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

Summary Reviewer 

A 53-year-old male enrollee has requested authorization and coverage for methadone 10 mg tablets, 566 pills per 30 days. The Health Insurer has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollees pain. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. High-dose methadone is not recommended for chronic non-malignant pain. Clinical practice guidelines specifically identify the markedly increased risk of overdose when morphine equivalent dose exceeds 60 mg per day, as in this patients case. Due to the history of obesity, he is also at increased risk of obstructive sleep apnea, and this risk is amplified by high-dose opiates. The records do not document other approaches to pain management. Documentation of spinal cord stimulator evaluation, weight loss counseling or alternative medication was not provided. Clinical guidelines support tapering the patient and providing alternative pain management methods. Thus, methadone 10 mg tablets, 566 pills per 30 days are not medically necessary for the treatment of this patient. Therefore, the requested medication quantity 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 61-year-old female enrollee has requested reimbursement for the intermittent limb compression device provided from 8/28/15 through 9/26/15. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees medical condition status post hip replacement. The physician reviewer found there is evidence based clinical practice guidelines and peer-reviewed literature supporting the use of intermittent pneumatic compression for DVT prophylaxis following total hip arthroplasty. Kakkos and colleagues report that the addition of intermittent mechanical leg compression augments the efficacy of anti-coagulation in preventing DVT in patient undergoing both knee and hip replacement. The American College of Chest Physicians state that optimal strategies for thromboprophylaxis after major orthopedic surgery include pharmacologic and mechanical approaches. Thromboprophylaxis was recommended for up to 35 days post-operatively, with an intermittent pneumatic compression device recommended for a minimum of 10-14 days (Falck-Ytter, et al). In addition, the American Academy of Orthopaedic Surgeons also recommend that patients undergoing elective hip arthroplasty who are not at elevated risk for venous thromboembolism (VTE) or for bleeding should receive pharmacologic prophylaxis and mechanical compressive devices for the prevention of VTE (Mont, et al). In this case, the patient underwent left total hip arthroplasty on 8/28/15 and was prescribed a DVT prophylaxis unit with intermittent limb therapy for 30 days. DVT risk factors for this patient include her age, the magnitude of surgical procedures, the use of a tourniquet, and ambulatory limitations in the post-operative period. Therefore, the intermittent limb compression device provided from 8/28/15 through 9/26/15 was medically necessary for the treatment of the patients medical condition.  Therefore, the device at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 60-year-old male enrollee has requested authorization and coverage for verapamil. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. The current literature is challenging to interpret, given the varied patient inclusion criteria, including the focus on patients in the active disease stage with dynamic and evolving symptoms, varied treatment protocols, and the conflicting findings reported. Most studies include patients with at least 30 degree curvature. Many patients with lesser curvature do not have difficulty with penetration and can be managed by observation. In this patients case, the documentation does not support difficulty in penetration due to degree of curvature. Per the records, he was noted to have 15 degree curvature. As such, the use of verapamil would not be considered a clinically appropriate and generally accepted standard of care for the management of this patient. Therefore, verapamil is not likely to be more effective than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 60-year-old male enrollee has requested authorization and coverage for verapamil. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that penile traction therapy is a therapeutic option for men with Peyronies disease. Penile traction may help to preserve or increase penile length and reduce penile curvature when used as monotherapy or as adjuvant therapy for surgical and intralesional treatments. There is paucity of clinical justification regarding the efficacy of injection therapy with verapamil. Furthermore, addition of verapamil to oral therapy or other nonsurgical therapies does not appear to provide significant improvement. In sum, verapamil is not likely to be superior over other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 60-year-old male enrollee has requested authorization and coverage for verapamil. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for verapamil injections in this clinical setting. The records document erectile dysfunction secondary to Peyronies plaque formation. He has difficulty maintaining erections and was diagnosed with plaque related erectile issue due to 15 degree lateral curvature. The medical evidence does not support an overall benefit of the use of this medication in terms of erectile outcomes, and the literature has noted minimal benefit to verapamil on lesion size reduction. This patients in-office response to Trimix suggests that his erectile function is intact and curvature is mild. Per the records, the patient may benefit from more standard therapies, inclusive of ultrasound and vacuum devices, to assist with mild curvature. Thus, verapamil is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 55-year-old female enrollee has requested reimbursement for cervical spine surgery performed on 7/25/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees neck pain and tingling in the upper extremities.The physician reviewer found there is sufficient support for the services at issue in this clinical setting. Davis and colleagues performed a prospective, randomized, controlled, multicenter clinical trial on two-level symptomatic degenerative disc disease. Their findings supported the use of cervical arthroplasty at two contiguous levels and demonstrated advantages over two-level anterior cervical discectomy and fusion. The U.S. Food and Drug Administration has approved the use of artificial disc replacement for skeletally mature patients for reconstruction of the disc from C3-C7 following discectomy at two contiguous levels for intractable radiculopathy (arm pain and/or neurologic deficit) with or without neck pain, or myelopathy due to abnormality localized to the level of the disc space and at least one of the following conditions confirmed by radiographic imaging: herniated nucleus pulposus, spondylosis (defined by the presence of osteophytes) and/or visible loss of disc height compared with adjacent levels. This patient presented with persistent and worsening neck pain radiating down the left upper extremity, with tingling and weakness, and progressive right upper extremity symptoms. Associated symptoms included clumsiness and inability to grasp and hold objects. She was no longer able to work. Clinical examination findings evidenced C6 and C7 myotomal weakness consistent with imaging evidence of nerve root compromise at the C5-C6 level and bilateral neural foraminal stenosis at the C6-C7 level. Detailed evidence of long-term reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. Evidence-based criteria were met to establish the medical necessity of this surgical intervention. Therefore, the cervical spine surgery performed on 7/25/17 was medically necessary for the treatment of this patient. Therefore, 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 50-year-old male enrollee has requested reimbursement for Decision-Dx Melanoma testing performed on 11/14/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the National Comprehensive Cancer Network guidelines state that while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to help differentiate benign from malignant neoplasms, or to help distinguish melanomas at low-risk versus high-risk for metastasis, routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. This patient has an early stage melanoma. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, DecisionDx-Melanoma testing provided on 11/14/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 27-year-old male enrollee has requested reimbursement and prospective authorization and coverage for continued sub-acute inpatient care from 7/26/17 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollee who is diagnosed with a brain injury.The physician reviewer found there is support for the services at issue in this clinical setting. The documented therapy and physician notes show that there has been improvement in this patients clinical status during his time at sub-acute inpatient care facility. Specifically, the documentation reports improvements in standing, heel to floor distance, tracking, head control, increased wheelchair tolerance, development of spontaneous swallowing, and command following.  Despite his traumatic brain injury, this patients young age and overall good health are positive prognosticators. Taking into account the documented improvement in the patients medical status with the therapy he is receiving and his positive prognosticators, the services at issue were and are medically necessary for the treatment of his medical condition. Therefore, continued sub-acute inpatient care from 7/26/17 forward was and is medically necessary for the treatment of this patients medical condition.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1
The parent of a 17-year-old female enrollee has requested reimbursement for autonomic testing performed on 8/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees chronic fatigue and presumed postural orthostatic tachycardia syndrome (POTS).   The physician reviewer found automatic testing encompasses multiple tests to evaluation autonomic function. Goals include evaluating the severity and distribution of autonomic function, diagnosing limited autonomic neuropathy, diagnosing and evaluating orthostatic intolerance, monitoring the course of dysautonomia, and monitoring response to treatment. Evaluations include tests of sudomotor function, tests of cardiovagal function, and tests of adrenergic function. The role of autonomic testing is to increase sensitivity and specificity in the detection of autonomic failure. The two work hand in glove and each enhances the other (Low, et al). 
