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

Summary Reviewer 3


A 65-year-old male enrollee has requested reimbursement for genetic testing performed on 4/16/15.  The Health Insurer has denied this request indicating that the testing at issue was investigational for the evaluation of the enrollees medical condition.  The physician reviewer found that HLA-B5701 genetic testing is the standard of care in the treatment of HIV patients. U.S. Department of Health and Human Services (HHS) guidelines recommend HLA-B5701 genetic testing when initiating antiretroviral therapy or when considering abacavir. The test can take up to 2 to 3 weeks to obtain results so providers generally order the testing ahead of time to prevent a later delay in treatment. In addition, abacavir is a preferred regimen and is likely to be in the next selection of treatment options for this patient.  In sum, HLA-B5701 genetic testing 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, the testing at issue was 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 


A 44-year-old female enrollee has requested has requested reimbursement for magnetic resonance imaging (MRI) (CPT code 73221) performed on 5/16/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary for evaluation of the enrollees bilateral shoulder pain. The physician reviewer found the submitted documentation fails to establish the medical necessity of the diagnostic procedure at issue. The clinical documentation submitted for review does not demonstrate that the patient was treated with a trial of conservative therapy such as anti-inflammatory medications, rest, and physical therapy prior to the MRI. In sum, given the lack of support demonstrating the patient underwent a trial of conservative therapy, the MRI (CPT code 73221) performed on 5/16/16 was not medically necessary for evaluation of the patients medical condition.  Therefore, the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 60-year-old female enrollee has requested authorization and coverage for lumbar fusion surgery. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees low back pain.The physician reviewer found that the lumbar fusion and decompression is utilized to prevent motion of the spine and to shield load bearing across deteriorated spinal joints that can cause pain or neurological disability. The International Society for the Advancement of Spine Surgery (ISASS) guidelines support the use of fusion for the treatment of degeneration disease without spondylolisthesis where conservative management has failed. The ISASS guidelines are also consistent with the standard of care. Evidence of spondylolisthesis is not required and it is a contradiction to the national guidelines referenced above. In sum, guidelines and standard practice support lumbar fusion as medically necessary for treatment of the patients degeneration of the lumbar spine. Therefore, the requested surgery is 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


A 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 8/20/15. 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 that due to the advantages tomosynthesis brings to radiologists in the interpretation of digital mammography, the American College of Radiology (ACR) statement on breast tomosynthesis has urged the technique be removed from the investigational category. The advantages relate to the separation of dense glandular tissue from underlying architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional (2D) mammographic views was likely of more benefit to the patient than had the study been done with 2D imaging alone. 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 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 8/20/15. 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 that the breast tomosynthesis performed on 8/20/15 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. In this case, the patient presented for a breast cancer screening with tomosynthesis. The study by Skaane and colleagues concluded that 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. Based on the medical literature cited above, there is support for the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. 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 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 8/20/15. 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 that 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. In this case, however, there were no problems to be resolved. The patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. In addition, there had been no change when the current study was compared to prior studies. Her breasts were described as being composed almost entirely of fat. Tomosynthesis has not been shown to provide significant increased value in patients who have diffusely fatty breasts.  With diffusely fatty breasts, routine 2D mammography is highly accurate. As such, the breast tomosynthesis performed on 8/20/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available modalities. 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 patient is a 49-year-old female who developed shoulder pain and left leg atrophy. The patient has requested authorization and coverage for Rituxan (rituximab intravenous solution 500 mg/50 mL). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The patient was diagnosed with an inflammatory neuropathy for which Rituximab was requested after intolerance to IVIG. Rituximab is a reasonable alternative in this case. The medical literature includes several studies and reports that support the efficacy of Rituximab in CIDP and CIDP variants. Therefore, Rituxan (rituximab intravenous solution 500 mg/50 mL) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 25-year-old male enrollee has requested authorization and coverage for Stelara injections. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of hidradenitis suppurativa. The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. HS is a painful and debilitating disease that affects physical and emotional health of patients. The apocrine glands become diseased. There are only a few U.S. Food and Drug Administration approved medications for the treatment of HS.  The evidences show that most patients have recalcitrant disease even with surgery and medical treatment. Recently, the pathophysiology of HS is thought to be immunologically influenced and the IL12/23 pathway is implicated in HS based on small studies demonstrating expression of IL12/23 in macrophages infiltrating HS lesioned skin and infiltration of the HS dermis by IL17 producing T-helper cells. Several small case reports of patients experiencing improvement in disease have been published with Stelara (ustekinumab), which blocks IL12/23. The submitted documentation indicates that this patient has failed numerous standard therapies. Smoking and obesity are known to increase disease activity, so smoking cessation would be important for this patient. However, the provider noted that the patient is doing well on the Stelara injections. This patient meets the criteria for the administration of this medication. Accordingly, Stelara injections have been demonstrated as medically necessary for treatment of this patients medical condition. Therefore, based on the information noted 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 Upheld

