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

Summary Reviewer 


The parent of a 16-year-old female enrollee has requested reimbursement for residential treatment services provided from 8/26/15 through 12/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. The patient could have been treated in a lower level of care from 10/19/17 through 10/25/17. On 10/17/17, the patient weighed 120.40 pounds and was 102% of her IBW. The patient had exceeded her ideal body weight of 118 pounds. The patient was engaged during her therapy sessions and she completed 98% of her meal plans over the week. She continued to struggle with anxiety and depression but she reported to staff on many occasions that she felt that the RTC level of care was excessively restrictive for her and she had a desire to be discharged. The patient did not report any suicidal ideation or homicidal ideation. The patient was medically stable. By 10/19/17, she no longer required 24 hour supervision. It is standard of care to treat patients in the least restrictive environment possible. This patient continued to require treatment for her eating disorder but her treatment could have been accomplished at a less restrictive environment. Accordingly, the eating disorder RTC services from 10/19/17 through 10/25/17 were not medically necessary for the treatment of this patients medical condition. Based upon the information set forth above, 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 29-year-old female enrollee has requested reimbursement for the human papilloma virus (HPV) testing provided on 8/26/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for HPV. The physician reviewer found that according to the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines, Pap-only strategies are now limited to women younger than 30 years, but co-testing is expanded even to women younger than 30 years in some circumstances. The American College of Obstetricians and Gynecologists (ACOG) noted that if screening with primary HPV testing is used, it should be performed as per the ASCCP guidance. According to this patients provider, the patient was at increased risk for abnormal Pap smears and thus increased risk for the changes that lead to cervical cancer. Thus, the HPV testing provided on 8/26/16 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 Upheld

Summary Reviewer 2


A 29-year-old female enrollee has requested reimbursement for the human papilloma virus (HPV) testing provided on 8/26/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for HPV. The physician reviewer found that overall, the routine inclusion of HPV screening in women under age 30 does not provide additional benefit over cytology and increases the risk of unnecessary interventions. This patient was under age 30. The guidelines from the American Cancer Society (ACS) and the American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology (ASCP) all recommend delaying co-testing until after age 30. Thus, there is a lack of documentation supporting an indication for the HPV testing performed on 8/26/16, and the testing 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, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 29-year-old female enrollee has requested reimbursement for the human papilloma virus (HPV) testing provided on 8/26/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for HPV. The physician reviewer found that according to the recommendations from the American College of Obstetrics and Gynecology (ACOG) and the American Society for Colposcopy and Cervical Pathology (ASCCP), women aged 21-29 years should have a Pap test alone every three years and HPV testing is not recommended. The guidelines further recommended that women ages 30-65 years should have a Pap test and an HPV test (co-testing) every five years. It also is acceptable to have a Pap test alone every three years. From the chart and patient statements, the HPV testing performed at this patients postpartum visit was not clinically indicated for evaluation of this patients medical condition. There was no medical record documenting any previous normal or abnormal Pap smear testing. Overall, the current guidelines only support an indication for the Pap smear, not the HPV testing. Thus, the HPV testing provided on 8/26/16 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, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a five-year-old male who has been diagnosed with disorder of dysregulated anger and aggression of early childhood, combined, proactive and reactive aggression. The patientas parent has requested reimbursement for intensive outpatient mental health treatment for children and adolescents provided from 7/15/19 through 7/31/19. 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 Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In terms of risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to impulsivity, self-harm, and aggression. With regard to functional status, the records support a score of 3. The patient had moderate functional impairment, due to conflict with parents and other adults as well as peers, and recent expulsion from school. Gains were made in the context of a structured setting. In terms of comorbidity, the records support a score of 1. There were no developmental or medical issues. With regard to level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment, due to expulsion from school. In terms of environmental support, the records support a score of 2 due to his parentsa attempts to participate in treatment, with some struggles to manage the patientas behavior and medications at home. In terms of resiliency and treatment history, the records support a score of 4. The records indicate poor resiliency and/or response to treatment, due to a lack of response to previous intensive treatment, and his current turmoil and difficulty making progress toward developmentally appropriate behaviors. With regard to treatment and acceptance of the parents, the records support a score of 2 due to their participation in treatment. Thus, the patient had a total score of 17. This recommended level of care is high-intensity community-based services. An intensive outpatient program, such as the one the patient was attending, is consistent with this level of care. Furthermore, a program specializing in young children was needed for the patient. Therefore, intensive outpatient mental health treatment for children and adolescents provided from 7/15/19 through 7/31/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 29-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 2/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  There is insufficient evidence to support the use of drug level monitoring for biologics in this clinical setting. The quality of evidence is considered to be low due to the fact that studies to date have primarily been retrospective.  High-quality, randomized controlled trials are lacking.  The evidence to date does not demonstrate that this strategy leads to better clinical outcomes.  Therefore, Anser IFX testing performed on 2/25/16 was not likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 29-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 2/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that this patient demonstrated clinical response at the time of Anser IFX testing.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment. While there have been testimonials, there are few well-controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results.  Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  In sum, Anser IFX testing performed on 2/25/16 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 29-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 2/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that in this patients case, Anser IFX testing was ordered to determine Remicade (infliximab) level and whether antibodies to infliximab were present.  The use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear infliximab levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing.  Based on the clinical literature, Anser IFX testing performed on 2/25/16 was not likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 46-year-old female enrollee has requested authorization and coverage for total disc arthroplasty (CPT 22858 and 22856).  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for the requested services in this clinical setting.  The evidence-based literature supports the use of two-level contiguous cervical artificial disc replacement as an option over anterior cervical discectomy and fusion for the treatment of symptomatic degenerative disc disease.  This patient presents with neck pain radiating into the right arm with weakness.  Clinical examination findings are consistent with imaging evidence of neural compression and spondylosis at the C5-6 and C6-7 levels. Per the medical records, a conservative nonoperative treatment has been tried and failed to provide sustained improvement. The use of two-level artificial disc replacement will allow for motion preservation, which would be sacrificed with the use of fusion.  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 Overturned

