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

Summary Reviewer 


A 36-year-old male enrollee has requested reimbursement for the Oncotype DX colon cancer assay performed on 10/9/14. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees colon carcinoma. The physician reviewer found that presently, medical evidence shows that adjuvant chemotherapy confers a survival advantage for patients with stage III colorectal cancer but not for those with stage II disease (Gray, et al). Meta-analyses have not shown any survival advantage for 5-FU/leucovorin treatment in stage II patients but the reasons for these findings are complex. The benefits for stage III patients are significant and it is likely that stage II patients benefit as well (Figueredo, et al). Therefore, subset analyses to identify patients with prognostic features that may predict for chemotherapy benefit have been analyzed (Benson, et al). The Oncotype DX test uses a reverse transcriptase-polymerase chain reaction assay for 12 genes in an algorithm that can be used to predict recurrence (OConnell, et al). The test was validated independently in the QUASAR trial as an excellent prognostic indicator (Gray, et al). Consistent with this support, the Oncotype DX colon cancer assay performed on 10/9/14 was medically necessary for evaluation of this patients colon cancer. In conclusion, the testing at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 58-year-old female who presented to her provider on 2/04/21 because of chronic knee pain.  The patient has requested reimbursement for an MRI performed on 2/12/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that MRI is the most optimal means to evaluate an internal derangement. Plain x-rays are of only limited value. The American College of Radiology (ACR) has established aAppropriateness Criteriaa to help referring practitioners in the most efficient and efficacious use of imaging for various clinical presentations. Several variants are described. The first is titled aChronic knee pain. Initial imaginga, and in that variant, MRI is felt to be not appropriate, but it recommends plain x-rays. However, the following three variants describe chronic knee pain when the initial knee x-ray is negative or when it is positive for multiple x-ray abnormalities. In each of these variants, MRI is felt to be ausually appropriatea. In other words, regardless of the plain x-ray findings, an MRI may be worthwhile. The reason that plain x-rays are of only limited value is that the menisci and ligaments are not visible on plain x-rays. One can assess the degree of degenerative disease and whether there are any acute bony structural abnormalities, but this information is only of limited interest in this patient. One can assume that she does not have a fracture, and whether or not she has degenerative change has no bearing. The Health Insurer contends that the patient should have had documentation of various physical examination maneuvers to justify the MRI. The patient was seen by a sports medicine practitioner. An experienced sports medicine practitioner should be able to assess the need for an MRI and potential surgical correction on clinical grounds. In this patient, she had knee symptoms for at least two months and already had physical therapy and conservative management. There is sufficient support for the services at issue in this setting. Therefore, the MRI performed on 2/12/21 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 30-year-old female enrollee has requested reimbursement for laboratory services (82784, 83718, 85652, 84480, 84479, 84478, 82607, 36425, 86705, 85025, 86665, 86665. 86664, 83540, 83550, 86803, 86645, 80053, 86790, 86790, 86663, 82306, 84481, 84443, 86039, 86038, 82465, 86644, 82728, 82746, 87340, 86709, 82784, 82784, 80061, 80074 and 80050) provided on 8/16/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that code 83718 represents a test for lipoproteins and was not medically necessary because there was no evidence of a lipid-related disease. Code 84478 represents a measurement of triglycerides and was not medically necessary because there was no evidence of a lipid-related disease. Code 86705 represents hepatitis B core antibody and was not medically necessary because other hepatitis B screening was also done. Code 85025 represents a complete blood count and was not medically necessary because the same test was apparently coded as 80050. Code 86803 represents a test for hepatitis C and was not medically necessary because a screening test for all three types of viral hepatitis had also been done. Code 86663 represents an Epstein-Barr virus antibody and was not medically necessary because Epstein-Barr virus does not cause chronic fatigue. Code 87340 represents a test for hepatitis B surface antibody and was not medically necessary because a screening test for this infection was also ordered. Code 86709 represents a test for hepatitis A antibody and was not medically necessary because a screening test for this infection was also ordered.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer
 
