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

Summary Reviewer 

A 54-year-old female enrollee has requested authorization and coverage for Xyzal 5 mg two tablets per day. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees allergies and sleep difficulties. The physician reviewer found that the Xyzal is a second generation piperazine derivative oral anti-histamine. Xyzal is U.S. Food and Drug Administration (FDA) approved for the treatment of allergic rhinitis, seasonal allergic rhinitis orally at 2.5 or 5 mg once daily. Higher doses are approved for the treatment of chronic idiopathic urticarial. Oral antihistamines are typically second-line therapy for allergic rhinitis after intranasal corticosteroids (Wallace, et al). The patient states that she has used Zyrtec in the past but it stopped working. However, there is a lack of data that pharmacologic tolerance develops to antihistamines (Simons). Also, there is a paucity of evidence that doses of second-generation antihistamines greater than those maximally recommended increase efficacy for allergic rhinitis (Hansen). Although the patient states that the increased dose of Xyzal has helped her sleeping, this is not an FDA approved indication and would not be considered an extenuating circumstance. In this case, there is a lack of evidence of primary therapies being implemented and failed such as avoidance measures and intranasal corticosteroids (Wallace, et al). As such, the request for Xyzal 5 mg two tablets per day is not medically necessary. Based on the foregoing discussion, the requested medication is 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 three-year-old female enrollee has requested reimbursement for acute care hospital admission from 7/01/18 through 7/02/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who experienced bleeding following tonsillectomy.  The physician reviewer found that an adenotonsillectomy is a common surgical procedure in children and is considered to be painful, particularly in the early postoperative period. Up to a week postoperative, children continue to complain of significant discomfort. Patients frequently seek out medical attention, with the majority of patients returning during the first postoperative week for evaluation of bleeding, pain, and dehydration. This patient underwent tonsillectomy, experiencing one episode of post-tonsillectomy bleeding with clot formation. She was referred to the emergency department by the surgeon, and was hemodynamically stable upon presentation. She was admitted, with no further episodes of bleeding. While it was reasonable to monitor her in the hospital post-hemorrhage to establish ability to tolerate food and fluids by mouth, to determine adequacy of pain management, and to ensure no further bleeding, she was overall stable and did not require acute inpatient management. She could have been safely managed at a lower level of care, such as observation. Thus, acute care hospital admission from 7/01/18 through 7/02/18 was not medically necessary 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 Overturned

Summary Reviewer 

The patient is a 48-year-old female who underwent bilateral mastectomies for breast cancer and deep inferior epigastric perforators (DIEP) flap and latissimus flap breast reconstruction. The patient has requested authorization and coverage for three (3) surgical days for reconstructive lymphedema surgeries. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. As noted by the provider, the lymphaticovenous anastomosis procedure will take eight hours of operative time and the free lymph node transplant will take eight hours of operative time. It is not reasonable to plan these procedures for the same operative session, as 16 hours of elective anesthesia time is not reasonable. This is an excessively long anesthesia time for a single operative session. It is not reasonable to expect a surgeon to perform a 16-hour elective procedure and anticipate optimal outcomes. The procedures are made even more complex by the patientas previous surgeries and her history of radiation therapy, raising the risk that the procedures will be even longer than the total anticipated operative time of 16 hours. Staging these procedures is medically appropriate. Therefore, three (3) surgical days for reconstructive lymphedema surgeries are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 34-year-old female enrollee has requested authorization and coverage for ivabradine (Corlanor) 7.5 mg tablet. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees dysautonomia with postural orthostatic tachycardia syndrome (POTS). The physician reviewer found that the patient has documented dysautonomia with POTS, with inappropriate and symptomatic sinus tachycardia on cardiac monitors which has been severely symptomatic and life-limiting over an extended period. In addition to Florinef and Northera to treat POTS, she has been tried on the standard first-line standard therapies including beta blockers, which were ineffective, and midodrine which caused side effects. She was recently started on Corlanor which has markedly improved her symptomatology and tachycardia. Although primarily used for congestive heart failure (CHF), Corlanor has been used for POTS and inappropriate sinus tachycardia. Although not a first-line indication for POTS, there is significant published data, including a randomized trial on the positive effects of Corlanor in POTS and inappropriate tachycardia syndrome (Page, et al; McDonald, et al; Sheldon, et al). As standard first- and second-line medications have already been tried and the patient continued to have life limiting symptoms or side effects, treatment with Corlanor was reasonable and showed significant clinical improvement. Based on the published data, the failure of other first- and second-line medications, and the excellent clinical response, Corlanor 7.5 mg tablet is medically necessary long-term therapy for this patient and this particular clinical indication. Based on the foregoing discussion, 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 Upheld

