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

Summary Reviewer

The patient is a 49-year-old male with a history of acute trauma to the thigh resulting in a thigh compartment syndrome. He underwent an emergency fasciotomy; however, the submitted documentation indicates the treating surgeon was not familiar with post-surgical care. The record noted a 14-inch draining skin incision. The patient was transported by air ambulance from Florida to Dallas, Texas. The patient has requested reimbursement for air ambulance services provided on 11/25/17. The Health Plan has denied this request and reported that the services at issue were not medically necessary. This denial is the subject of this appeal and determination.  There is sufficient support in the documentation and the medical literature for the medical necessity of the services at issue. Early fasciotomy is the gold standard of prevention and treatment of compartment syndrome; however, the resulting wounds may significantly increase morbidity. To address the challenge of timely and safe closure of fasciotomy wounds, numerous methods have been described. Thorough knowledge of available techniques and their comparative advantages is essential for their clinical implementation, careful selection of patients, management of possible complications, decreased morbidity, and hospital recovery time are also crucial for optimization of functional and aesthetic outcomes. The patient had a 14-inch long draining wound and the submitted documentation indicates the initial surgeon was not familiar with current fasciotomy wound closure techniques. Transfer by air ambulance to a tertiary care institution was needed in light of the 14-inch long draining open wound and the patients pain. There was an urgent need for wound management at a tertiary care center to prevent deep infection, facilitate healing, and prevent complications such as deep vein thrombosis. The patient could not utilize public transportation due to the need for maximum assistance with ambulation. His ambulation was limited to use of bathroom only with assistance. He required dressing changes by medical personnel with sterile precautions as needed to keep wound clean during transport. While the record had noted that the patients vital signs were stable, stable vitals do not mean a sudden change in vitals cannot take place at any moment due to bleeding from an open wound. The presence of emergency medical personnel was essential. Tertiary care in Dallas, Texas was chosen because it was near his home. His treatment in Orlando, Florida would have necessitated a prolonged stay for follow-up care and inability to use public transportation. As noted above, the surgeon in Florida was unfamiliar with vacuum assisted closure.  Vacuum assisted closure technique has one of the lowest complication rates. In sum, air ambulance services provided on 11/25/17 were medically necessary for treating this patients medical condition. Therefore, for the reasons stated above, the services at issue were 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 

A 56-year-old female enrollee has requested authorization and coverage for Oxycontin. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to establish the medical necessity for the requested medication. According to Argoff and Silvershein A review of published studies found no data to suggest that either short acting opioids or long acting opioids are generally more efficacious for treating any particular chronic non-cancer pain condition. In this case, the patient has a long history of pain and has had a number of interventions with ketamine infusions, sympathetic blocks, and opioids. However, there is no notation of results of a prior urinary drug testing before the conversion to another opioid medication, especially since the prescribing provider has had limited interaction with this patient to establish a baseline.  All told, the medical necessity of the requested mediation has not been established in this clinical setting. Therefore, 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 Overturned

Summary Reviewer 

A 30-year-old female enrollee has requested reimbursement for extended inpatient stay at Sharp Memorial Hospital provided from 11/04/17 through 11/06/17. 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 postoperative ileus is a delay in the return of gastrointestinal motility after surgery, and is common after colectomy. It can result in nausea, abdominal pain, absence of flatus, and absence of bowel movements, all of which this patient had. Postoperative ileus is the main determinant of the length of stay after colorectal surgery. Postoperative ileus can justify an extended length of stay after surgery. Additionally, given the risk for post-colectomy complications, a prolonged postoperative ileus raises concerns for complications such as leak or intra-abdominal infection, supporting the inpatient level of care until ileus had resolved in this case. These concerns are heightened in patients with possible Crohns disease, especially those on anti-tumor necrosis factor medications. Therefore, the extended inpatient stay provided from 11/04/17 through 11/06/17 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 63-year-old female enrollee has requested reimbursement for breast tomosynthesis (three-dimensional mammogram) performed on 10/31/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found the medical literature supports the service at issue in this patients case. Skaane and colleagues noted the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, three-dimensional mammogram performed on 10/31/16 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the service 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 63-year-old female enrollee has requested reimbursement for breast tomosynthesis (three-dimensional mammogram) performed on 10/31/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that there is sufficient support for the service at issue in this patients case. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. In sum, breast tomosynthesis (three-dimensional mammogram) performed on 10/31/16 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the service 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 63-year-old female enrollee has requested reimbursement for breast tomosynthesis (three-dimensional mammogram) performed on 10/31/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  A routine mammogram would have been sufficient in this clinical setting.  Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms. Thus, breast tomosynthesis (three-dimensional mammogram) performed on 10/31/16 was not likely to have been more efficacious than other modalities for evaluating this patient.  Based upon the information set forth above, the service at issue was 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 Upheld

