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

Summary Reviewer 3


A 53-year-old female enrollee has requested reimbursement for the bilateral three dimensional digital breast tomosynthesis provided on 10/16/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that there is currently a lack of peer-reviewed literature that supports the use of three dimensional breast tomosynthesis compared to available techniques, especially in a patient without an increased risk of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in randomized clinical trials. All told, the digital breast tomosynthesis on 10/16/15 was not 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 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 Overturned

Summary Reviewer 

A 42-year-old male enrollee has requested authorization and coverage for anterior lumbar interbody fusion to lumbosacral vertebral segment L5 to S1 and two associated inpatient days. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient has a history of chronic low back pain and radicular manifestations in the left lower extremity. Anterior lumbar interbody fusion is associated with higher fusion rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine, including those with instability. There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone anterior lumbar interbody fusion has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. Per Mummaneni and colleagues, With regard to the type of interbody spacer used, frozen allograft is associated with lower pseudarthrosis rates compared with freeze-dried allograft; however, this was not associated with a difference in clinical outcome. The current medical evidence supports the requested services in this clinical setting. Therefore, anterior lumbar interbody fusion to lumbosacral vertebral segment L5 to S1 and two associated inpatient days are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15.  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 sufficient support for the services at issue in this clinical setting.  According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  The medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  All told, breast tomosynthesis performed on 7/13/15 was 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 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 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15.  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 current medical evidence supports the services at issue in this clinical setting.  Due to the tomographic nature of the technique, breast tomosynthesis allows radiologists to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers.  In this case, it was more advantageous for the patient to have her mammogram include breast tomosynthesis than having had it with two-dimensional imaging alone.  Therefore, breast tomosynthesis performed on 7/13/15 was likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were 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 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15.  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 breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this case, the patients presenting symptom was breast pain.  Breast pain is rarely associated with breast cancer, especially without a recognizable mass.  In addition, her breast density was described as containing scattered areas of fibroglandular elements.  Her breasts were not particularly dense.  Breast tomosynthesis has not been shown to provide significant increased value in this clinical setting.  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 Overturned

Summary Reviewer 

The parent of a 15-year-old female enrollee has requested authorization and coverage for Focalin XR 25mg, 1 capsule every morning. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees attention deficit disorder (ADD) without hyperactivity.   The physician reviewer found in a study by Borgheini, brand name medications had a higher bioavailability than generic medication. This same study also indicated that illness recurred quite readily after brand was switched to generic. Desmarais and colleagues in a review article citing studies from 1974 through 2010 raise concern about the efficacy of generic drugs versus their brand equivalents, suggesting that amount of active ingredients in the generic was quite different than similarly dosed brand names. These studies indicate that use of generic medications may lead to higher dosing requirements and may lead to relapse of symptoms or need for more intensive services. Medical guidelines generally recommend change in medication after two to three failed medication trials.  In this is a case, Adderall XR, Concerta and Metadate CD and Vyvanse were tried and failed in some significant way. While there may be other products on the market with similar ingredients, medical studies have shown that some individual patients may respond better to one product over another. Upon review of this patients submitted medical records, this appears to be one of those cases. Therefore, the requested Focalin XR is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 56-year-old female enrollee has requested reimbursement for the hip surgery (CPT codes 29914 and 29915) provided on 6/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees right hip impingement syndrome. The physician reviewer found that surgical treatment of symptomatic femoroacetabular impingement aims to improve symptoms, potentially delay hip osteoarthritis, and prevent the need for a possible total hip arthroplasty. Hip arthroscopy and open surgical hip dislocations are the two most common surgical approaches used for this condition. The arthroscopic procedure avoids some of the complications of open surgery and results in over 75% positive results. Femoroacetabular impingement may be of the cam or pincer-type or it may be mixed. In this patients case, the femoroacetabular impingement was mixed, degenerative changes were mild, and conservative treatment failed to improve her condition, thus surgery was recommended. The patient met the surgical criteria for the procedure which included correction of the cam and pincer as well as repair of the labrum. Based upon a review of the medical records including the magnetic resonance imaging (MRI) scan and operative report, the hip surgery (CPT codes 29914 and 29915) provided on 6/17/16 was 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 56-year-old female enrollee has requested reimbursement for the hip surgery (CPT codes 29914 and 29915) provided on 6/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees right hip impingement syndrome. The physician reviewer found that in the peer-reviewed medical literature, Hellman and colleagues reviewed five approaches for surgical management of femoroacetabular impingement syndrome, including arthroscopy. The authors reported that when nonsurgical treatment methods fail, surgical options were recommended, but there was no long-term outcome data to support one method over another. Harris and colleagues concluded that the outcomes of operative treatment of femoroacetabular impingement are significantly better than nonsurgical management. This patient presented with a three year history of hip pain that had severely worsened six months prior to initial examination. The pain interfered with her work duties and activities of daily living. Clinical examination findings were consistent with femoroacetabular impingement syndrome. She failed over six months of conservative treatment including activity modification, chiropractic care, ice, and anti-inflammatory medications. There were no significant degenerative findings of the right hip. Therefore, the right hip arthroscopy with femoroplasty and acetabuloplasty (CPT codes 29914 and 29915) performed on 6/17/16 was 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 56-year-old female enrollee has requested reimbursement for the hip surgery (CPT codes 29914 and 29915) provided on 6/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees right hip impingement syndrome. The physician reviewer found that Femoroacetabular impingement is recognized as a common cause of hip pain resulting from abnormal contact between the proximal femur and acetabular rim. Abnormalities can be identified on either the femoral or acetabular side, but are most commonly seen on both sides. Harris and colleagues demonstrated that surgical treatment is effective and recommended in patients who fail to improve with routine conservative therapy. In this case, the patient is a physical trainer who performed activity modification and independent exercise, underwent chiropractic care, and was treated with nonsteroidal anti-inflammatory medications and opioid pain medications. The 4/23/16 magnetic resonance imaging (MRI) was interpreted as demonstrating moderate to high grade cartilage loss, but that appears to have been an overestimate based on the preoperative x-rays and operative findings documented in the surgical report. The 4/26/16 x-rays did not reveal substantial cartilage space narrowing. All told, the hip surgery (CPT codes 29914 and 29915) provided on 6/17/16 was 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 


