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

Summary Reviewer 

The parent of a 14-year-old female enrollee has requested reimbursement for acute psychiatric inpatient treatment provided from 4/15/19 through 5/03/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In terms of risk of harm, the records support a score of 5. The records documented an extreme risk of harm, due to suicidal ideation with plan and recent self-harm. With regard to functional status, the records support a score of 4. The patient had serious functional impairment due to conflict with parents and recent threats of self-harm. In terms of comorbidity, the records support a score of 1. There was no comorbidity, due to lack of substance abuse, medical concerns, or developmental concerns. With regard to stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to multiple school changes and recent trauma involving an online pedophile making threats to harm the patient and her family. In terms of environmental support, the records support a score of 2. The patient had a supportive environment due to her parents involvement in treatment and treatment planning. With regard to resiliency and treatment history, the records support a score of 5. The patient had minimal response to recent treatment, including multiple hospitalizations and residential treatment. In terms of treatment acceptance and engagement, the records support a score of 4. The patient demonstrated initial resistance to participating in treatment. Thus, the patient has a total score of 24. Due to the extreme risk of harm, medically managed residence-based services were indicated. Furthermore, due to multiple recent treatment failures with shorter hospitalizations, an extended hospitalization incorporating an extended diagnostic assessment, intensive treatment and careful treatment planning was indicated for this high-risk patient. Therefore, acute psychiatric inpatient treatment provided from 4/15/19 through 5/03/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 




The parent of a 15-year-old female enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) mental health care services provided from 11/9/16 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 issues. The physician reviewer found that the documentation provided for review provides insufficient evidence to support that IOP treatment from 11/9/16 forward was not and is not medically necessary for treatment of this patients medical condition. The records report that the patients overall mood had improved, and there was no documentation of self-harming behavior. The patient continues to have frequent mood dysregulation which appears to be a chronic issue. However, there is a lack of data supporting the efficacy of further IOP treatment for her chronic mood dysregulation. There is no indication that she was or is having any medical problems from anorexia nervosa that require frequent monitoring. The provider recommended the patient engage in dialectical behavioral therapy (DBT) and seek a specialist to help with the patients mood dysregulation. Thus, the records indicate that the patient was a candidate for treatment as an outpatient. All told, IOP mental health care services provided from 11/9/16 forward were not and are not medically necessary for treatment of this patients anorexia nervosa, major depressive disorder, and social anxiety disorder. Based on the foregoing discussion, 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 Upheld

Summary Reviewer 


The parent of a nine-year-old female enrollee has requested reimbursement for a dental expander. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees dental condition. The physician reviewer found There is a lack of support for the services at issue in this clinical setting.  The documentation indicates that the patient was treated with a palatal expander due to a narrow upper arch with crowding and description of a unilateral crossbite.  While the handicapping labio-lingual deviation index was 27, the method of scoring was questionable.  There is no documentation provided to corroborate this score, and the scoring does not appear congruous with the limited case notes provided.  The records included no preoperative work-up other than the handicapping labio-lingual deviation index score, which may have been calculated retrospectively.  The literature does not have a consensus on whether interceptive treatment is always necessary, relying on variables such as whether the crossbite observed is unilateral or bilateral, whether that noted is a true unilateral crossbite or caused by a variation in the path of closing, and the degree of crossbite.  The submitted records fail to demonstrate the medically necessity of the services at issue in this patients case.  All told, the dental expander 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 64-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma gene expression profile testing performed on 7/23/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. Therefore, DecisionDx-Melanoma gene expression profile testing performed on 7/23/18 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 15-year-old female enrollee has requested reimbursement for mental health inpatient treatment services provided from 8/25/16 through 8/26/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder. The physician reviewer found that applying the guidelines from the American Psychiatric Association (APA), the mental health inpatient treatment services provided from 8/25/16 through 8/26/16 were not medically necessary for treatment of this patients eating disorder. In records dated 8/25/16, the patients weight was 141.2 pounds and 117.7% of her ideal body weight and she was compliant with her meal plan. Thus, the patient did not require 24-hour supervision in a highly restricted setting in a mental health treatment environment to manage her anorexia and depression safely and adequately. All told, the mental health inpatient treatment services provided from 8/25/16 through 8/26/16 were not medically necessary. Based on the foregoing discussion, the services at issue were 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 16-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 2/21/19 forward. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions.The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. During the dates of services at issue, in terms of risk of harm, the records support a score of 1. The patient has not had self-harm behaviors since 1/03/19. With regards to functional status, the records support a score of 2. The patient reported urges to engage in eating disorder behavior without participating in eating disorder behaviors. In terms of comorbidity, the records support a score of 3. The patients diagnoses included anorexia nervosa, major depressive disorder and generalized anxiety disorder with a history of suicide attempts in the past and self-injurious behavior. With regards to level of stress of the recovery environment, the records supported a score of 2. The patients family was engaged in treatment and recovery. In terms of level of support of the recovery environment, the records support a score of 2. The parents were engaged in treatment. In terms of resiliency and treatment history, the records support a score of 2. On 2/25/19, the patient noted decreased depression. No self-harm behavior or urges were noted. In terms of acceptance and engagement of the child, the records supported a score of 2. On 2/25/19, the patient reported feeling more hopeful, and her behavior was described as more social. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents were actively involved in treatment. Thus, the patient has a composite score of 16. This score correlated with outpatient services. Therefore, mental health residential treatment provided from 2/21/19 forward were not and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 51-year-old female who developed neck and left shoulder pain after spending more time using a computer for work. The patient has requested reimbursement for physical therapy services provided from 2/15/21 through 5/05/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that this patient had been undergoing physical therapy for a long time, without documented significant functional benefit. Despite the therapy, she continued to have symptoms. The patient could have been transitioned to independent exercises or modalities that would have been expected to be no less effective for her condition than the ongoing physical therapy under review. There is no proven benefit of prolonged formal exercises or manual therapy for her conditions. The treatment of calcific tendinopathy revolves around analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and steroid injections in the painful acute phase and exercises to avoid stiffness of the shoulder. The treatment of frozen or stiff shoulder consists of addressing etiological factors, addressing pain to allow for range of motion, initiation of a gentle range of motion program, and progression of the program over time. Progression of the program does not require formal therapy. The current medical evidence does not support the services at issue in this clinical setting. Therefore, physical therapy services provided from 2/15/21 through 5/05/21 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The parent of a 12-year-old female enrollee has requested reimbursement for fecal calprotectin testing provided on 7/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that the current medical literature suggests that this test is commonly used by providers in the care of Crohns disease patients. There are ample studies demonstrating the usefulness of calprotectin in the diagnosis and continued care of Crohns disease patients. All told, the peer-reviewed medical literature supports the utility of the fecal calprotectin testing performed on 7/17/15 as likely to have been more beneficial for evaluation of this patients Crohns disease than any available testing. Based upon the information set forth above, I have determined 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

