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

Summary Reviewer 


A 35-year-old male enrollee has requested reimbursement for substance abuse residential treatment from 6/17/15 through 7/03/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting.  This patient had a concerning history of alcohol use that began in late adolescence.  His drinking was dominating multiple functional domains, impaired his sociability and relationships, and resulted in an arrest with subsequent probation.  He lacked insight into the extent of his addiction as he thought he could resume drinking alcohol.  Thus, 11 days of residential treatment was an insufficient duration of treatment to address the patients convoluted relationship with alcohol and mobilize the meaningful therapeutic momentum needed to foster sustained sobriety.  In the absence of residential programming, the patient would have more than likely returned to a pathological and self-defeating pattern of alcohol consumption.  The comprehensive services were delivered in accordance with an individual treatment plan.  Further, the services were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  The placement facilitated active treatment and also provided opportunity to further explore and treat his anxiety, which was identified as a trigger for his drinking.  Finally, the duration of services was consistent with community practice standards.  All told, substance abuse residential treatment services provided from 6/17/15 through 7/03/15 were medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 39-year-old male with biopsy proven idiopathic membranous nephropathy. Rituximab effected an improvement in proteinuria/nephrotic syndrome. However, the patients proteinuria has worsened and obinutuzumab (Gazyva) has been recommended as a second-line therapy. The patient has requested authorization and coverage for Gazyva injections. The Health Insurer has denied this request indicating that the requested medication is considered investigational. This patients records do not document that standard therapies including prednisone, cyclophosphamide, mycophenolate and cyclosporine have been tried and failed, or that the patient has a contraindication to these medications. Moreover, there is no indication in the medical literature that Gazyva is safe and effective for treatment of idiopathic membranous nephropathy. For these reasons, the requested obinutuzumab (Gazyva) injections are 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 medication 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

The patient is a 39-year-old male with stage III chronic kidney disease. He initially presented with 9-10 grams of proteinuria per day. He was treated with rituximab in August 2015. A renal biopsy in June 2016 demonstrated PLA2R+ membranous glomerulonephritis. The patient has subsequently been treated with mycophenolate. Proteinuria was recently measured at 8.1 grams per 24 hours. The patient has requested authorization and coverage for obinutuzumab (Gazyva) injections. The Health Insurer has denied this request indicating that the requested medication is considered investigational. Gazyva does not have U.S. Food and Drug Administration (FDA) approval for treatment of membranous glomerulonephritis. In addition, a review of published peer-reviewed medical literature indicates that there are insufficient data to support Gazyva as efficacious and safe for treatment of membranous glomerulonephritis. Standard therapy for membranous glomerulonephritis for which extensive data have been published includes the Ponticelli protocol with steroids and chlorambucil, Cytoxan, and calcineurin inhibitor therapy with cyclosporine or tacrolimus, which have not been tried in this patient. In a 10-year follow-up of one of the studies in membranous glomerulonephritis, treated patients using steroids and chlorambucil or Cytoxan had a higher likelihood of complete or partial remission with 88% versus 47% in the placebo group and a greater likelihood of surviving without renal failure 92% versus 60% (Ponticelli, et al). There is no documentation of a contraindication to any of these medications. In summary, the requested obinutuzumab (Gazyva) injections are 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 medication 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

The patient is a 39-year-old male with persistent PLA2R titer and persistent nephrotic syndrome. The records indicate that the patient previously responded to anti CD-20 therapy with rituximab. The patient has requested authorization and coverage for obinutuzumab (Gazyva) injections. The Health Insurer has denied this request indicating that the requested medication is considered investigational. Gazyva is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Currently, there is a lack of clinical trials showing that Gazyva is effective for treatment of membranous glomerulonephritis. In addition, rituximab has been demonstrated to more efficiently deplete CD-20 and is likely beneficial in this patient. Thus, the requested obinutuzumab (Gazyva) injections are 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 medication 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 59-year-old female enrollee has requested reimbursement for a cooling or combined cooling/heating device. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees medical condition. The physician reviewer found the use of continuous flow cryotherapy for reduction of postoperative swelling and pain has become commonplace in knee and shoulder surgery.  However, prolonged exposure to extreme cold may induce an injury identical to that of frostbite.  