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

Summary Reviewer 1

A 40-year-old female enrollee has requested reimbursement for testing for inherited thrombophilic disorders performed on 10/19/19. 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 has a history of recurrent pregnancy loss and has tested positive for MTHFR mutation. Although this is cited by her provider as a risk factor for pregnancy loss, based on the current literature, it is unclear if MTHFR polymorphisms independently increase the risk of pregnancy loss. Diagnostic testing, including an immunology and thrombophilia work-up, is recommended for recurrent pregnancy loss. However, the minimum immunology work-up for women with recurrent pregnancy loss is measurement of anticardiolipin antibody (IgG and IgM) and lupus anticoagulant. Specifically in regards to thrombophilia testing, there is contradictory literature on the association between maternal inherited thrombophilia and recurrent spontaneous abortion occurring in the first trimester. Evaluation for an inherited thrombophilia can be considered in rare cases of recurrent, unexplained late fetal loss (after nine weeks of gestation) associated with evidence of placental ischemia and infarction and maternal vessel thrombosis. Based on the above information, there is a lack of clinical data to support the above work-up in this patient. Therefore, testing for inherited thrombophilic disorders performed on 10/19/19 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 40-year-old female enrollee has requested reimbursement for testing for inherited thrombophilic disorders performed on 10/19/19. 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 two prior early miscarriages. As a result, her provider ordered multiple genetic blood tests for inherited thrombophilias. The use of these tests to evaluate women with prior miscarriages is not supported by available literature. An extensive literature review has shown a lack of association of heterozygosity of the MTHFR mutation and miscarriage. Rey and colleagues concluded, aMethylenetetrahydrofolate mutation, protein C, and antithrombin deficiencies were not significantly associated with fetal loss.a The American College of Obstetricians and Gynecologists does not recommend screening for this in non-pregnant or pregnant women. Thus, testing for inherited thrombophilic disorders performed on 10/19/19 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 40-year-old female enrollee has requested reimbursement for testing for inherited thrombophilic disorders performed on 10/19/19. 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 testing for thrombophilias after early miscarriage has not been shown to be clinically useful in the low risk population. Finding a genetic mutation in this population for MTHFR, Factor V (Leiden) or prothrombin genes would not change the clinical management of the patient currently or with a new pregnancy. Testing for these mutations has only been found to be clinically useful in a patient who has a personal history of a venous thrombotic event or a first-degree relative with gene mutation who has had a venous thrombotic event. In this case, the literature does not support testing for these mutations because there would be no change in clinical management. All told, testing for inherited thrombophilic disorders performed on 10/19/19 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 21-year-old male who underwent esophagogastroduodenoscopy with biopsies for a history of abdominal pain, belching, and bloating. The documentation noted a history of hypothyroidism. The physician reviewer found that according to the ASA guideline for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures, such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care may be necessary in patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, ASA class III or higher, or morbid obesity. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, during endoscopic procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal during most procedures, and monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic variant. In this case, the records do not support the medical necessity of monitored anesthesia care over conscious sedation. Therefore, anesthesia services provided on 5/07/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 63-year-old female enrollee has requested reimbursement for advanced lipoprotein testing performed on 10/19/20. 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 submitted documentation fails to demonstrate the superior efficacy of the services at issue. There are no widely accepted clinical studies demonstrating that treatment strategies directed at advanced lipoprotein testing parameters will improve clinical outcomes in individuals with dyslipidemias. Clinical trial data to date does not support the superiority of measurement of such parameters beyond what is known from a basic lipid panel in assessing treatment. This was also the conclusion of the American College of Cardiology/American Heart Association 2013 guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Risk in Adults. Therefore, advanced lipoprotein testing performed on 10/19/20 was not likely to have been more beneficial than other available standard methods of evaluation.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 63-year-old female enrollee has requested reimbursement for advanced lipoprotein testing performed on 10/19/20. 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 current medical evidence has not established the superior effectiveness of the services at issue. Lipoprotein particles, which carry cholesterol and triglycerides, are comprised in part of apolipoproteins. Although some have proposed that the measurement of lipoproteins or apolipoproteins may be useful in some patients, the 2010 American College of Cardiology Foundation/American Heart Association guideline for assessment of cardiovascular risk in asymptomatic adults does not recommend the use of these tests for cardiovascular risk assessment in asymptomatic adults. Therefore, advanced lipoprotein testing performed on 10/19/20 was not likely to have been more beneficial than other available standard methods of evaluation.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 63-year-old female enrollee has requested reimbursement for advanced lipoprotein testing performed on 10/19/20. 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 there is support for a portion of the services at issue. The National Lipid Association stated that lipoprotein (a) testing is reasonable to refine atherosclerotic cardiovascular disease risk in adults with the following: first-degree relatives with premature atherosclerotic cardiovascular disease risk (less than 55 years of age in men; less than 65 years of age in women); a personal history of premature atherosclerotic cardiovascular disease; primary severe hypercholesterolemia (LDL greater than or equal to 190 mg/dL) or suspected familial hypercholesterolemia. This patient does appear to meet the first of these criteria for lipoprotein (a) measurement. Thus, CPT 83695 was likely to have been more beneficial than other available standard methods of evaluating this patient. Apolipoprotein B may be a useful risk assessment tool in patients with normal LDL who have a high family risk for premature coronary artery disease. However, apolipoprotein B assays have not been fully standardized, and there is a lack of consensus on predictive or treatment value. Rosenson suggests the measurement of LDL particle concentration, or the surrogate measure of apolipoprotein B, in individuals with insulin resistance disorders who have not achieved their minimal acceptable LDL cholesterol targets. This patient does not meet these criteria for lipoprotein B measurement. Therefore, CPT codes 82172 and 83704 were not likely to have been more beneficial than other available standard methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center services provided from 9/19/16 forward. 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 condition. The physician reviewer found the residential treatment center services provided from 9/19/16 forward were and are medically necessary for treatment of the patients medical condition. The medical records show that the patient is aggressive, irritable, critical of others, agitated, rude and argues with peers and staff. There are significant gaps in his ability to modulate his behavior. On 9/22/16, the individual therapy note stated that he presented agitated, critical of others and defensive. He blamed others and was dismissive of feedback. The therapist noted that his struggle with negative self-talk exacerbates his impulsive and disrespectful behaviors. On 9/26/16 the group therapy note stated that the patient struggles with accepting feedback about his behaviors and suggestions of he could improve. The patient argues and becomes defensive, particularly with his disrespect for female staff members was addressed. On 10/2/16, the notes indicate the he continued to be agitated and argued with staff and peers. He continues to be agitated and angry, and becomes unable to be directed and aggressive. Based on the documentation submitted for review, the patient requires the structure and 24-hour setting of continued residential treatment center services in order to allow learned gains to become established prior to discharge to a lower level of care. Therefore, the services at issue were and 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 39-year-old male enrollee has requested reimbursement for Anser IFX testing provided on 4/23/14. 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.  The medical evidence has not established whether therapy guided by following trough drug levels and drug antibodies is superior to routine good clinical care.  The data available are uncontrolled and come from retrospective analyses.  In general, for a patient failing therapy, there is a trend toward lower trough drug levels with or without the presence of antibody.  However, many patients fail therapy with a normal drug level for a variety of reasons.  All told, Anser IFX testing performed on 4/23/14 was not likely to have been more effective than other methods of evaluation.  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