The parent of a 12-year-old female enrollee has requested reimbursement for fecal calprotectin testing provided on 7/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that given the available medical literature, there is a role for fecal inflammatory markers including calprotectin in this clinical setting. The testing is a non-invasive means of gauging the presence of intestinal inflammation. Moreover, the use of fecal calprotectin values have become more widely used in inflammatory bowel disease centers and are routinely being incorporated into research studies given their value in distinguishing inflammatory from non-inflammatory symptoms. Considering the importance of determining response to treatment in patients with Crohns disease, the fecal calprotectin testing performed on 7/17/15 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, I have determined 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

The parent of a 12-year-old female enrollee has requested reimbursement for fecal calprotectin testing provided on 7/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that Fecal calprotectin is a noninvasive laboratory test which is frequently used in clinical practice to evaluate for the presence of intestinal inflammation. In addition to its utility in screening for inflammatory bowel disease, it also has utility in evaluating for flares or recurrent inflammation in the setting of known inflammatory bowel disease. This test can be particularly helpful in a situation where a patients symptoms may be due to another cause, to assess for presence of deep remission in a patient who is asymptomatic, and to evaluate for response to treatment in a patient with atypical or mild symptoms at diagnosis. Fecal calprotectin testing has become a standard measurement in the practice of pediatric gastroenterology, as it often allows the physician to avoid or defer a repeat colonoscopy on a child. All told, there is adequate peer-reviewed medical data demonstrating that the fecal calprotectin testing provided on 7/17/15 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 59-year-old male who sustained left ear trauma while riding his bicycle. The patient has requested reimbursement for otoplasty performed on 10/14/19. 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 the submitted photographs document left facial trauma. Post-acute photographs show a missing left earlobe, and photographs post repair show a natural looking earlobe on the left side. No other ear deformity is seen. Per the records, the patient underwent reconstruction of a partially avulsed left earlobe with release of the left ear scar contracture, adjacent tissue transfer, and full thickness skin graft. Hendricks and colleagues stated, aProminent ears are by far the most common congenital ear deformity. Many techniques have been described using one or a combination of three basic methods: cartilage cutting, cartilage weakening and pure cartilage shaping techniques. The ideal otoplasty technique should yield a natural correction of the deformity, with low recurrence rates and with little risk of complications.a Otoplasty is considered in the medical literature to refer to correction of a variety of causes of prominent ears. In this patientas case, there was no report of prominent pinna or corrected deformity of the pinna in the medical information received for review. Therefore, the otoplasty performed on 10/14/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 49-year-old female enrollee has requested reimbursement for Guardant 360 provided on 11/01/17. 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 molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Molecular profiling, such as with Guardant 360, is reasonable and medically necessary. Therefore, Guardant 360 testing provided on 11/01/17 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 57-year-old female enrollee has requested reimbursement for DecisionDX-melanoma gene expression test performed on 8/12/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees left cutaneous melanoma. The physician reviewer found that the staging and prognosis of cutaneous malignant melanoma is classically determined by the system discussed by Balch and colleagues. There may be some further value in adding the mitotic rate to this system. By Balch staging, the melanoma would be classified as T2b and with the negative sentinel nodes, her stage would by IIA. This predicts for a 10 year survival of at least 64%. DecisionDX is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either Class 1 (with a greater than 90% disease free survival at five years), or Class 2 (with a less than 80% disease free survival at five years). Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDX classification, in patients undergoing sentinel node sampling. However, it is not clear how the five year DecisionDX data compares to the 10 year Balch data, and whether it can be used additionally to make clinical decisions. Berger and colleagues reported on 156 cases but there was not sufficient follow-up to determine the actual value of the test. The National Comprehensive Cancer Network (NCCN) guidelines state that there is interest in these types of assay but they can only be used in the context of a clinical trial. In sum, DecisionDX-melanoma gene expression test performed on 8/12/16 was not likely to have been more effective than the other options available in the evaluation of this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 57-year-old female enrollee has requested reimbursement for DecisionDX-melanoma gene expression test performed on 8/12/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees left cutaneous melanoma. The physician reviewer found that the DecisionDX-melanoma gene expression profile test  has been developed in patients with stage I and II cutaneous melanoma. However, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. In addition, this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. Per the National Comprehensive Cancer Network (NCCN) guidelines, the gene expression profile test is still not recommended for routine (baseline) genetic testing of primary cutaneous melanomas. Accordingly, the gene test performed on 8/12/16 was not likely to have been of greater benefit than available standard therapy for the evaluation of this patient.Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.