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

Summary Reviewer 3

The patient is a 36-year-old male with a history of gastroesophageal reflux disease (GERD) for more than 12 years, with breakthrough symptoms of upper abdominal burning and sour taste despite proton pump inhibitor (PPI) use. His symptoms interfere with sleep. An endoscopy on 7/30/15 showed an irregular Z-line and a hiatal hernia. A video esophagogram on 12/16/15 showed no hiatal hernia or spontaneous reflux, but there was reflux to the clavicles with vigorous Valsalva maneuver, followed by spontaneous clearing. An esophageal manometry on 1/4/16 showed normal motility and a decreased lower esophageal sphincter pressure. An endoscopy on 3/7/16 showed a normal esophagus and mild antral gastritis. A pH study on 3/7/16 showed markedly elevated acid exposure. Per the provider letter dated 3/27/17, the patient has failed treatment with omeprazole and ranitidine, and has symptoms including chest pain and pressure, difficulty swallowing, and bloating. The patient has requested authorization and coverage for transoral incisionless fundoplication (TIF) with EsophyX device. The Health Insurer has denied this request as investigational. There is a lack of medical literature supporting the efficacy of TIF for the treatment of GERD. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) reported that numerous published series have reported significant adverse events and that there is a lack of sham-controlled trials comparing TIF with anti-reflux surgery (Auyang, et al). SAGES concluded that further studies are required to define optimal techniques and most appropriate patient selection criteria, and to further evaluate device and technique safety (Auyang, et al). These conclusions are supported by recent reports of adverse events during the procedure and the need for surgery to revise ineffective TIF (Ashfaq, et al; Bell, et al; Edriss, et al). For these reasons, the request for TIF with EsophyX device 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 36-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 12/16/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that Polymerase chain reaction testing is appropriate and medically indicated when done to test for chlamydia, gonorrhea, and trichomonas. In this case, it appears the patient was tested for trichomonas (not by polymerase chain reaction testing, but via RNA testing), and was not tested for chlamydia or gonorrhea. Instead, multiple polymerase chain reaction tests were done for various other vaginal organisms, some of which do not even cause infection, including candida species, lactobacillus species, Atopobium vaginae, Megasphaera species, and Gardnerella vaginalis quantification. Polymerase chain reaction testing for these organisms is not standard of care. The standard testing for evaluation of a vaginal discharge includes assessing the symptoms, the appearance of the discharge, pH testing of the vaginal fluid, examination of the discharge under the microscope, and sometimes DNA probes or cultures. Therefore, polymerase chain reaction testing performed on 12/16/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 36-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 12/16/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that Polymerase chain reaction testing has been compared to traditional clinical testing for vaginitis. The literature supports the use of polymerase chain reaction testing because it resulted in significantly higher sensitivity and negative predictive value than clinician diagnosis or in clinic testing. Schwebke and colleagues noted that polymerase chain reaction testing showed a statistically higher overall percent agreement with each of the reference methods than did clinician diagnosis or clinic testing. The authors noted that the test was also superior for detecting more than one cause for vaginitis. Polymerase chain reaction testing is commonly used in clinical practice. In sum, polymerase chain reaction testing performed on 12/16/18 was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 36-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 12/16/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for vaginitis panel testing using polymerase chain reaction technology in this patients case. Although these methods have high sensitivity and specificity and a shorter turn-around time than culture, polymerase chain reaction testing offers no proven benefit over standard culture in symptomatic women. Furthermore, there is a lack of evidence on the clinical utility and impact of polymerase chain reaction testing for vaginitis. There is a lack of studies showing that polymerase chain reaction testing leads to better patient management decisions and/or better health outcomes. Studies of diagnostic accuracy alone are inadequate, especially because most symptomatic women can be diagnosed with a standard workup and/or a trial of empiric therapy. Thus, polymerase chain reaction testing performed on 12/16/18 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for residential and mental health treatment provided from 4/01/14 through 5/20/15.  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.  During the dates of service in dispute, there was no evidence of the patient being a danger to herself or others, no evidence of self-injurious behavior or urges, and no aggression towards others.  There was no evidence or documentation of eating disorder behaviors, no weights, and no intake monitoring.  She had no substance abuse problems.  She was engaged and an active participant in the treatment process, as were her parents.   She was redirectable and open to suggestion.    She was independent in her activities of daily living, and there were no cognitive difficulties.   She was medically stable and tolerated medication changes without difficulty.  Amantadine was helpful for impulsivity. However, this did not require a structured residential setting for institution and maintenance.  There was a glaring paucity of documentation to support the necessity of this level of care, and the treatment she received did not meet criteria for residential level of care in terms of hours of treatment.  Although this patient required ongoing intensive psychological and psychiatric care for psychotherapy and medication management, she did not require supervision in a 24-hour per day, seven days per week structured setting.  All told, residential and mental health treatment provided from 4/01/14 through 5/20/15 were not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The parent of a 16-year-old female enrollee has requested authorization and coverage for Rituxan. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that current medical evidence has not established the superior efficacy of the requested medication in this patientas case. Ringold and colleagues noted, aIn patients with juvenile idiopathic arthritis (JIA) and polyarthritis and moderate or high disease activity receiving a first tumor necrosis factor inhibitor (TNFi) (with or without disease-modifying antirheumatic drug (DMARD)), switching to a non-TNFi biologic (tocilizumab or abatacept) is conditionally recommended over switching to a second TNFi.a The authors also noted, aA second TNFi may be appropriate for patients who had a good initial response to their first TNFi (i.e., secondary failure), particularly failure due to the presence of suspected or measured antidrug antibodies to the first TNFi.a Furthermore, the authors also noted, aIn patients with JIA and polyarthritis and moderate or high disease activity despite a second biologic, using a TNFi, abatacept, or tocilizumab (depending upon prior biologics received) is conditionally recommended over rituximab. In this case, the medical record does not indicate that the patient utilized non-TNFi biologics, such as tocilizumab and abatacept, or a second TNFi after failing Humira therapy. All such options would be in keeping with the 2019 guideline. These options are recommended prior to rituximab therapy. Data on the use of rituximab in JIA is very limited. In addition, the patientas provider planned to combine Humira with rituximab as indicated in the 5/19/20 office visit note. Data supporting the efficacy and safety of such combination therapy for JIA appears scarce and is not supported by the medical literature. Rituximab prescribing information states there is limited data available on the safety of the use of rituximab with other biologic agents or DMARDs other than methotrexate. Therefore, Rituxan is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