Summary Reviewer 

The parent of a 17-year-old female enrollee has requested reimbursement for psychiatric residential treatment center services provided from 7/17/18 through 9/13/18. 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. The medical records indicate that the patient was not actively suicidal. She did engage in some self-harm behavior prior to her treatment. In terms of functional status, the records support a score of 3. The patient had issues with level of functioning due to mental illness in the past. She had been missing school due to her anxiety and withdrew from school in March 2018. During the initial portion of treatment, it was noted that she would at times go a few days between showers. With regards to comorbidity, the records support a score of 1. The patient did not have active medical problems or substance use that affected primary psychiatric issues. In terms of level of stress of the recovery environment, the records support a score of 2. There was no indication of an unsafe home environment. In terms of 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. With regards to resiliency and treatment history, the records support a score of 3. She showed engagement with providers, and previous treatment had not been successful in optimal relief of symptoms. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient was hesitant to participate in treatment after admission for a brief timeframe. Overall, she was cooperative in treatment. With regards to 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. Therefore, the patient has a composite score of 17. This score correlates with intensive outpatient services. Therefore, psychiatric residential treatment center services provided from 7/17/18 through 9/13/18 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 26-year-old female enrollee has requested reimbursement for CPT code 81291 performed on 10/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a family history of a clotting disorder. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. The American College of Obstetricians and Gynecologists notes that there is a lack of association between either heterozygosity or homozygosity for the methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism and negative pregnancy outcomes, including any increased risk of venous thromboembolism. Thus, screening with either MTHFR mutation analyses or fasting homocysteine levels is not recommended. In sum, CPT code 81291 performed on 10/11/17 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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 26-year-old female enrollee has requested reimbursement for CPT code 81291 performed on 10/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a family history of a clotting disorder. The physician reviewer found there is is support for the services at issue in this clinical setting. As it relates specifically to evaluation of pregnancy losses, the testing performed is not indicated. However, the medical evidence supports testing when a patient or a first-degree relative has a history of a thrombotic event. This patients family history indicates that she may be at higher risk during pregnancy and during the immediate postpartum time period, and the results of this testing may impact patient management. Therefore, CPT code 81291 performed on 10/11/17 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 26-year-old female enrollee has requested reimbursement for CPT code 81291 performed on 10/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a family history of a clotting disorder. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Knowledge of the patients MTHFR status does not impact her care during pregnancy. All pregnant patients are advised to have adequate folic acid intake to prevent neural tube defects.  There is no recommended treatment during pregnancy for a known mutation in the MTHFR gene. Thus, the superior efficacy of CPT code 81291 performed on 10/11/17 has not been established. 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 Upheld

Summary Reviewer 

A 34-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the shoulder. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees shoulder pain. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. There are multiple possible causes for traumatic shoulder pain, including pathology within the rotator cuff, glenohumeral joint, labrum or osseous structures. The initial imaging examination for the evaluation of traumatic shoulder pain is radiographs. Radiographs can detect unsuspected fracture or dislocation, arthritis, calcific tendinopathy or avascular necrosis. MRI is the next appropriate test for the evaluation of shoulder pain with normal radiographs when a rotator cuff disorder is suspected. MRI is highly accurate in the diagnosis of rotator cuff tendinosis and rotator cuff tears. Additionally, soft tissue detail is optimally depicted on MRI, such as tendon retraction, muscle atrophy and fatty infiltration. These findings can alter the course of management in the setting of rotator cuff injury. According to the American College of Radiology (ACR) appropriateness criteria for the evaluation of shoulder pain, radiographs are usually the appropriate initial imaging examination, followed by MRI, when rotator cuff or internal pathology is suspected. In this case, radiographs should be the initial test, prior to MRI. Thus, the requested MRI of the shoulder is not medically necessary for the evaluation of this patient. Therefore, the requested services are not medically necessary for evaluation 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 40-year-old female with a history of psychosis, mood instability and diagnosis of bipolar affective disorder. The patient has requested reimbursement for inpatient services provided from 6/25/20 through 7/02/20. 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. Although the patient met medical necessity criteria for inpatient level of care upon her initial presentation on 6/11/20, she had stabilized significantly by 6/25/20. As of 6/26/20, she was noted to be well-groomed, her mood was happy, and she had less thought blocking. At this point, she could have been discharged to a lower level of care. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. In terms of risk of harm, the records support a score of 2. The patient had a low risk of harm given lack of suicidality. She did endorse situation passive suicidal ideation upon learning of discharge. With regard to functional status, the records support a score of 3. The patient was disabled from mental illness and could not work. She had some disturbance in eating and sleeping habits, although they were improving. In terms of comorbidity, the records support a score of 2. The patient had minor medical comorbidity and had no substance abuse problems. With regard to level of stress of the recovery environment, the records support a score of 2. The patientas recovery environment was mildly stressful. She is away from family on the East Coast and more isolated due to COVID-19. Her husband is supportive. In terms of level of support for the recovery environment, the records support a score of 2. The patient had an outpatient psychiatrist and is able to advocate for her needs. With regard to treatment history, the records support a score of 2. The patient has had good response to outpatient treatment in general and her last inpatient hospitalization was 2015. In terms of engagement, the records support a score of 2. While inpatient, the patient had been adherent with treatment plan, including medication. Therefore, the patient has a composite score of 15. Thus, she did not meet criteria for inpatient level of care. All told, inpatient services provided from 6/25/20 through 7/02/20 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 46-year-old female enrollee has requested reimbursement for substance use residential treatment provided from 6/07/18 through 6/24/18. 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 in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 2 due to a lack of current suicidal ideation with active intent or plan. The records noted that the patient had passive suicidal ideation. With regards to functional status, the records support a score of 3 due to overall fair functional level in treatment but consideration of functional problems when in the community and using substances. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and history of mood symptoms. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living environment with roommates. In terms of level of support of the recovery environment, the records support a score of 2 due to overall supportive recovery environment. With regards to treatment and recovery history, the records support a score of 3 due to current motivation for treatment but unclear response to treatment in the past. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment. Thus, the patient has a composite score of 16. This correlates with low-intensity community-based services. Therefore, residential treatment was not medically indicated. In sum, substance use residential treatment provided from 6/07/18 through 6/25/18 was not medically necessary for the treatment of this patient.