Summary Reviewer 


The parent of a 15-year-old male enrollee has requested reimbursement for intensive outpatient program (IOP) services provided from 4/28/16 through 7/8/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse. The physician reviewer found that outpatient treatment and least restrictive options are considered first-lines of care as referenced by The American Academy of Child and Adolescent Psychiatry (AACAP), which recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. The documentation indicates that this patient had not been in any type of behavioral health therapy for the three months prior to the disputed stay. Prior to that treatment, the patient was in talk therapy and there was no indication that the patient was receiving outpatient substance abuse treatment to address his substance use, anxiety, or oppositional behaviors. The psychiatric admission evaluation indicates the patient was cooperative and did not demonstrate any suicidal or homicidal ideation. His thoughts were logical and he did not have any cognitive issues that would have prevented participation in outpatient behavioral health therapy for substance abuse treatment. The patient appeared to make progress in treatment. He was cooperative, calm and engaged actively in the IOP. He was able to verbalize improvement in his relationships with family as well as his some of his target symptoms. In large, the treatment progress notes were extremely vague. Outpatient therapy for cannabis use has shown benefit as noted by Gates and colleagues, who noted that those receiving psychosocial intervention used cannabis on fewer days compared with those given inactive control. All told, the IOP services provided from 4/28/16 through 7/8/16 were not medically necessary for treatment of this patients behavioral health issues. 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 Overturned

Summary Reviewer 

A 59-year-old male enrollee has requested reimbursement for magnetic resonance imaging of the knee provided on 12/03/19. 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 total knee replacement is a relatively common successful procedure for pain relief and functional restoration in patients with advanced osteoarthritis. The key to long-term success in both primary and revision total knee arthroplasty is stability, as well as adequate and stable fixation between components and underlying bone. As ligamentous balancing is the key to success, it is necessary to know if a pre-operative trauma has resulted in ligamentous disruption, particularly of the medial or lateral collateral ligament, in order to decide if a posterior stabilized or a more constrained implant will be required. In this case, there was a history of significant trauma to the knee resulting from the large dog running into the knee. This had resulted in pain, swelling, and instability. As such, it was necessary to find out the cause of the reported instability before the surgery. Therefore, the surgeon found it necessary to obtain an MRI scan to evaluate the ligaments prior to the surgical procedure. There is sufficient support for the services at issue in this clinical setting. Therefore, magnetic resonance imaging of the knee performed on 12/03/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 53-year-old female enrollee has requested reimbursement for clinical chemistry test (84999) performed on 10/01/18. 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 this patient had an early stage melanoma. Per the National Comprehensive Cancer Network guidelines, 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. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. 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. Therefore, clinical chemistry test (84999) performed on 10/01/18 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 34-year-old female enrollee has requested reimbursement for emergency room services provided on 12/22/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that this patient presented with low back pain described as spasms. Her pain was not sudden in onset, but had commenced three days prior. The patient had not sustained any recent trauma. She denied any systemic symptoms. The patient was not experiencing any acute neurologic deficit. Because this patients back pain was not acute in nature and was without any systemic symptoms or deficits, it does not meet prudent layperson criteria for an emergency. The patients symptoms on 12/22/17 did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health. Therefore, the Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 49-year-old female with a history of Grovers disease.  She has tried and failed therapy with topical steroids and prednisone. She has had success with a three-month trial of isotretinoin. The patient has requested coverage for Myorisan (isotretinoin) 40 mg 60/30 days. 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. The submitted documentation supports the medical necessity of the requested medication. Grovers disease is a persistent inflammatory condition of the skin which can be associated with severe pruritus.  There are no U.S. Food and Drug Administration (FDA) approved therapies for this condition due to its rarity. There is some evidence in the medical literature that systemic retinoids may be helpful for this condition. This patient has tried and found benefit with isotretinoin. Given the lack of alternatives, there is sufficient support for the requested medication in this patients case. Thus, Myorisan (isotretinoin) 40 mg 60/30 days is medically necessary for the treatment of this patient. Therefore, 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 patient is a 60-year-old female with a diagnosis of psoriatic arthritis. The patient has requested authorization and coverage for Cosentyx. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that although the patient has tried and failed multiple prior therapies for her psoriatic arthritis, she has not tried and failed the additional plan preferred therapies that are not truly medically contraindicated, including Humira, Cimzia Simponi or Stelara. A family history of skin cancer does not constitute a contraindication to any of the preferred therapies. Additionally, Stelara is a drug with a different mechanism of action than the anti-tumor necrosis factor agents that the provider is concerned about. Dobbin-Sears and colleagues noted that Ustekinumab is used in the treatment of psoriatic arthritis following the failure of nonsteroidal anti-inflammatory drugs and conventional disease-modifying antirheumatic drugs (DMARDs), and as an alternative to, or after failure of, an anti-tumor necrosis factor agent. Stelara remains a preferred alternative which is medically appropriate in this setting. Therefore, Cosentyx is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 52-year-old female enrollee has requested authorization and coverage for ablation of varicose veins. 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 medical necessity for ablation of varicose veins has not been established as medically necessary in this clinical setting. The Doppler report lacks a complete, anatomically detailed ultrasound report to ensure that there is junctional reflux in both of the GSVs, the right AAGSV, and left SSV. In the absence of a detailed ultrasound report, the requested services are not indicated for this patient. Based on the above, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 53-year-old female has requested reimbursement for advanced lipoprotein testing.  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 based on the submitted records, this patient presented with some coronary risk.  In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  In sum, advanced lipoprotein testing performed on 3/15/16 was not likely to have been more efficacious than 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 53-year-old female has requested reimbursement for advanced lipoprotein testing.  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 medical records fail to establish the superior efficacy of the services at issue.  There is a lack of accepted studies which demonstrate that strategies to correct the residual risk potentially identified by novel lipoprotein will further reduce cardiovascular risk.  It is not clear that advanced lipoprotein testing adds significant information to what is already known from a fasting lipid panel.  There is insufficient evidence to support the use of advanced lipoprotein analysis in clinical practice.  In sum, advanced lipoprotein testing performed on 3/15/16 was not 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 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.