The parent of a 16-year-old female enrollee has requested authorization and coverage for Rituxan. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that Rituximab has not been approved by the U.S. Food and Drug Administration (FDA) for the diagnosis of juvenile idiopathic arthritis (JIA) but is approved for adult rheumatoid arthritis. This medication has been not been studied extensively in JIA. There are currently no national guidelines or large randomized controlled studies recommending this therapy for JIA. The current guidelines recommend a trial of a second TNFi.  In this case, the patient has failed methotrexate and Humira.  The guidelines would recommend a second TNFi, tocilizumab or abatacept over rituximab.  The medical records fail to demonstrate any extenuating circumstances for going against the guidelines. All told, Rituxan is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

The parent of a 16-year-old female enrollee has requested authorization and coverage for Rituxan. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the use of Rituxan in this case is not likely to be more beneficial than the available standard therapy. According to the 2019 American College of Rheumatology/Arthritis Foundation guideline for the treatment of juvenile idiopathic arthritis, biologic medications available to treat children with juvenile idiopathic arthritis include Actemra, Enbrel, Humira, and Orencia after failure of standard DMARD therapy. According to the Rituxan prescribing information, it is indicated for the treatment of rheumatoid arthritis in combination with methotrexate in adult patients with moderately-to-severely active rheumatoid arthritis who have had an inadequate response to one or more tumor necrosis factor antagonist therapies. This patient has failed a single biologic therapy according to the medical records. There are other options that are considered a standard of care in this case, including Orencia intravenous or subcutaneous, Actemra intravenous or subcutaneous, or Enbrel. These medications are indicated for juvenile idiopathic arthritis.  There is no data available to suggest that this patient would respond more to Rituxan as opposed to the biologic medications that are approved for juvenile idiopathic arthritis. Thus, Rituxan is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 50-year-old female enrollee has requested authorization and coverage for ultrasound ablation. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees uterine fibroids. The physician reviewer found the request for ultrasound ablation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although there is some medical literature that suggests MR-guided high intensity focused ultrasound is a promising technique, there is a lack of peer-reviewed literature that shows increased effectiveness of this technique compared to other currently available minimally invasive techniques, such as uterine fibroid embolization. In addition, there is a lack of documentation provided that indicates that patient would not be a suitable candidate for uterine fibroid embolization or other traditional standard of care treatments. For these reasons, the requested procedure 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 50-year-old female enrollee has requested authorization and coverage for ultrasound ablation. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees uterine fibroids. The physician reviewer found the two most common symptoms of uterine fibroids are abnormal uterine bleeding and pelvic pressure. The most common kind of abnormal bleeding associated with leiomyomas is heavy or prolonged menstrual bleeding. Hysterectomy remains the most common surgical treatment for fibroids because it is the only definitive treatment that eliminates the possibility of recurrence. HIFU is a noninvasive approach uses high-intensity ultrasound waves directed into a focal volume of a leiomyoma. The ultrasound energy penetrates soft tissue and produces well-defined regions of protein denaturation, irreversible cell damage, and coagulative necrosis. Although short-term studies show safety and efficacy, long-term studies are needed. There is a lack of well-designed clinical studies evaluating the safety and efficacy of HIFU using relevant outcome measures are lacking. Studies have generally lacked comparison to the currently accepted treatments of uterine myomas (Chittawar and Kamath). In addition, the published evidence regarding HIFU does not adequately address the potential for regrowth of treated myomas over time, especially beyond three years. In conclusion, given the lack of well-designed randomized controlled trials with adequate follow-up periods and appropriate outcome measure, ultrasound ablation has not been established as 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 50-year-old female enrollee has requested authorization and coverage for ultrasound ablation. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees uterine fibroids. The physician reviewer found that symptomatic uterine fibroids are a fairly common medical condition, and standard and definitive therapy for a patient with these clinical demographics is hysterectomy. There is increasing data to support the use of MR-guided focused ultrasound for treatment of uterine fibroids (Ikink, et al). However, there is limited information of the long-term comparative effectiveness in relation to the numerous additional therapeutic options available. In addition to the patients largest fibroid, there are still at least two other sizable submucosal fibroids that would remain. In this clinical setting, ultrasound ablation is not likely to be more beneficial for treatment of the patients medical condition than other standard options. 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 Overturned

Summary Reviewer 

The patient is a 58-year-old female with a history of acromegaly. She underwent a transsphenoidal resection of a pituitary mass in 2005, followed by radiation therapy. The physician reviewer found that the acromegaly is a chronic, progressive, and potentially lethal disease caused by a growth hormone (GH) secreting pituitary adenoma and resultant excess in circulating levels of GH and insulin-like growth factor-1 (IGF-1). Transsphenoidal pituitary adenoma resection is generally the first-line therapy for acromegaly. Pharmacologic agents available for treatment of persistent acromegaly include somatostatin-receptor ligands, GH-receptor antagonists and, in selected cases, dopamine agonists. Somatostatin receptor ligands, such as Sandostatin LAR, are considered the mainstay in the medical management of acromegaly. However, this agent requires deep tissue injection and can be associated with substantial treatment burden or deleterious long-term sequelae, including injection site pain, nodules, bruising, inflammation, and scarring. Injectable somatostatin receptor ligands may also negatively affect patient quality of life; patients have reported anxiety, frustration, and loss of independence caused by the injections. Accordingly, oral octreotide capsules (OOCs), such as Mycapssa, were developed as a potential treatment option to address challenges encountered with injectable medications. Recent data suggests that maintenance of mean IGF-1 levels for the OOC group from baseline to end of treatment indicates that patients who switched from injectable somatostatin receptor ligands to oral octreotide capsules retain biochemical control of acromegaly. The medical evidence supports the requested medication in this clinical setting. Therefore, Mycapssa 20 mg capsule DR is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 54-year-old male who has a history of bilateral nasal congestion. In a letter dated 6/26/20, the provider noted that the patientas symptoms include no nasal discharge, difficulty breathing, no postnasal drip, no sinus pain, no headaches, no sore throat, and no ear fullness.The patient has requested authorization and coverage for repair nasal vestibular stenosis (CPT 30465). 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 the submitted documentation supports the medical necessity of the requested services. This patient has bilateral nasal obstruction. He has enlarged turbinates, deviated septum and valve collapse. A Cottle maneuver showed improvement of nasal breathing, indicating nasal vestibular stenosis. The provider is planning on septoplasty, bilateral turbinate reduction, and repair of bilateral vestibular stenosis. Vestibular stenosis is diagnosed by observing valve collapse and a positive Cottle maneuver. Not repairing the vestibular stenosis will cause the patient to continue to have difficulty with nasal obstruction. Expanding the nasal valve is essential in improving nasal obstruction in patients with valve collapse. Therefore, the requested repair nasal vestibular stenosis (CPT 30465) is medically necessary for the treatment of this patient.