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

Summary Reviewer 3

A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 9/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the services at issue in this clinical setting. Corneal collagen crosslinking has been U.S. Food and Drug Administration (FDA) approved as a treatment for progressive keratoconus. In this case, based on the patients young age and significant progression in the right eye, he was at risk for further progression of the keratoconus. Thus, corneal collagen crosslinking performed on 9/04/18 was likely to have been superior over other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 19-year-old male enrollee has requested reimbursement for behavioral health services from 3/01/17 through 3/10/18. 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 Psychiatric Association treatment guidelines for substance use disorders note that  intensive outpatient program level of care can be used as step-down programs for individuals leaving hospital or residential settings who are at a high risk of relapsingto stabilize patients by retaining them in treatment and providing more extended intensive outpatient monitoring of relapse potential and co-occurring disorders. In this patients case, the six dimensions for American Society of Addiction Medicine Level 2.1 (intensive outpatient program) are met. The patient had an unclear risk of withdrawal. There were no medical conditions/complications reported. His emotional/behavioral/cognitive conditions/complications included comorbid anxiety and attention deficit/hyperactivity disorder. Per the records, he was only in the contemplation phase, thus requiring a structured program. The patient had a high likelihood of relapse, given his admission to his parents that he desired to continue substance use as well as his failed urine drug test in March 2018. The patient was unable to engage with his parents in a way that would allow his environment to be supportive. Intensive outpatient program level of care was in accordance with generally accepted standards of medical practice. Therefore, behavioral health intensive outpatient services from 3/01/17 through 3/10/18 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 38-year-old male enrollee has requested reimbursement for the homocysteine testing provided on 9/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees anemia. The physician reviewer found that Homocysteine was performed as part of this patients anemia work-up, specifically as a companion test to vitamin B12 level along with methylmalonic acid. Measurement of the serum concentrations of the metabolic intermediaries homocysteine and methylmalonic acid can be more sensitive for the diagnosis of vitamin B12 deficiencies than serum vitamin levels alone (Lindenbaum, et al). If concentrations of both metabolites are increased, vitamin B12 deficiency is confirmed, with a sensitivity and specificity of 94% and 99%, respectively (Savage, et al). Consistent with this support, the homocysteine testing provided on 9/5/14 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, I have determined 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 38-year-old male enrollee has requested reimbursement for the homocysteine testing provided on 9/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees anemia. The physician reviewer found that in the case under discussion, the patient was being evaluated for anemia. Part of the differential is nutritional deficiency in folate or vitamin B12. Discriminating between these two deficiencies is possible by analyzing homocysteine and methylmalonic acid levels. Homocysteine levels are elevated in folate deficiency since methyl-tetrahydrofolate is a methyl donor to cobalamin. In contrast, folate is not required for the conversion of methylmalonyl-CoA to succinyl-CoA where S-adenosylcobalamin is the cofactor (Allen, et al; Tefferi). Given these findings, the homocysteine testing provided on 9/5/14 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, I have determined 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 38-year-old male enrollee has requested reimbursement for the homocysteine testing provided on 9/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees anemia. The physician reviewer found that based on the records provided, the patient is a 38-year old male with unexplained anemia. Although elevated homocysteine levels have been associated with anemia, an elevated homocysteine level does not point to a specific cause of the anemia (den Elzen, et al). Moreover there is a lack of clinical trials that demonstrate outcome improvement with treatment targeted at reducing homocysteine levels (Lonn; Toole, et al). Likewise, even though results of homocysteine levels may be abnormal and considered independent risk markers for coronary disease, there is a paucity of scientific data demonstrating outcome benefits by treating routinely obtained abnormal results. Thus, the homocysteine testing provided on 9/5/14 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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 66-year-old male enrollee has requested authorization and coverage for Dupixent 300 mg/2 mL, quantity of four every 30 days. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees asthma. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Dupixent is U.S. Food and Drug Administration (FDA) approved for the treatment of moderate to severe eosinophilic asthma and atopic dermatitis. The patient does not have a diagnosis of atopic dermatitis. Although the records noted severe asthma eosinophilic phenotype, the documentation does not include a recent complete blood count showing peripheral blood eosinophils greater than 150 cells/uL in the last 12 months. The most recent documentation does not support that he has a diagnosis of oral corticosteroid-dependent asthma with persistent airflow obstruction. On 6/05/18, he was noted to have improved and even borderline obstruction in the pre-bronchodilator pulmonary function tests. The plan was to continue the current medications which included Singulair, Zyflo and Symbicort. The records do not support the requested medication in this clinical setting. As of 6/05/18, the patient had borderline obstruction and did not have oral corticosteroid-dependent asthma. Furthermore, there is no documentation in the last year of a complete blood count with significant eosinophilia. Thus, Dupixent 300 mg/2 mL, quantity of four every 30 days is not medically necessary for the treatment of this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a seven-year-old male enrollee has requested authorization and coverage for Saizen 8.8 mg cartridge. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency. The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, the patients height is not more than 2 SDS below the mean for age and gender, and his adult predicted height, based on the bone age and height assessment in March 2015, is approximately 66.5 inches, appropriate for his genetic potential. His growth factors are normal, he does not have any known morphological abnormalities of his pituitary gland, and there is no documentation of abnormal growth velocity for age. The delayed bone age is most consistent with a diagnosis of constitutional delay rather than GH deficiency. The patient underwent provocative testing with serial GH levels assayed for a period of three hours after the baseline measurement, but it is not clear from the results provided that two separate provocative tests were performed, with serial measurements of GH levels for 2-3 hours after each test independently. Although the U.S. Food and Drug Administration (FDA) has approved GH therapy for children with intrauterine growth retardation/small for gestational age with failure to catch-up in height, this patients height is not below the 3rd percentile on the growth curve, and thus he would not meet criteria for failure to catch- up in height. In addition, his adult height prediction is not short enough to qualify for GH on the basis of the FDA-approved idiopathic short stature indication. For the reasons provided, 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 