The patient is a 37-year-old female with a history of mood and psychotic disorder and borderline personality disorder. The patient was admitted to a residential treatment center (RTC) three weeks after she reportedly overdosed on Ativan. She was admitted to the RTC on 12/29/15. The patient was treated with psychotherapy, milieu therapy, and psychopharmacology with Geodon and lithium. The patient has requested reimbursement for RTC services provided from 1/15/16 through 2/11/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. Based on the Level of Care Utilization System (LOCUS) criteria, an accepted, national standard for determining the appropriate level of care for adults, the patient demonstrated moderate risk of harm (score 3) given a suicide attempt three weeks prior to her admission at the RTC.  However, the patient had some improvement in the RTC and did not have any suicidal or homicidal ideation by 1/15/16. The patient had moderate functional impairment (score 3) with a serious deterioration in her ability to fulfill her responsibilities. She has ongoing severe interpersonal deficits. The patient has made progress while she has been in the RTC. Documentation by 1/15/16 states that the patient had improved insight, was more self-aware, was more engaged, and her psychotic symptoms were resolving. The patient had significant co-morbidity (score 3) with a mood and psychotic disorder as well as borderline personality disorder. The patients recovery environment was moderately stressful (score 3) as she broke up with her boyfriend four months prior to entering the RTC and this was seen as a major transition for the patient. The patient had limited support from others (score 3) and she demonstrated equivocal response to treatment and recovery (score 3) as she had been treated in an outpatient settings prior to her admission. The patient demonstrated limited engagement and recovery (score 3) as she was attentive and engaged during treatment. However, the patient was guarded and would not share her entire inner-experience. Documentation states that the patient showed more self-awareness and has been more engaged in groups. This gives the patient a composite score of 21, which is consistent with partial hospitalization program (PHP). The patient required treatment for her mood and psychotic disorder and borderline personality disorder, but this could have been done at a PHP level of care. Therefore, the RTC services provided from 1/15/16 through 2/11/16 was 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 7/11/15.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. In addition, there is support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, as this case. 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 provided on 7/11/15.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that Tomosynthesis provides advantages to radiologists in the interpretation of digital mammography. Tomosynthesis allows for the separation of dense glandular elements from underlying mass/architectural distortion especially in cases of heterogeneously dense tissue, such as in this case. This often results in a decrease in callbacks and increase in detection of small cancer. For these reasons the addition of tomosynthesis to the usual two-dimensional (2D) views was likely of greater benefit to the patient than had the exam been done using 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 3


A 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 7/11/15.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the breast tomosynthesis performed on 7/11/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. In this case, the patient has heterogeneously dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  All told, the services at issue were 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 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 Overturned