Summary Reviewer 2


A 46-year-old female enrollee has requested authorization and coverage for total disc arthroplasty (CPT 22858 and 22856).  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence supports the requested services in this clinical setting.  This particular implant has been approved for two-level use.  Most of the literature indicates an initial advantage to cervical disc replacement compared to anterior cervical discectomy and fusion.  However, long-term results of both procedures are similar or there is a slight advantage to total disc arthroplasty.  Davis and colleagues noted that four-year results from their study continued to support total disc replacement as a safe, effective, and statistically superior alternative to anterior cervical discectomy and fusion for the treatment of degenerative disc disease at two contiguous cervical levels.  In sum, the requested total disc arthroplasty is likely to be of greater benefit than other treatment options.  Therefore, as 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 Overturned

Summary Reviewer 3


A 46-year-old female enrollee has requested authorization and coverage for total disc arthroplasty (CPT 22858 and 22856).  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition. The physician reviewer found it is not likely to be beneficial for this patient to undergo two-level cervical intervertebral disc arthroplasty.  There are general concerns referencing cervical artificial disc replacement.  The properties of wear and the resultant patient response to wear debris from bearing surfaces of hip, knee and spinal disc share the same phenomenon.  There is a predictable level of long-term complications after total hip and total knee replacement, which are attributable to the problems of wear.  The techniques for revision after total disc arthroplasty are controversial.  If the patients implant fails with either edge wearing of the methyl methacrylate portion of the implant or subsidence of the metallic components into the vertebral bodies, then a second anterior approach may become necessary.  This approach would have increased risk since the tissues through which the surgical approach is made have already undergone postoperative scarring.  Studies of longer duration are needed to assess the longer term potential complications of a methyl methacrylate arthroplasty within the cervical spine.  There is documentation in the literature for an increased incidence of dysphasia following a repeat anterior approach to the cervical spine.  A justification and rationale for total disc arthroplasty is the prevention of adjacent segment disorder through preservation of motion.  However, it remains controversial whether or not motion at the replaced intervertebral disc will be maintained over time.  Thus, the requested total disc arthroplasty is not likely to be more effective than other treatment options.  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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 37-year-old female with a history of pelvic pain, fibroid uterus, and dysfunctional uterine bleeding.  She has a history of abnormal Pap smears that required excisional procedures.  She had an Essure device placed for permanent contraception. For the complaint of pelvic pain and dysfunctional bleeding, she has tried conservative treatment with combined oral contraceptive pills and progesterone only pills. She did not have success with either of these medications in treating her complaints. The patient has requested authorization and coverage for an abdominal hysterectomy. 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 patient has longstanding pelvic pain and dysfunctional uterine bleeding in the setting of an Essure placement.  The patient meets the standard indications for hysterectomy: 1) uterine leiomyomas, 2) abnormal uterine bleeding, and 3) pelvic pain. She has tried conservative treatment without success. In addition, the Essure may be contributing to her pelvic pain. Studies have shown a 10-fold risk of reoperation after the placement of Essure for both pelvic pain and irregular bleeding. This patient has a history of excisional biopsies for cervical dysplasia.  Per the records, the appropriate treatment for this patient is total hysterectomy including the cervix so that she is not at risk for additional cervical disease or bleeding from the remaining cervix, both which are common. The fallopian tubes should also be removed to include the Essure device. Thus, the requested abdominal hysterectomy is medically necessary 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 64-year-old female enrollee has requested placement of permanent sacral nerve stimulator performed on 12/09/14.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees fecal incontinence. The physician reviewer found the current medical evidence supports the services at issue in this clinical setting.  There is clinical data to support the long-term efficacy and safety of the services at issue for the treatment of bowel dysfunction.  Wexner and colleagues published results of a prospective multicenter study of sacral nerve stimulation for fecal incontinence.  The authors concluded that sacral nerve stimulation using InterStim is a safe and effective treatment for patients with fecal incontinence.  Moya and colleagues reported results of 50 patients implanted with sacral nerve stimulators.  After six months, sacral nerve stimulation significantly improved fecal incontinence and positively impacted quality of life.  All told, the permanent sacral nerve stimulator provided on 12/09/14 was likely to have been superior over other treatment modalities.  Based upon the information set forth above, the services at issue were 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 Overturned

Summary Reviewer 2

A 64-year-old female enrollee has requested placement of permanent sacral nerve stimulator performed on 12/09/14.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees fecal incontinence. The physician reviewer found there is sufficient support for the services at issue in this patients case.  According to the American Society of Colon and Rectal Surgeons guideline for the treatment of fecal incontinence, sacral neuromodulation may be considered as a first-line surgical option for incontinent patients with and without sphincter defects.  The treatment consistently demonstrates reduction in frequency of incontinence episodes in studies.  In this patients case, the permanent sacral nerve stimulator provided on 12/09/14 was likely to have been of greater benefit than other treatment options.  Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.