Summary Reviewer 

The parent of a 15-year-old male enrollee has requested reimbursement for mental health residential services provided from 1/10/18 through 4/20/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. On 12/29/17, the documentation noted that the patient had purchased knives and a taser gun. However, these records are from admission. The records for the disputed timeframe indicated evidence of low risk of harm. Additionally, this note had minimal objective evidence. This record does not document that violent acts or self-harm were committed. In terms of functional status, the records support a score of 2. The patient has demonstrated episodic failure to achieve expected levels of functioning in relationships with family and peers. With regards to comorbidity, the records support a score of 1. The patient did not have active medical problems or active substance use issues. In terms of level of stress of the recovery environment, the records support a score of 2. There is no indication of an unsafe home environment. With regards to level of support of the recovery environment, the records support a score of 2. The patients family was actively involved in treatment on a regular basis. In terms of resiliency and treatment history, the records support a score of 3. It appears that the patients major depression symptoms were under good control with minimal signs or symptoms. He continued to have oppositional behaviors. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient was able to establish positive relationships with clinicians despite oppositional behaviors. In terms of acceptance and engagement of the parents, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 16. This score correlates with intensive outpatient services. Therefore, mental health residential services provided from 1/10/18 through 4/20/18 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 40-year-old female enrollee has requested reimbursement for CPT code 15847, excision, excessive skin and subcutaneous tissue provided on 1/25/16. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees hernia and diastasis recti. The physician reviewer found that the patient has a diagnosis of a reducible ventral hernia, excessive abdominal skin and a rectus diastasis. The pain is attributed to the rectus diastasis and ventral hernia, by evaluation of the provider who recommended a combined procedure. Conservative management stated by the patient included analgesics such as narcotics and over the counter medications. Overall, the patient has evidence of chronic back pain. However, it is not clear if the performed abdominal muscle plication was the likely source of her functional deficit of pain. The repair of diastasis recti is not generally considered to be a functional treatment but can be an integral part of cosmetic procedures including abdominoplasty. As stated by the American Society of Plastic Surgeons (ASPS), abdominoplasty and panniculectomy are typically performed for purely cosmetic indications. In evaluating functional status following abdominoplasty, Coriddi and colleagues noted that, rectus plication did not significantly improve functional outcomes. Oneal and colleagues state that non-operative therapy and significant work-up for other reasons of the pain should be evaluated prior to abdominoplasty with muscle plication. Given that the repair of diastasis recti is not well-recognized as a reconstructive procedure, repair of the diastasis recti was not medically necessary given the findings, review of the photographs, and documentation from the provider. The photographs show evidence of minimal skin excess and mild abdominal protuberance. The provider noted that on examination the diastasis is approximately 2-3 cm, which supports a mild condition. All told, CPT code 15847, excision, excessive skin and subcutaneous tissue provided on 1/25/16 was not medically necessary for treatment of this patients medical condition. Based on these findings, the surgery at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 
The parent of a nine-month-old male enrollee has requested reimbursement for cranial remolding orthosis provided on 6/5/15. The Health Insurer has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollees occipital flattening/plagiocephaly. The physician reviewer found that the American Academy of Pediatrics (AAP) guidelines, on cranial orthotics, state that cranial remolding orthosis is reserved for severe deformities and is not medically indicated for mild to moderate deformities. The AAP also noted that the use of cranial remolding orthosis may be used to confirm the diagnosis and to direct the subsequent management and treatment. Management and treatment of this condition may include molding helmets or surgery. Additionally, referral to a physical therapist may be considered if torticollis does not improve with neck stretching exercises within two to three months. A study by Lipira and colleagues looked at positioning and molding helmets. Their results revealed the following: the helmeted group had a larger reduction than the repositioned group in both maximum (4.0% versus 2.5%; P = .02) and mean asymmetry (0.9% versus 0.5%; P = .02). The greatest difference was localized to the occipital region. Another important facet to consider is the developmental outcome of the infant. Miller and colleagues looked to see if there was an increased rate of later developmental delay in school-aged children who presented as infants with deformational plagiocephaly, without obvious signs of delay at the time of initial evaluation. They concluded that infants with deformational plagiocephaly comprised a high-risk group for developmental difficulties presenting as subtle problems of cerebral dysfunction during the school-age years. In this patients case, he was diagnosed with severe plagiocephaly. The AAP guidelines as well as the medical literature support the use of cranial remolding orthosis for treatment of this patient. Therefore, for the reasons stated above, the equipment at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


The parent of a 14-year-old male enrollee has requested authorization and coverage for the ReWalk Exoskeletal Device durable medical equipment (DME). The Health Insurer has denied this request indicating that the requested equipment is investigational for treatment of the enrollees T8 incomplete spinal cord injury due to spinal tumor.  The physician reviewer found the ReWalk exoskeleton relies on arm strength to maintain balance and posture with bilateral Canadian crutches. This patients level of cord dysfunction at T8 is significantly below the intervention of his arms and his skills as a pianist would imply significant arm dexterity. Both his rehabilitation provider and his physical therapist state that he has mastered the system and can ambulate when fitted with the exoskeleton. In the medical literature, Goemaere and colleagues noted concern that non-standing paraplegics will lose bone density. Kunkel and colleagues reported improved bone density with standing and as well as reduction in contractures. Jain and colleagues found that there is a significant impact with standing in the emotional well-being of a paraplegic. Further, White and Hayes found success with use of the ReWalk system in their studies. Moreover, the U.S. Food and Drug Administration (FDA) approved the ReWalk system as a medical device in 2014 for use in this clinical setting. Given this support, the requested ReWalk Exoskeletal Device DME is likely to provide this patient with an improved health outcome beyond that anticipated with standard available alternatives. Based upon the information set forth above, the requested equipment is 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

