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

Summary Reviewer 


A 63-year-old female enrollee has requested reimbursement for inpatient hospital stay provided from 8/5/15 through 8/6/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the medical necessity for the inpatient hospital stay provided from 8/5/15 through 8/6/15 has not been established in this clinical setting. On 8/5/15 the patient presented to the ED following an episode of altered level of consciousness. The patient did not have a significant history of cardiovascular disease. At the time of admission, the patient was described as being awake and alert, without any new focal neurologic or cardiac findings. The laboratory studies and imaging performed in the ED were unremarkable. None of the patients testing results revealed pathology that required complex therapy or that prompted urgent intervention. Finally, no complicating event occurred during the course of the hospital stay to require an escalation in the patients level of care, or to necessitate more intense monitoring. The patient was discharged from the hospital on 8/6/15 with plans to follow up at a later date. In sum, the documentation provided failed to support the medical necessity for inpatient admission on the dates in dispute. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 41-year-old transgender female who has been diagnosed with gender dysphoria. In a letter dated 11/05/19, the provider noted that facial feminization surgery was a medically necessary treatment of her gender dysphoria. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. The World Professional Association for Transgender Health (WPATH) position statement noted non-genital surgical proceduresnotably facial feminization surgeryare often of greater practical significance in the patients daily life than reconstruction of the genitalsThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Therefore, surgery (67900, repair of brow ptosis, 21121, genioplasty, 31599, unlisted procedure larynx, 30410, rhinoplasty, 21138, reduction forehead, contouring and application of prosthetic material or bone graft, 21295, reduction of masseter muscle and bone, 21172, reconstruction superior-lateral orbital rime and lower forehead, and 20926, tissue grafts) provided on 12/09/19 with associated inpatient admission were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 47-year-old female enrollee has requested reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck and shoulder pain. The physician reviewer found that the American College of Occupational and Environmental Medicine (ACOEM) state that if manipulation does not bring improvement in three to four weeks, it should be stopped and the patient reevaluated. In this case, while the patient presented with subjective pain, the provider has not documented clinical assessments and evaluations to support continued treatments. Most importantly, the records do not include discussions on objective functional improvement as an indication for the extended duration of care. Per 10/19/15 report, the patient was instructed to use ice as needed and to take NSAIDs at her discretion. The patients diagnosis on 7/6/16 included cervicalgia and pain in right shoulder. Overall, the medical necessity for continued chiropractic care cannot be determined without documentation of objective functional improvement. Therefore, reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16 were not medically necessary for treatment of this patients medical condition. Based on the records provided, 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 Upheld

