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

Summary Reviewer 


A 64-year-old female enrollee has requested authorization and coverage for an epidural steroid injection. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.  The physician reviewer found that the request for an epidural steroid injection is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient presents with chronic low back pain, and acute abdominal pain. The patient has stenosis at L4-5 without documented lower extremity pain, and negative for straight leg raise. The physical exam revealed no signs of radiculopathy including deep tendon reflexes or straight leg raise changes. Given the lack of documented signs and/or symptoms of radiculopathy, the requested services are not indicated for this patient. Therefore, 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 patient is a 58-year-old male. He presented to the emergency department on 8/18/20 with lower abdominal pain, nausea, and chills for two days, as well as constipation with no bowel movement for days. The patient has requested reimbursement for inpatient hospital level of care provided from 8/18/20 through 8/21/20. 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 the submitted documentation fails to demonstrate the medical necessity of the services at issue. In patients with uncomplicated diverticulitis, outpatient management or observation is the standard of care. The safety and efficacy of outpatient management of acute uncomplicated diverticulitis has been demonstrated. A systematic review of the literature underscored this [4]. The observation level of care can be appropriate over outpatient care when there is a possible microperforation. In this case, there was a locule of free air, which suggested microperforation, leukocytosis on presentation, and distended abdomen with ileus and ongoing lack of bowel movements on the day after presentation. However, there was no protracted fever or hypotension to suggest that antibiotics were ineffective. The patient improved on intravenous antibiotics and was appropriately discharged on oral antibiotics. His diet was gradually advanced as he started having bowel movements on the night after presentation. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, abscess, fistula, or other complication, was documented. Therefore, inpatient hospital level of care provided from 8/18/20 through 8/21/20 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 64-year-old male with attention deficit/hyperactivity disorder (ADHD) and intermittent explosive disorder. The patient was most recently prescribed divalproex for mood stability and Vyvanse for ADHD. The medical record made no mention of substance use disorder and did not detail the past psychiatric history or outcome of prior medications tried and failed. It appears that the patient was prescribed mixed-amphetamine salts for his ADHD, but experienced excessive perspiration, which prompted the prescription of Vyvanse in July 2017.  On 8/14/17, the records noted that the medication was well-tolerated and efficacious, and the hyperhidrosis resolved. The patient has requested coverage for Vyvanse 30 mg capsules. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  Stimulant medication is the gold standard pharmacologic intervention for ADHD.  Vyvanse is a central nervous system stimulant that was approved by the United States Food and Drug Administration in 2007 for the treatment of ADHD. The compound is a prodrug of dextroamphetamine. After oral administration, Vyvanse is rapidly absorbed and converted to dextroamphetamine, which is responsible for the drugs activity. Amphetamines generate a clinical effect by inhibiting norepinephrine and dopamine reuptake into the presynaptic neuron and increasing release of these monoamines into the extraneuronal space of the prefrontal cortex. In this patients case, the medical records do not substantiate the medical necessity of Vyvanse. Considering that amphetamines are associated with greater potency and mood lability when compared to methylphenidate-based products, and both classes are indicated for the treatment of ADHD, it would reasonable, safe and appropriate to trial long-acting methylphenidate. Considering this patients comorbidity, the Health Insurers alternative methylphenidate may be a better clinical fit. All told, Vyvanse 30 mg capsules are not medically necessary for the treatment of this patient. Therefore, the requested medication is 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 63-year-old female enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) performed on 3/14/16.   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 patients case.  This patient has a very strong family history of breast cancer with a lifetime risk of 26.4%.  Mammography is a first-line screening tool for breast cancer, but the technique has well-known limitations.  In a patient with a lifetime risk exceeding 20-25%, the American Cancer Society has recommended annual MRI exams as an adjunct to mammography due to the increased sensitivity in detecting early cancer.  In sum, MRI of the breasts performed on 3/14/16 was likely to have been superior over 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 63-year-old female enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) performed on 3/14/16.   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 that breast MRI has an important role in both screening and diagnostic settings.  In the last several years, several organizations, including the American Cancer Society and the American College of Radiology, have attempted to establish guidelines for the appropriate use of breast MRI.  The medical literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  In this patients case, the records document a calculated lifetime risk for developing breast cancer of 26.4%.  The National Comprehensive Cancer Network recommends that annual breast MRI be considered and begun 10 years prior to the age at which the youngest relative developed breast cancer.  In her case, her daughter developed relatively severe breast cancer at age 42.  For this patient, MRI was warranted.  Therefore, MRI of the breasts performed on 3/14/16 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 63-year-old female enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) performed on 3/14/16.   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.  According to Warner and colleagues, screening with both MRI and mammography might rule out cancerous lesions better than mammography alone in women who are known or likely to have an inherited predisposition to breast cancer.  The literature supports the use of breast MRI for women with higher risk of breast cancer.  This patient has a strong family history of breast cancer, and it was appropriate to screen for breast cancer with MRI.  Thus, MRI of the breasts performed on 3/14/16 was likely to have been more effective than other modalities.  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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a seven-year-old male enrollee has requested reimbursement and prospective authorization and coverage for inpatient mental health treatment from 2/8/17 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 that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. The patient was admitted to an inpatient unit in mid-November 2016.  The patients stay was approximately three months prior to the Health Insurers denial. The progress notes reflect variable behaviors on the part of the patient. It appears that he has days where he exhibits self-injurious behaviors and days where he is calm and cooperative.  However, the progress notes do not reflect a drastic change or improvement in his behavior. He continues to have issues with nonadherence to his medication regimen. The treatment goals listed by the inpatient team appear to be more of long-term goals and include generalization of skills. It is unlikely that generalization of learned skills would occur in an inpatient environment, as this environment is artificial and not indicative of any home type environment.  It is also not clear that continued inpatient care would result in increased adherence to medications, as the patient appears to almost randomly refuse medications. The standard practice in this clinical setting is to utilize an evidence based instrument such as the Child and Adolescent Level of Care Utilization System (CALOCUS) when determining the necessary level of care for children. This system provides a tool that would ensure that a patients level of care meets their individual needs at the least restrictive setting possible. The American Academy of Child and Adolescent Psychiatry always recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports (Winters).  There was a lack of medical information provided to indicate that this patient could not have been treated in a less restrictive setting.  According to the submitted documentation, continued inpatient care is not the least restrictive environment for this patient. As such, inpatient mental health treatment for 2/8/17 forward were not and are not medically necessary. Therefore, for the reasons stated above, 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 