The parent of a 14-year-old male enrollee has requested authorization and coverage for the ReWalk Exoskeletal Device durable medical equipment (DME). The Health Insurer has denied this request indicating that the requested equipment is investigational for treatment of the enrollees T8 incomplete spinal cord injury due to spinal tumor.  The physician reviewer found the current peer-reviewed medical literature supports the requested ReWalk Exoskeletal Device as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Miller and colleagues noted that, powered exoskeletons allow patients with spinal cord injury to safely ambulate in real-world settings at a physical activity intensity conducive to prolonged use and known to yield health benefits. Asselin and colleagues reported that paraplegic patients were able to ambulate efficiently using the powered exoskeleton for overground ambulation, providing the potential for functional gain and improved fitness. The clinical documentation submitted for review indicated the patient had a spinal cord injury due to a cancerous tumor. The patients cancer was in remission. The patient was in a wheelchair. The patient had reduced lung capacity. The patient had a successful trial of the unit with an improved ability to ambulate and to transfer from one position to another. The peer-reviewed literature indicates that exoskeletons such as the ReWalk device may allow patients to ambulate with a normal velocity and may assist the patient to have improved fitness. An upright posture may also permit this patient to have an increase lung capacity, whereas, continual sitting in a wheelchair has led to decreased lung capacity. According to the support in the medical literature as well as this patients performance with a trial with the requested device, the ReWalk Exoskeletal Device is 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 equipment is 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


The parent of a 14-year-old male enrollee has requested authorization and coverage for the ReWalk Exoskeletal Device durable medical equipment (DME). The Health Insurer has denied this request indicating that the requested equipment is investigational for treatment of the enrollees T8 incomplete spinal cord injury due to spinal tumor.  The physician reviewer found that based on the available medical literature, the requested ReWalk device is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The U.S. Food and Drug Administration (FDA) approval allows the use of this device by the public with a physicians prescription. However, the benefits with respect to health and mobility in the setting of this condition have not been conclusively established. The published data are scarce and low quality (Lajeunesse, et al). The ReWalk device is an adjunctive mobility device that is less efficient and less reliable than standard mobility devices. For these reasons, the requested ReWalk Exoskeletal 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 equipment 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 Overturned

Summary Reviewer 1

A 48-year-old female enrollee has requested authorization and coverage for reconstructive lymphedema surgeries and one (1) inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrolleeas condition than any available standard therapy. The physician reviewer found that transplantation of lymph nodes with a blood supply is termed vascularized lymph node transfer (VLNT). This procedure involves harvesting a lymph node or several lymph nodes along with their vascular supply from a donor site and transferring this vascularized tissue to the affected extremity as a free tissue transfer. A microsurgical anastomosis is performed between the blood vessels of the lymph node flap and the recipient site vessels, thus establishing blood flow to the lymph node flap. While both lymphaticovenous anastomosis and VLNT have been demonstrated to be effective in the treatment of lymphedema, the provider plans to combine both procedures in a three-part surgery over three consecutive days. Chen and colleagues conducted a pilot series of combined VLNT and lymphaticovenous anastomosis for lower extremity lymphedema compared with VLNT alone. The authors reported, aAt one year follow up, the VLNT and lymphaticovenous anastomosis group scored a greater circumference reduction rate at all levels in comparison to the VLNT group. Nevertheless, no statistically significant difference was found.a Treatment combination of VLA and VLNT at the same procedure appears to be investigational at this time. Therefore, reconstructive lymphedema surgeries and one (1) inpatient bed day are not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 48-year-old female enrollee has requested authorization and coverage for reconstructive lymphedema surgeries and one (1) inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrolleeas condition than any available standard therapy. The physician reviewer found that 
there is sufficient support for the requested services in this clinical setting. Chang and colleagues noted, aMany studies seem to support some efficacy of lymphovenous bypass and vascular lymph node transfer.a Beederman and colleagues followed 274 patient and reported, aPatients with secondary upper or lower extremity lymphedema who undergo vascularized lymph node transplant/lymphovenous bypass demonstrate improved functional status and reduced affected limb volumes postoperatively. Patients with upper extremity lymphedema appear to have a more substantial reduction in limb volume differential compared to lower extremity lymphedema patients.a Coriddi and colleagues noted, aPhysiologic surgical treatment of lymphedema results in improved quality of life outcomes in most patients.a Based on the literature, lymphaticovenous anastomosis and vascularized lymph node transfer offer benefits to patients who have undergone extensive attempts at decongestive therapy and still have significant lymphedema. The patient is noted to be compliant with her therapy. Therefore, reconstructive lymphedema surgeries and one (1) inpatient bed day are likely to be more beneficial than other available standard therapy.