Therefore, continuous flow cryotherapy is not recommended for ankle and foot surgery.  Complications related to cryotherapy are rare but can be devastating.  They include chronic pain, frostbite, and loss of digits.  Cold packs are effective and are generally recommended after foot and ankle surgery.  Based upon a review of the literature, the device at issue was not likely to have been superior over other treatment options.  Based upon the information set forth above, the device at issue was 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 59-year-old female enrollee has requested reimbursement for a cooling or combined cooling/heating device. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the device at issue in this clinical setting.  Evidence-based medical guidelines and peer-reviewed literature indicate there is a lack of large volume long-term studies evidencing significant overall outcome differences with regards to continuous flow cryotherapy versus standard cold packs, in surgeries of this type. Additionally, the use of the combined cold/deep vein thrombosis prophylaxis unit is not supported for this patient.  There are limited deep vein thrombosis risk factors identified for this patient. There is no documentation that anticoagulation therapy would be contraindicated.  Therefore, the device at issue was not likely to have been more beneficial for the treatment of the patients medical condition than standard cold packs.  Based upon the information set forth above, the device at issue was 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 59-year-old female enrollee has requested reimbursement for a cooling or combined cooling/heating device. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees medical condition. The physician reviewer found the medical evidence has not established the superior efficacy of the device at issue.  The use of icepacks has been in regular and common use for decades.  In this patients case, there is a lack of evidence indicating that the device at issue was likely to have been more effective than simpler methods of applying cold, such as icepacks.  Per the medical literature, simpler applications of cold have been demonstrated to be equally efficacious.  Therefore, the device at issue was not likely to have been of greater benefit than other treatment options.  Based upon the information set forth above, the device at issue was 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 23-year-old female enrollee has requested authorization and coverage for FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis. The Health Insurer has denied this request indicating that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found arraybased 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 five years, it has emerged as a first-line investigation.  This test has become an important and mainstream tool in the practice of clinical genetics.  Data have now emerged showing that actionable findings from chromosomal microarray justify its use.  All told, the requested services are likely to be of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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 23-year-old female enrollee has requested authorization and coverage for FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis. The Health Insurer has denied this request indicating that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  Chromosomal microarray testing is an appropriate first-line test for patients with non-syndromic developmental delay/intellectual disability, as well as patients with autism spectrum disorders.  There are clear management implications that chromosomal microarray testing has provided for patients.  In sum, FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis is likely to be of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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 23-year-old female enrollee has requested authorization and coverage for FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis. The Health Insurer has denied this request indicating that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found Autism spectrum disorder is a biologically based neurodevelopmental disorder.  Identification of a genetic diagnosis may provide additional information about prognosis, expected outcome, and recurrence risk.  However, few studies have evaluated the effect of genetic testing on such outcomes, and it is unclear whether or not genetic testing affects health outcomes.  In this case, the documentation does not show how using genetic testing to diagnose autism spectrum disorder will directly impact treatment options.  In sum, the superior efficacy of FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis has not been established.  Based upon the information set forth above, the requested services are 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 60-year-old female with osteoporosis. She has had a suboptimal response to Actonel, Forteo and Evista. The physician reviewer found that Osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis. This can lead to acute and chronic pain. A newer medication, denosumab (Prolia) is a fully human monoclonal antibody which has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. This patient has failed therapy with multiple other agents in the past. There is sufficient support for the medication at issue in this setting. Therefore, Prolia provided on 3/20/18, 10/15/18, 5/10/19 and 12/16/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 44-year-old transgender male who has documented gender dysphoria. The patient has requested authorization and coverage for CPT codes 15734 (muscle, myocutaneous, or fasciocutaneous flap; trunk), 54660 (insertion of testicular prosthesis), 55180 (scrotoplasty; complicated) and 14040 (adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 square cm or less). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that World Professional Association for Transgender Health (WPATH) states that scrotoplasty and testicular implants, as well as phalloplasty in general, are medically necessary treatments for gender dysphoria. WPATHas position statement notes, aIn addition to hormonal balancing, medically necessary gender affirming/confirming surgical procedures are described in section XI of the standards of care. These procedures include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, scrotoplasty, and penile and testicular prostheses, as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient.a Coleman and colleagues noted that for treatment of gender dysphoria, phalloplasty includes, aa pedicled or free vascularized flap, vaginectomy, scrotoplasty, and implantation of erection and/or testicular prostheses.a The current medical evidence supports the requested services in this clinical setting. Therefore, CPT codes 15734 (muscle, myocutaneous, or fasciocutaneous flap; trunk), 54660 (insertion of testicular prosthesis), 55180 (scrotoplasty; complicated) and 14040 (adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 square cm or less) are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 36-year-old female who is appealing denial of reimbursement for repair of nasal vestibular stenosis with graft performed on 3/12/20. . The patient has requested reimbursement for repair of nasal vestibular stenosis with graft performed on 3/12/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that Samra and colleagues stated, aNasal valve collapse is a common cause of functional upper airway obstruction that leads to varying difficulty with nasal inspiration, diminished exercise tolerance, and significant decreases in quality of lifeaSurgical management of the nasal valve is focused primarily on widening the valve and providing support to the lateral wall with appropriate autologous grafting techniques.a This patient underwent reconstructive surgery for correction of breathing obstruction secondary to deviated nasal septum and collapsed internal nasal valves. Postoperatively, her nasal airway was further decreased. Physical examination revealed nasal septal deviation to the left side, obstructing approximately 50% of the airway. Both internal valves were compromised from the septal deviation with narrowing of the internal valve angle, and there was a positive Cottle test on both sides. She was reported at surgery to have extremely distorted anatomy and heavily scarred tissue. There was a large amount of scarring in the internal attic of the vestibule on the right side. Based on the medical information received for review and peer-reviewed medical literature, the nasal reconstruction was medically necessary for relief of breathing obstruction. Therefore, repair of nasal vestibular stenosis with graft performed on 3/12/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 44-year-old female who has requested reimbursement for DecisionDx-Melanoma testing performed on 1/02/20.  The patient has requested reimbursement for unlisted multianalyte assay with algorithmic analysis performed on 1/02/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Prognostic gene expression profiling (GEP) testing to differentiate melanomas at low versus high risk for metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive result, GEP testing should not guide clinical decision-making in this group. It remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known cliniopathologic factors or multivariate 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. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models. Therefore, unlisted multianalyte assay with algorithmic analysis performed on 1/02/20 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 22-year-old male enrollee has requested reimbursement for substance use intensive outpatient program services provided from 2/03/15 through 4/29/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.    It appears that his last alcohol use was two to four months before presentation while his last marijuana use was in December 2014.  Aside from nicotine use and hashish experimentation, the patient had no other substance use history.  The patients strengths included his motivation for recovery, therapeutic engagement, stable housing and a supportive family willing to participate in his care.  Although the patient had elements consistent with a formal thought disorder in absence of substance use, his symptom burden was being addressed with psychiatric services and pharmacotherapy, and did not necessitate services at the intensive outpatient program level of care.  On 2/02/15, the treatment plan called for 12-step programming, increased relapse prevention and improved awareness of family and life stressors.  Since the patient had no prior history of chemical dependency treatment and family therapy in the outpatient setting, there is no evidence to suggest that outpatient services with community programming would have been insufficient in attaining said treatment goals. Thus, based on the clinical presentation coupled with relevant peer-reviewed medical literature and current practice guidelines, substance use intensive outpatient program services provided from 2/03/15 through 4/29/15 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.