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 11/16/15 through 12/15/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse, depression, and post-traumatic stress disorder (PTSD).   The physician reviewer found that the records indicate that this patient had been receiving treatment at the IOP level of care for the three months immediately prior to his admission to RTC. He was transferred because he was not making progress and was considered at high risk for suicide. His history also reveals severe functional impairment. In addition, he had three previous psychiatric hospital admissions prior to the RTC. Thus, he meets the American Society of Addiction Medicine (ASAM) criteria for 24-hour treatment as he was considered a high risk for harm, he had severe social impairment that could not be managed with IOP, and had a history that his providers noted placed him at high risk for destabilization and relapse without RTC level of care. He also needed high levels of motivation from staff to address his lack of treatment engagement. Given these findings, the RTC services provided from 11/16/15 through 12/15/15 were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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 28-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 10/18/18 through 2/12/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that 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 1 due to a lack of current suicidal or homicidal ideation or self-harm. With regards to functional status, the records support a score of 2 due to some difficulty meeting obligations and disruptions in usual activities. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to stable medical issues and no active substance use. With regards to level of stress of the recovery environment, the records support a score of 2 due to recent move back in with parents. In terms of level of support of the recovery environment, the records support a score of 2 due to positive relationship with family overall and parents ability to aid her. With regards to treatment and recovery history, the records support a score of 3 due to no significant recent intensive forms of treatment prior to her residential admission and unclear response to prior treatment. In terms of engagement and recovery status, the records support a score of 3 due to variability in cooperation in treatment and limited insight into the need for treatment. The patient has a composite score of 15. This score of correlates with high intensity community-based services. Therefore, residential treatment was not medically indicated. Thus, mental health residential treatment provided from 10/18/18 through 2/12/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 62-year-old female enrollee has requested reimbursement for carotid duplex scan performed on 4/26/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees right carotid bruit. The physician reviewer found that Carotid artery disease is considered asymptomatic in the presence of narrowing of the internal carotid artery without a history of symptoms or physical examination findings consistent with ischemia in the ipsilateral carotid territory.  Nonspecific symptoms, such as dizziness and lightheadedness, are not indicative of carotid stenosis. Therefore, patients with these symptoms are considered asymptomatic. Guidelines from the U.S. Preventive Services Task Force do not recommend screening for carotid artery stenosis for patients that are asymptomatic. Furthermore, there is a lack of evidence that the auscultation of the neck to detect carotid bruits is accurate or provides benefit.  In this case, the documentation does not support that the patient had symptoms which were concerning for carotid artery stenosis.  She is considered asymptomatic, as she has not had symptoms that would indicate ischemia in the ipsilateral carotid artery territory of the brain. Thus, carotid duplex scan performed on 4/26/17 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

An 18-year-old female enrollee has requested reimbursement for mental health residential treatment from 7/17/17 through 9/16/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees 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. The progress notes indicate that the patient was not engaging in self-harm behaviors or expressing suicidal ideation. She did have a history of suicidal ideation and attempts. In terms of functional status, the records support a score of 2. The patient has had some issues with level of functioning, but the progress notes indicate significant improvement after a period of deterioration as evidenced by appropriate activities of daily living and grooming. With regards to comorbidity, the records support a score of 2. The patient did not have active medical problems and reported a history of mild cannabis use issues.  She did not describe continued cravings, and there was no documentation of withdrawal symptoms from substances. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have interpersonal conflict with the family as a focus of treatment. However, the progress notes document that her family therapy sessions were productive and not adversarial. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. In terms of resiliency and treatment history, the records support a score of 3. The patient had good response to a short period in the residential treatment center prior to the disputed dates. Her presentation during the disputed timeframe indicates that she was cooperative in treatment. She had a history of residential treatment in the past, and it is not clear that her symptoms resolved with past treatment efforts. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy actively and was able to develop a positive relationship with clinicians. In terms of acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient had a composite score of 17. This score correlates intensive outpatient services. Therefore, mental health residential treatment provided from 7/17/17 through 9/16/17 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 20-year-old female who has been diagnosed with a maxillofacial skeletal deformity. The patient has requested authorization and coverage for reconstruction midface, LeFort 1; three or more pieces, segment movement in any direction, without bone graft (21143) and reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy, with bone graft (includes obtaining graft) (21194). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. The patient has a maxillofacial skeletal deformity that cannot be corrected with orthodontics alone. The requested surgery will result in improved musculoskeletal and dento-osseous relationships and improvement in mastication and associated temporomandibular joint and associated muscular disorders. The requested procedure is medically appropriate for the treatment of this patientas  condition and is within generally accepted standards of medical care. Therefore, reconstruction midface, LeFort 1; three or more pieces, segment movement in any direction, without bone graft (21143) and reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy, with bone graft (includes obtaining graft) (21194) are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 58-year-old male enrollee has requested authorization and coverage for endovenous laser therapy procedure. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who is diagnosed with venous insufficiency. The physician reviewer found that the 58-year-old male enrollee has requested authorization and coverage for endovenous laser therapy procedure. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who is diagnosed with venous insufficiency.