POTS is defined by a constellation of symptoms, including increase in heart rate of 30 beats per minute (40 for children and teenagers) from supine to standing, worsening symptoms with standing, symptoms lasting more than six months, and absence of other causes of orthostasis. Activities of daily living may exacerbate symptoms, with resulting fatigue. Cardiac complaints are common, such as chest pain and lightheadedness, as are non-cardiac complaints such as nausea, headache, poor sleep, and fatigue. Memory may be affected, as well as attention. Based on this patients clinical presentation, the differential diagnosis of chronic fatigue versus POTS, and need to establish an appropriate recovery plan, autonomic testing was appropriate. For these reasons, the autonomic testing performed on 8/24/15 was likely to be more beneficial for evaluation of the patients medical condition than any other available testing. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2
The parent of a 17-year-old female enrollee has requested reimbursement for autonomic testing performed on 8/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees chronic fatigue and presumed postural orthostatic tachycardia syndrome (POTS).   The physician reviewer found this patients provider was faced with a diagnostic conundrum of how much the patients chronic fatigue syndrome versus depression versus POTS were contributing to her overall loss of well-being. As part of the diagnostic work-up the patient received a comprehensive assessment of her autonomic nervous system with an evaluation that was positive for abnormal sudomotor function, borderline cardiovagal impairment and preserved cardiovascular adrenergic function. Given this patients presentation, evaluation with autonomic testing was appropriate because POTS may occur with co-morbidities including diabetes, chronic fatigue, sleep disturbances, dizziness, syncope, migraines, gastrointestinal disorders of a functional nature, fibromyalgia and joint hypermobility, but co-morbid conditions can occur with or without tilt-table-defined POTS. In addition, POTS subtypes can be defined by using small fiber and autonomic structural and functional criteria. Given the complexities in this patients case from a diagnostic perspective, the autonomic testing provided on 8/24/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3
The parent of a 17-year-old female enrollee has requested reimbursement for autonomic testing performed on 8/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees chronic fatigue and presumed postural orthostatic tachycardia syndrome (POTS).  The parent of a 17-year-old female enrollee has requested reimbursement for autonomic testing performed on 8/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees chronic fatigue and presumed postural orthostatic tachycardia syndrome (POTS).   The physician reviewer found POTS may or may not be associated with autonomic neuropathy, characterized by an increased heart rate of 30 beats per minute with symptoms related to upright posture. Affected patients present with orthostatic intolerance, postural tachycardia, exercise intolerance, fatigue, dizziness and in some cases with other dysautonomic symptoms such as gastrointestinal or sudomotor dysfunction. In the peer-reviewed medical literature, Plash and colleagues concluded that diagnosis of POTS should consider orthostatic intolerance criteria and not be based solely on orthostatic tachycardia regardless of test used. Al-Shekhlee and colleagues compared two groups of patients retrospectively and noted a decreased sweat output on the quantitative sudomotor axon reflex test is the most frequent abnormal finding suggesting sympathetic cholinergic neuropathy. All told, the current scientific data supports the utility of autonomic testing in this diagnostic setting. Thus, the autonomic testing performed on 8/24/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 62-year-old male enrollee has requested authorization and coverage for insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has obstructive sleep apnea and has mild septal deviation. A drug-induced sleep endoscopy showed no concentric collapse at velum and complete anterior-posterior collapse at some levels. The patient has not been able to tolerate continuous positive airway pressure therapy. The Inspire device has been approved by the U.S. Food and Drug Administration for the treatment of obstructive sleep apnea. Per the submitted records, this patient is a candidate for the Inspire device, given that he has anterior-posterior collapse at the tongue base. Therefore, insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator is likely to be more effective than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 62-year-old male enrollee has requested authorization and coverage for insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the requested services in this clinical setting. This patient meets clinical criteria for consideration of surgical management of the obstructive sleep apnea symptoms. Drug-induced sleep endoscopy documented the location of obstruction with anterior-posterior, but no concentric, collapse at the tongue base. The patient has failed a prior trial of continuous positive airway pressure therapy. Per the medical evidence, upper airway stimulation is a safe and effective therapy for patients with obstructive sleep apnea. Woodson and colleagues noted long-term improvements and reported that adverse events were uncommon. In sum, insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator is likely to be superior over other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 62-year-old male enrollee has requested authorization and coverage for insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. Hypoglossal nerve stimulator has been demonstrated to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed continuous positive airway pressure, have nonconcentric airway collapse, an apnea-hypopnea index between 20 and 50, and a body mass index less than 32. This procedure has been approved by the U.S. Food and Drug Administration. With a body mass index of 26.6, apnea-hypopnea index of 19.3 and nonconcentric airway collapse, this patient meets the criteria. He has failed continuous positive airway pressure therapy, which is the gold standard treatment for obstructive sleep apnea. Thus, insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator is likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The patient is a 45-year-old male with a diagnosis of amyotrophic lateral sclerosis (ALS). The patient initially presented in 2013 with right hand cramps and weakness. Nerve conduction studies showed denervation and chronic lower motor neuron changes in the left cervical, left lumbosacral, trapezius and thoracic paraspinal muscles. The patient has requested authorization and coverage for edaravone (Radicava). The Health Insurer has denied this request as investigational. Radicava is a free radical scavenger that slows the functional deterioration in some patients with ALS. Radicava is U.S. Food and Drug Administration (FDA) approved for patients ALS without any restriction to the variant or severity of ALS. There is evidence for the benefit of Radicava in patients with early ALS which suggests Radicava would also benefit the greater ALS population. Therefore, the request for Radicava is 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 medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.