A 33-year-old female enrollee has requested reimbursement for physical therapy/acupuncture provided from 2/01/19 through 4/08/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Osteochondromatosis can cause various clinical issues, including impingement of nerves, causing chronic pain and neurological symptoms and reducing quality of life. Management can include analgesics and other palliative measures. There is no role for prolonged physical therapy for this condition per se, except to address functional issues as needed. In this case, the patient has had pains and functional symptoms. She underwent physical therapy for a prolonged period of time that included various exercises and palliative interventions. As of the time period under review, although she continued to have symptoms, there were no indications that she could not have performed an independent exercise and palliative measure program to address her chronic symptomatology. More physical therapy would not have been expected to positively impact her clinical course or outcomes. The physical therapy in question was not medically necessary for the treatment of this patient. All told, physical therapy/acupuncture provided from 2/01/19 through 4/08/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 41-year-old male who was admitted to the hospital on 2/05/20 following a rollover motor vehicle accident. The patient has requested reimbursement for continuation of sub-acute level stay from 4/18/20 through 4/30/20. 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 Tibial plateau fractures are complicated injuries, each requiring an individualized initial approach, whether surgical or nonsurgical. Early mobilization and other rehabilitation interventions can be helpful in mitigating complications following these fractures, such as joint stiffness and atrophy of the muscles and bony tissues. There is, however, no consensus regarding rehabilitation practices, as immobilization and weight-bearing restriction recommendations from orthopedic surgeons vary widely. There remains a dearth of high-quality literature informing best rehabilitative practices, particularly with respect to the timing of weight-bearing allowance.  Despite surgical and rehabilitative care, these fractures can result in significant persistent impairments with respect to the knee and global functionality. In the current case, as of early to mid-April 2020, the patient had been in the inpatient rehabilitation setting for an extended period of time. He had essentially plateaued at a level where he was requiring assistance for lower body self-care and transfers. He was non-ambulatory but able to propel a wheelchair. Barriers to progress included his body habitus, pain and environmental barriers. There are no indications that he required ongoing inpatient services at the skilled nursing facility level as of 4/28/20 to 4/30/20 inclusively. He did not have skilled nursing needs or ongoing rehabilitation goals requiring inpatient care. His care during that time was custodial in nature, while he awaited re-hospitalization for further surgery. Care from 4/18/20 through 4/30/20 could have been provided in a less intensive setting of care until more intensive rehabilitation could be pursued after additional surgery and with liberalized weight-bearing restrictions. Therefore, continuation of sub-acute level stay from 4/18/20 through 4/30/20 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 48-year-old female enrollee has requested reimbursement for genetic testing performed on 5/25/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees breast cancer. The physician reviewer found that understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise, but is not yet ready for routine clinical use.  Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of NGS, such as with FoundationOne testing, continues to be the subject of ongoing clinical trials, and use outside of a clinical trial at this time is not reasonable or medically necessary. In addition, this patient still has treatment options available to her, such as TDM-1. Thus, genetic testing performed on 5/25/17 was not medically necessary 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 Overturned

