment from 9/28/15 through 10/05/15 and future mental health residential treatment was not and is not medically indicated for the treatment of this patient.  Therefore, the services at issue were not and are 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 61-year-old male enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 3/29/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that National Comprehensive Cancer Network recommends testing with Oncotype DX Prostate Cancer Assay post-biopsy for men with low or favorable intermediate risk disease. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. This patient has a low risk prostate cancer and met this criteria. Therefore, Oncotype DX Prostate Cancer Assay performed on 3/29/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 20-year-old male enrollee has requested authorization and coverage for chondrocyte implantation with Denovo. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation supports the superior efficacy of the requested services.  The patient is skeletally mature and he has had localized knee pain for greater than six months.  The lesion present appears to be discreet and single and does not include evidence for a kissing lesion.  No systemic arthritic conditions have been diagnosed.  When nonsurgical treatment has become ineffective for patellofemoral osteoarthritis, other procedures are appropriate.  Depending upon the specific findings for a given patient, these procedures may include soft tissue realignment either through lateral release or tubercle transfer and/or autologous chondrocyte implantation for focal cartilage defects.  The specific combination of realignment procedures and cartilage resurfacing procedures depend upon the clinical problems presented to the surgeon.  While additional lesions including trochlear lesions may not necessarily rule out cartilage transplantation, this patient does not have a trochlear lesion by either direct inspection on arthroscopy or indirect visualization through MRI.  This increases the likelihood that a satisfactory clinical result will be obtained.  Given this patients young age, if the lesion is not addressed then there will be progressive deterioration of the patellofemoral joint.  All told, the requested chondrocyte implantation with Denovo is likely to be more efficacious than other treatment alternatives.  Based upon the information set forth above, the requested services are 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 2


A 20-year-old male enrollee has requested authorization and coverage for chondrocyte implantation with Denovo. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of large volume, long-term, peer-reviewed outcome studies to support the safety and effectiveness of the chondrocyte implantation with Denovo for the treatment of focal articular defects of the patella.  In this case, the patient presents with pain emanating from his left knee patellofemoral joint and a well-circumscribed defect in the posterior patella medially.  Detailed evidence of a recent comprehensive nonoperative treatment protocol trial or previous operative treatment and failure has not been submitted.  Given the absence of evidence-based, peer-reviewed support for the use of Denovo chondrocyte implantation, the superior efficacy of the requested services has not been established.  Based upon the information set forth above, the requested services are 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 3


A 20-year-old male enrollee has requested authorization and coverage for chondrocyte implantation with Denovo. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found per Vasiliadis and Wasiak, treatments for managing articular cartilage defects of the knee, including drilling and abrasion arthroplasty, are not always effective.  An alternative is autologous chondrocyte implantation.  The authors reviewed 431 cases in 6 trials.  The authors noted that additional good quality randomized controlled trials with long-term functional outcomes are required to draw conclusions on the use of autologous chondrocyte implantation for treating full thickness articular cartilage defects in the knee.  Farr and colleagues noted the need for prospective, randomized controlled studies to refine the indications and contraindications for the requested services.  Thus, chondrocyte implantation with Denovo is not likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested services are 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 Overturned

Summary Reviewer 1

A 61-year-old male enrollee has requested reimbursement for surgical services (atrial fibrillation ablation) performed on 7/10/13. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees recurrent symptomatic atrial fibrillation. The physician reviewer found the services at issue were likely to be more effective for this patient than other available treatment options. The treatment of atrial fibrillation with catheter ablation has undergone changes during the past 10 years with evaluation of new technology. The Heart Rhythm Society gave a Class I status to the procedure at issue in patients with structurally normal heart and paroxysmal atrial fibrillation who have failed one or more type I or type III anti-arrhythmic drugs (Calkins, et al). This was based on review of at least eight randomized trials and other non-randomized trials. The STOP-AF trial was published in April 2013 and showed good success rate and improved patient symptoms with cryoablation for paroxysmal atrial fibrillation, compared to conventional therapy (Packer, et al). In addition, the American College of Cardiology guidelines in 2014 gave a Class I status to catheter ablation for symptomatic paroxysmal atrial fibrillation when individuals had failed one or more type I or type III anti-arrhythmic medications (January, et al). In sum, the services at issue were 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 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 Overturned

Summary Reviewer 2

A 61-year-old male enrollee has requested reimbursement for surgical services (atrial fibrillation ablation) performed on 7/10/13. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees recurrent symptomatic atrial fibrillation. The physician reviewer found the surgical services performed on 7/10/13 were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the documentation submitted for review, the patient presented with symptomatic paroxysmal atrial fibrillation in spite of a prior remote ablation in 2011 and suppressive antiarrhythmic medication trials. Since the patient continued to have significant symptoms in spite of attempts at rate control and rhythm control a second atrial fibrillation ablation procedure in this clinical setting was reasonable and medically appropriate and considered the standard of care in the medical community. The highest success in preventing atrial fibrillation with ablation is in those patients with paroxysmal (as opposed to persistent) atrial fibrillation (January, et al). Also, cryoablation has favorable results compared to radiofrequency ablation (Packer, et al). Given that the repeat ablation procedure performed on 7/10/13 was clinically indicated to relieve symptoms and is the standard of care in the medical community, the surgical services at issue were 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 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 Overturned

Summary Reviewer 3


A 61-year-old male enrollee has requested reimbursement for surgical services (atrial fibrillation ablation) performed on 7/10/13. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees recurrent symptomatic atrial fibrillation. The physician reviewer found according to the documentation submitted for review, the patient presented with symptomatic chronic atrial fibrillation that failed aggressive attempts to manage his condition medically. The guidelines listed above support the use of catheter-based ablation (radio frequency or cryoablation) for management of patients in this clinical setting. For the reasons provided above, the services at issue were 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 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 
The patient is a 31-year-old male with rectal bleeding and pain with bowel movements since July 2020 who has been diagnosed with an anal fissure. The patient has requested authorization and coverage for Botox (onabotulinumtoxinA for injectable 100 unit). 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 Botox injection is a standard of care treatment option for fissures that do not respond to medical management. According to the Clinical Practice Guideline for the Management of Anal Fissure from the American Society of Colon and Rectal Surgeons, Compared with topical nitrates, the use of calcium channel blockers for chronic anal fissures has a similar efficacy, with a superior side effect profile, and can be used as first-line treatment. The guideline also notes, Botulinum toxin has similar results compared with topical therapies as first-line therapy for chronic anal fissures, and modest improvement in healing rates as second-line therapy following treatment with topical therapies. It is not standard of care to require treatment with both nitroglycerin and a calcium channel blocker. Botox is a standard treatment option for fissures that do not respond to medical management. An alternative to Botox is lateral internal sphincterotomy, but this has potential for complications, including fecal incontinence. It is medically appropriate to pursue Botox injections prior to consideration for surgery. Therefore, Botox (onabotulinumtoxinA for injectable 100 unit) is medically necessary for the treatment of this patient.