A 51-year-old female enrollee has requested reimbursement for chiropractic services provided on 5/19/16, 5/25/16, 6/02/16, 6/03/16, 6/06/16, 6/08/16, 6/10/16, 6/13/16, 6/20/16, 6/27/16, 7/01/16, 7/11/16, 7/18/16 and 7/21/16.  The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollees pain. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient has had extensive chiropractic treatment. The records noted that diagnosis of subluxation complex of vertebral of the head region, which is not what the patient states that she is being treated for or improving from. The providers notes are almost the same from each visit, and there is no documented functional improvement.  It is unclear how many visits were rendered under the diagnosis of subluxation complex of vertebral of the head region.  The current medical evidence does not support the services at issue in this clinical setting. All told, chiropractic services provided on 5/19/16, 5/25/16, 6/02/16, 6/03/16, 6/06/16, 6/08/16, 6/10/16, 6/13/16, 6/20/16, 6/27/16, 7/01/16, 7/11/16, 7/18/16 and 7/21/16 were 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 Upheld

Summary Reviewer 

The patient is an 11-year-old male who has been diagnosed with autism spectrum disorder and attention deficit/hyperactivity disorder (ADHD). The patientas parent has requested reimbursement for speech therapy provided from 3/13/19 through 6/12/19. 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. The records indicate that the patient was performing at a range from the average to very superior range in the speech areas of concern, including articulation and pragmatic speech. No short-term speech therapy goals were indicated. The American Speech-Hearing Association lists as one of its criteria for discharge from therapy awhen the communication disorder has been remediated or compensatory strategies have been successfully established.a One of the major areas of language difficulty in children with autism spectrum disorder is pragmatic language. This patient was noted to score in the 97th percentile on the TOPL-2, which was in the superior range. He did not appear to require speech therapy to address deficits in pragmatic language. His pediatrician wrote a referral for speech therapy to address stuttering, but there is no comment regarding stuttering being an issue in his speech therapy reports. Therefore, speech therapy provided from 3/13/19 through 6/12/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 52-year-old male who has been diagnosed with spondylosis without myelopathy or radiculopathy, lumbar region; other intervertebral disc degeneration, lumbar; and low back pain.  The patient has requested authorization and coverage for the Intracept procedure. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that according to the U.S. Food and Drug Administration (FDA) Indications for Use, The Intracept Intraosseous Nerve Ablation System is intended to be used in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain of at least six months duration that has not responded to at least six months of conservative care, and is also accompanied by features consistent with Type 1 or Type 2 Modic changes on an MRI such as inflammation, edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent marrow, hypointensive signals (Type 1 Modic change), and changes to the vertebral body marrow including replacement of normal bone marrow by fat, and hyperintensive signals (Type 2 Modic change). There is a lack of support for the requested services in this patients case. FDA criteria would only have been plausibly met if the patient had chronic low back pain generators that had been clearly delineated as being linked to the spinal vertebral body(s) in origin. In this case, there were/are multiple plausible pathologic sources of significant pain generation. These included the documented tender trigger points (clinically associated with a peri-spinal soft tissue origin) and the tender facet joints (the portion of the spinal vertebrae dorsal to the vertebral bodies themselves). The non-radiating midline back pain, the noted pain-aggravating and pain-relieving factors, along with the diminished and painful spinal motion (in all directions) and intact neurologic examination were/are all non-specific to any pathologic entities. Overall, documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the patients chronic persistent pain. The records do not support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. Therefore, the requested Intracept procedure is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 57-year-old female enrollee has requested authorization and coverage for (azithromycin) Zithromax. 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 Zithromax is used to treat many different types of infections caused by bacteria, such as respiratory infections, skin infections, ear infections, and sexually transmitted diseases. The documentation submitted for review does not support these indications for use of Zithromax in this patients case. Moreover, there is a lack of medical literature for the use of Zithromax in gastrointestinal disease. The medical literature available for the use of Zithromax in gastrointestinal disease was for Parkinsons disease associated with gastroparesis and small bowel bacterial overgrowth, neither of which has been documented in the patients clinical documentation.  For the reasons provided, the patients request for (azithromycin) Zithromax has not been established as medically necessary. For the reasons provided, 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 