Summary Reviewer 1

A 42-year-old male enrollee has requested authorization and coverage for Tremfya. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that Psoriasis is a chronic inflammatory skin disease. Patients typically present with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (anti-TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. The best-documented association is non-melanoma skin cancer with psoralen plus ultraviolet A therapy and cyclosporine. In addition, patients treated with anti-TNF drugs may develop adverse events, such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. Anti-TNF biologic therapies of psoriasis patients increase the risk for malignancy and infection, mandating prior testing for tuberculosis. Tremfya has been recently approved by U.S. Food and Drug Administration for the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy. Tremfya represents a promising therapy, providing an alternative mechanism of action with high efficacy and safety profiles, sustained total skin clearance, and rapid onset of effect in psoriasis patients. Therefore, Tremfya is likely to be superior over other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 42-year-old male enrollee has requested authorization and coverage for Tremfya. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the American Academy of Dermatology guidelines for the management of psoriasis recommend topical therapy as first-line treatment. If ultraviolet therapy is not available, other first-line treatments include: acitretin, adalimumab, cyclosporine, etanercept, infliximab, methotrexate and ustekinumab. In this case, the patient has failed prior therapy with topical medications, narrowband ultraviolet B therapy, methotrexate, Cosentyx, Taltz, Stelara, and Enbrel. He was unable to tolerate Remicade. In a letter dated 1/14/19, the provider stated that the patient requires dual therapy with Otezla and Tremfya to achieve satisfactory control of his psoriasis. However, the combination of Otezla and Tremfya has not been widely accepted as the standard of care in the management of refractory psoriasis. It is not yet known if the combination of Otezla and Tremfya would be safe for long-term use. In sum, Tremfya is not likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 42-year-old male enrollee has requested authorization and coverage for Tremfya. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has severe and refractory disease that severely impacts his quality of life. He has tried many treatments. He is currently on a treatment regimen that is beneficial. The practice of prescribing patients with psoriasis two medications is commonly done and often yields better outcome than monotherapy. Both treatments have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of psoriasis. According to the most recent guidelines published by the American Academy of Dermatology, there is no contraindication to using two FDA approved psoriasis medications together. A randomized controlled trial with the two agents is impractical. There is sufficient support for the requested medication in this clinical setting. Thus, Tremfya is likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 24-year-old male enrollee has requested authorization and coverage for cervical spine surgery at the C4-5 level using the Depuy VG2 allograft cervical space and Depuy Synthes Stim-line instrumentation. 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 this patient presents with progressively worsening and severe neck, right shoulder/arm, and mid-back pain with associated headaches. Signs and symptoms have been reportedly consistent with possible cervical myelopathy, including hand clumsiness and hyperreflexia. His pain is interfering with sleep and activities of daily living. There is imaging evidence of a significant anterior osteophyte at the C5 level with history of superior endplate fracture, and degenerative changes at C4/5 without focal neural compression. There is discogram evidence of severe concordant pain at C4/5. Detailed evidence of a recent comprehensive nonoperative treatment protocol trial and failure has been submitted. The records suggest a history of dysphagia with recent improvement following discogram. Given the persistence of significantly abnormal findings, severe pain and functional limitations, imaging findings of cervical spondylosis with concordant findings at C4/5, and exhaustion of conservative treatment, surgical intervention is medically indicated and supported by evidence-based medical criteria. Therefore, the requested cervical spine surgery at the C4-5 level using the Depuy VG2 allograft cervical spacer and Depuy Synthes Slim-line instrumentation is medically necessary for the treatment of this patient.