A 42-year-old female enrollee has requested authorization and coverage for Trokendi XR. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees migraine headaches. The physician reviewer found that there is sufficient support in the medical literature and in the submitted documentation for the requested medication. Trokendi XR is an extended release version of topiramate. Its pharmacokinetic studies indicate smoother exposure, and less variation of blood levels compared to the immediate release formulation. Studies indicate better tolerability, fewer side effects, and better patient acceptance. Clinical notes in this case also indicate that the patients tolerability has been better at comparable doses. A review of topiramate studies in migraines treated with extended release topiramate support a clinically meaningful benefit of extended release topiramate versus immediate release topiramate in terms of significantly fewer cognitive effects, improved adherence, and overall better outcomes of migraine prophylaxis with topiramate. Based on the clinical notes, she has done better with Trokendi then the generic, immediate release. Trokendi XR is U.S. Food and Drug Administration approved and indicated for migraine prevention. While it has the same active ingredient as generic topiramate, it is not therapeutically equivalent as evidenced by studies as well as in this patient. All told, Trokendi XR is medically necessary for treatment of this patients medical condition.Therefore, for the reasons stated above, the requested medication is 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 

The patient is a 63-year-old male who was diagnosed in 2015 with mild obstructive sleep apnea with an apnea-hypopnea index of 8 per hour. The patient failed oral appliance treatment. He was recently diagnosed with lung sarcoidosis. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. This patient was diagnosed with obstructive sleep apnea by a home sleep study in 2015. This type of testing can underestimate the severity of the patients disease. He failed oral appliance. The patient is symptomatic and has lung sarcoidosis, which may affect the accuracy of a new home sleep study. Per the records, CPT code 95811 is medically indicated to diagnose and treat this patient appropriately. Therefore, CPT 95811, split night sleep study, is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 46-year-old female enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) with computer aided detection performed on 11/10/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollee, who has a history of left breast ductal carcinoma in situ. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  Breast MRI has an important role in both screening and diagnostic settings.  MRI studies of the breast are highly sensitive, but have a relatively low level of specificity.  In some studies, the specificity of breast MRI has been reported to be as low as 37%.  There is a lack of evidence to support the use of MRI as a surveillance tool rather than conventional mammography.  Concerning DCIS, there is considerable literature which suggests that the term carcinoma should be dropped when describing these changes.  Often, DCIS is characterized as stage 0, or a pre-cancerous condition.  The National Comprehensive Cancer Network (NCCN) has recommended routine follow-up physical examinations and regular follow-up mammography for surveillance following a diagnosis of DCIS.  The NCCN does not recommend follow-up surveillance MRI.  In this case, there has been no submitted information which would warrant routine use of MRI for this patient.  All told, breast MRI with computer aided detection performed on 11/10/15 was not medically indicated for the evaluation of this patient.  Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 39-year-old female has requested reimbursement for Anser ADA testing performed on 6/25/15. 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.  There is insufficient evidence to support the use of Anser ADA testing.  Studies performed thus far have included retrospective cohorts or have employed an observational design. There is a need for randomized controlled trials of tumor necrosis factor level and antibody driven care versus standard of care.  Therefore, Anser ADA testing performed on 6/25/15 was not likely to have been superior over 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 2


A 39-year-old female has requested reimbursement for Anser ADA testing performed on 6/25/15. 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 not currently sufficient medical evidence to support the effectiveness of Anser ADA compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small and retrospective and/or observational in nature. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect.  Therefore, Anser ADA testing performed on 6/25/15 was not likely to have been of greater benefit than other modalities for evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 39-year-old female has requested reimbursement for Anser ADA testing performed on 6/25/15. 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 this patient has been maintained on Humira but developed relapse of symptoms.  Anser ADA testing measures the Humira blood level and detects antibodies to Humira.  Patients with detectable levels and no antibodies will have to have a change in treatment management in order to control their disease, as the test implies an escape phenomenon to Humira.  Patients with undetectable levels and antibodies are under-dosed and a higher dose will be needed to achieve remission and control of disease.  Also, patients with a low level and detectable antibodies have a low drug level due to the development of antibodies. In this case, the patient responds to a higher dose and/or a higher frequency, or both.  It is important for the treating provider to have a roadmap of the nature of the patients clinical course.  There is sufficient support for Anser ADA testing in this patients case.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.