The patient is a 54-year-old male who was transported via air ambulance on 10/11/20. The patient has requested reimbursement for air ambulance transportation provided on 10/11/20. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. In order to be medically necessary, specific criteria must be met. These criteria include the following: the individualas condition must be such any form of transportation other than ambulance would be medically contraindicated; the individualas condition is such that time needed to transport by ground poses a threat to the patientas survival; the individual is transported to the nearest hospital with appropriate facilities for treatment; and there is a medical condition that is life-threatening. This patient was struck by the door of his own vehicle as it rolled from a neutral position, dragging him approximately 25 feet before the rear of the vehicle struck a tree. The patient sustained multiple bilateral rib fractures with bilateral pneumothoraces and a liver laceration, from which he could have exsanguinated. Based on the mechanism of injury, and the time needed for ground transport, air ambulance services were medically necessary in this case. Therefore, air ambulance transportation provided on 10/11/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 25-year-old female with a history of chronic sinus problems. The provider reports the patient presented with symptoms of recurring sinus infections requiring antimicrobial treatment four times in the preceding four months. The patients symptoms included facial pressure, headache, generalized fatigue and nasal congestion. The physical examination documented clear mucus and nasal septal deviation suggestive of acute rhinitis, most likely to be of bacterial origin and the provider recommended use of a topical fluticasone nasal spray and nasal irrigations along with computed tomography (CT) imaging of the paranasal sinuses. On 2/13/18, a follow-up note documented that the patient had been evaluated for nasal airway obstruction due to deviated nasal septum and rhinorrhea. CT imaging on 12/27/16 demonstrated that the frontal, ethmoid, maxillary and sphenoid sinuses were clear and that the sphenoid and frontal sinuses were found to be hypoplastic. The ostiomeatal units were found to be patent. This was in comparison to the previous CT scan dated 8/18/16. The patient has requested reimbursement for the CT maxillofacial without contrast material provided on 12/27/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary. Upon the review of the documentation, the provider stated in the physical examination that the patient did have symptoms of recurrent acute sinusitis over four months or longer and had been placed on multiple different medical therapies including antibiotics and other medications, but still had repeated rhinosinusitis. The patient was found on physical examination to have persistent rhinorrhea in addition to nasal septal deviation, which is one of the physical findings on examination to meet criteria for CT scan imaging. Practice guidelines acknowledge that CT imaging, as opposed to the plain radiography or magnetic resonance imaging (MRI), is the diagnostic modality of choice for confirming chronic rhinosinusitis or as an alternative to nasal endoscopy. Thus, the CT maxillofacial without contrast material provided on 12/27/16 was medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the diagnostic procedure 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 Upheld

Summary Reviewer 

The patient is a 62-year-old male with hyperlipidemia, diabetes and coronary artery disease including prior stent placement. There is documented intolerance to several -statins and Zetia. A clinic note dated 10/3/16 documents a low density lipoprotein (LDL) cholesterol of 99 mg/dl while taking pravastatin 80 mg per day. The patient has requested authorization and coverage for Repatha. The Health Insurer has denied this request as not medically necessary indicating the patient must first try the formulary alternative Praluent. Based on the records provided the patient is a 62-year-old male with known coronary disease, intolerance to several statins and Zetia, as well as suboptimal LDL control on maximum tolerated pravastatin dose. In this circumstance PSCK9 inhibitors have been shown to be safe, effective at further reducing LDL levels and result in improved cardiac outcomes. Repatha and Praluent have been demonstrated to be effective in this clinical setting, however there is a lack of controlled trials comparing the relative efficacy of these two medications (Sabatine, et al; Robinson, et al). The use of Repatha over Praluent is not clinically indicated, given that there is no documented intolerance or contraindication to the formulary preferred PCSK9 inhibitor. For the reasons provided, the request for Repatha is not medically necessary for treatment of the patients medical condition.  For the reasons provided, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.