Summary Reviewer 1


A 52-year-old female enrollee has requested authorization and coverage for sclerotherapy. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition.  The physician reviewer found that review of the submitted documentation and relevant literature fails to support the requested services in this clinical setting. With respect to the right leg, the documentation does not support the proposed treatment. The patient reports on multiple occasions that the issue is with her left leg. Her symptoms are mild on the right leg. With respect to the left leg, sclerotherapy is not indicated given the lack of evidence demonstrating that the truncal reflux has been corrected and in the absence of truncal reflux, the patients activity limiting symptoms persist. For the reasons provided, the requested services are not likely to be more beneficial for treatment of this patients medical condition than the available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 52-year-old female enrollee has requested authorization and coverage for sclerotherapy. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition.  The physician reviewer found that the requested services are not likely to be more effective for this patient than other available options. There is insufficient evidence in the record to support this indication. Both ultrasound reports are insufficient and below reporting standards for the disease. In addition, both direct and ultrasound guided primary venous sclerotherapy lack support in the literature. The review by Tisi and colleagues suggests that the current place of sclerotherapy in modern clinical practice is limited to the treatment of accessory recurrent varicose veins following surgery and thread veins. In sum, sclerotherapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 52-year-old female enrollee has requested authorization and coverage for sclerotherapy. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition.  The physician reviewer found that in this case, the ultrasound report does not indicate the extent of involvement of the great saphenous vein (or the sizes) and also does not indicate if the saphenofemoral or saphenopopliteal junctions are involved. There is also no indication of the size of the veins. The short saphenous vein in particular is described as only having reflux in its cranial extension. Despite the above, sclerotherapy is clinically indicated in this clinical setting given the lack of other treatment options available.  Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1
A 26-year-old male enrollee has requested reimbursement for cervical discography injection provided on 6/25/20. The Health Insurer indicates that the services at issue were investigational for the treatment of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue.  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Additional records were reviewed, and these records fail to demonstrate the superior efficacy of the services at issue. Manchikanti and colleagues concluded that lumbar provocation discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic lumbar discogenic pain. The evidence is weaker for cervical and nonexistent for thoracic discography. In this case, the patient has been treated for cervical pain. There is a history of cervical spine fusion in March 2019. The patient developed worsening neck pain for which he has undergone extensive conservative pain management, with no clinical response. He demonstrated high cervical mechanical pain characteristics unassociated with any significant referral or radiation. Examination revealed no high cervical facet clinical provocation by deep palpation. He is neurologically intact. However, there are limited large-scale, long-term references showing the safety and efficacy of this modality. There were no extenuating circumstances in this patients clinical data to support otherwise. Therefore, cervical discography injection provided on 6/25/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 26-year-old male enrollee has requested reimbursement for cervical discography injection provided on 6/25/20. The Health Insurer indicates that the services at issue were investigational for the treatment of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that neck pain in patients with clinical evidence of radiculopathy or myelopathy can be easily localized by clinical, electrodiagnostic, and imaging evidence and treated by anterior cervical surgery. Cervical discography is indicated when the pain is discogenic, but the imaging studies do not show a herniation or localized cervical spondylosis. Discography can localize the pain source by distinguishing between the painful, symptomatic discs from the asymptomatic non-painful discs. Discogenic neck pain alone without evidence of cervical disc herniation or cervical spondylosis constitutes a significant percentage of patients with chronic neck pain who are resistant to conservative treatment, as in this case. For patients who continue to have refractory neck pain and fail to respond to conservative treatment, anterior cervical fusion surgery or artificial cervical disc replacement may be a better choice, and preoperative cervical discography can guarantee that the pain source will be addressed, resulting in an excellent surgical result. Therefore, cervical discography injection provided on 6/25/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 26-year-old male enrollee has requested reimbursement for cervical discography injection provided on 6/25/20. The Health Insurer indicates that the services at issue were investigational for the treatment of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found this case was previously reviewed, and additional records were submitted. These additional records fail to demonstrate the superior efficacy of the services at issue. Cervical discogram or provocative discography in general has been controversial. In this case, it was unlikely that multiple levels were the cause of discogenic neck pain with normal imaging studies and absent any disc herniations. The patient is status post anterior cervical discectomy and fusion in 2019, with no relief of symptoms and significant narcotics use. The level of evidence for provocative discography is low in this setting. Therefore, cervical discography injection provided on 6/25/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 35-year-old female enrollee has requested authorization and coverage for CPT codes 64635-50 and 64636-50. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees sacroiliac joint dysfunction. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  This patient has a history of severe low back and lower extremity pain.  She underwent various modalities of treatments, without success.  Diagnostic sacroiliac joint blocks provided her with excellent pain relief.  This patients symptomatology and diagnostic assessments meet the criteria for radiofrequency neurotomy.  The current medical evidence supports radiofrequency neurotomy in managing sacroiliac joint pain confirmed by diagnostic blocks.  All told, the requested CPT codes 64635-50 and 64636-50 are medically indicated for the treatment of this patient.  Therefore, the requested services are medically necessary for treatment 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 62-year-old male who presented with complaints of severe low back pain. Past surgical history was positive for L4/5 and L5/S1 laminectomy. The physician reviewer found that this patient presents with persistent severe mechanical back pain. Functional limitations are noted in activities of daily living. Clinical examination findings have documented pain with lumbar flexion and extension. He is neurologically intact. He is status post prior laminectomies at the L4/5 and L5/S1 levels. There is imaging evidence of degenerative disc disease at L4/5 and L5/S1. There is radiographic evidence of 4 mm spondylolisthesis at L4/5. He has failed to improve with conservative treatment, including activity modification, medications, and physical therapy. Evidence-based peer-reviewed literature supports the use of lumbar fusion for patients with severe degenerative disc disease and spondylolisthesis. Given the patientas significant mechanical pain, failed conservative treatment, imaging findings of reportedly severe degenerative disc disease at L4/5 and L5/S1, prior lumbar laminectomy at both levels, and spondylolisthesis at L5/S1, the request for lumbar fusion surgery is supported to improve pain and restore function. Therefore, the requested lower back fusion is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 37-year-old female enrollee has requested reimbursement for gene testing performed on 1/19/15.  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 while fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign.  The Afirma test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, gene testing performed on 1/19/15 was likely to have been superior over other methods of evaluation.  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 37-year-old female enrollee has requested reimbursement for gene testing performed on 1/19/15.  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 the current medical evidence supports the services at issue in this clinical setting.  The advent of genetic testing and analysis has helped providers to better characterize the chances of malignancy and in this case suggested the need for surgery.  There is sufficient support for the services at issue in this patients case.  The services at issue provided information which aided in management.  Therefore, gene testing performed on 1/19/15 was likely to have been of greater benefit than other modalities.  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 37-year-old female enrollee has requested reimbursement for gene testing performed on 1/19/15.  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 the pathology report was consistent with a follicular lesion of undetermined significance. This patient had this nodule for several years and patient was reluctant to incur in the risk of surgery.  Per the medical records, the size of nodule, age and gender increased the patients risk for malignancy.  Afirma testing was a valuable tool in this case.  It made the recommendation and decision to remove the tumor more certain.  Therefore, gene testing performed on 1/19/15 was likely to have been superior over other available modalities for 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The patient is a 52-year-old male with progressive neurologic symptoms over several years with sensory changes, bladder issues, erectile dysfunction, and clumsiness in association with T2 lesions in the cervical and thoracic spine and in the brain. The patient was diagnosed with multiple sclerosis (MS) and his provider has recommended treatment with Avonex. The patient has requested authorization and coverage for Avonex Pen Kit. The Health Insurer has denied this request as not medically necessary indicating that the patient has not failed treatment with three preferred alternatives such as Glatopa, Copaxone, Rebif or Gilenya.  The request for Avonex Pen Kit is not medically necessary for treatment of the patients medical condition. In this case, the patient presents with recently diagnosed MS and treatment with Avonex has been recommended. The Health Insurer has denied this request due to lack of failure with preferred formularies that include Glatopa, Copaxone, Rebif and Gilenya. The Evidence study by Panitch and colleagues showed that Rebif is more effective than Avonex. Similarly, the Transforms study showed that Gilenya is more effective than Avonex (Cohen, et al). Given that Avonex is less effective in reducing relapses than Rebif and Gilenya, Avonex is not medically necessary for treatment of the patients MS. Therefore, the requested medication is 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 33-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 2/18/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees small bowel Crohns disease. The physician reviewer found the Anser IFX testing performed on 2/18/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case there was concern of an infusion reaction due to pre-formed ATI. In addition, the testing confirms that the patients symptoms were an infusion reaction and allowed for planning for subsequent infusions. Therefore, in this clinical setting the testing at issue 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.