A 39-year-old male enrollee has requested reimbursement for Anser IFX testing provided on 4/23/14. 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 a lack of support for the services at issue in this clinical setting.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures.  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, 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.  In addition, there are technical factors relating to the use of different assay methods across studies. It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  Therefore, Anser IFX testing performed on 4/23/14 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 39-year-old male enrollee has requested reimbursement for Anser IFX testing provided on 4/23/14. 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 effectiveness of Anser IFX in the management of Crohns disease compared with conventional courses of action remains unproven in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing.  Based on the clinical literature, Anser IFX testing performed on 4/23/14 was not likely to have been more effective than other modalities.  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 Upheld

Summary Reviewer 


A 45-year-old male enrollee has requested authorization and coverage for maxillary and mandibular osteotomies with advancement. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees obstructive sleep apnea (OSA).  The physician reviewer found that Maxillomandibular advancement can be an effective treatment for treatment of sleep disordered breathing based on several case series but more rigorous evaluation of the procedure is lacking (Prinsell). Current practice parameters list this procedure as an option for patients who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances, which are more often appropriate in mild and moderate OSA patients, have been considered and found ineffective or undesirable (Aurora, et al). Traditionally, mandibular advancement devices have been used for mild to moderate sleep apnea. This patients provider states that a mandibular advancement device is not likely to be effective in treating the patients sleep apnea. However, the most recent guidelines do not exclude the use of maxillomandibular advancement in severe OSA (Ramar, et al). In summary, the patient does have severe OSA and is CPAP intolerant but he has not tried a mandibular advancement device, a treatment which could result in adequate control of his sleep disordered breathing. Since there is another reasonable, non-surgical option available to him, the requested maxillary and mandibular osteotomies with advancement are not medically necessary. Based on the foregoing discussion, the requested services 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 Upheld

Summary Reviewer 

The parent of a 15-year-old male enrollee has requested reimbursement for mental health residential treatment provided from 9/22/14 through 11/11/14.  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.  The reasons or precipitating factors for the patients admission on 9/22/14 are unclear.  He was not a danger to himself or others.  Per the records, he was not violent or aggressive, and he showed no self-harm urges.  The patient was not on any medication, and he lived with his parents in a supportive environment.  There is no comprehensive admission assessment by a physician.  There is only a one paragraph intake assessment by a therapist.  There is no psychosocial history, prior medical history or psychiatric history.  There were no diagnoses provided.  The records do not include physician notes, nursing notes, treatment plans or group notes except for the group note dated 10/13/14.  The documentation is scanty at best and provided no insight as to what the patient was doing on a day to day basis, what services were rendered, or what benefit he received from these services.  This is not consistent with care that would or should be given at a residential treatment center.  This aside, the patient did not require 24-hour supervision in a restricted, structured setting.  He could have received continued evaluation and treatment at a lower level of care.  All told, mental health residential treatment provided from 9/22/14 through 11/11/14 was 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 24-year-old female enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). 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 that IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the medical records provided for review, the patient presents with a large mediastinal mass which requires radiation. The patient has an excellent long term survival, upwards of 90%, and therefore all efforts should be made to mitigate long term toxicities from radiation therapy which include heart and lung damage. IMRT can be utilized to minimize dose to the surrounding heart and lungs. Comparative planning between IMRT and three-dimensional (3D) conformal treatments were submitted for review. They reveal that the IMRT plan is able to significantly reduce radiation dose to the heart and lungs which will decrease the incidence of long term toxicities seen in these organs. The National Comprehensive Cancer Network (NCCN) guidelines state that IMRT can be used in treatment of patients with Hodgkin's disease. Furthermore, there are comparative studies which have demonstrated that IMRT reduces the radiation dose compared to older methods of delivering radiation such as 3D conformal techniques (Filippi, et al; Lu, et al). Therefore, IMRT is likely to be more beneficial for treatment of this patients Hodgkins disease than any available standard therapy. 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.