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

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested reimbursement for residential treatment provided from 4/11/18 forward. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 1. The medical records indicate that the patient was not actively suicidal and did not engage in self-harm. In terms of functional status, the records support a score of 2. The patient had some issues with level of function due to mental illness and oppositional behaviors but overall showed appropriate daily functioning while in treatment as evidenced by intact activities of daily living, cooperation with treatment and good school performance. With regards to comorbidity, the records support a score of 2. The patient did not have a history of past medical issues and had some past substance use issues. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have good relationship with his family and denied current stress at home of any significant nature. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment. In terms of resiliency and treatment history. The records support a score of 2. The patient reported improved symptom presentation while at the residential treatment center and was participating in therapy programming while on the unit. He was not displaying serious or disruptive symptoms. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy and indicated trust in his therapist. In terms of acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 15. This score correlates with outpatient services. Therefore, residential treatment from 4/11/18 forward was not and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for residential mental health treatment provided from 4/01/14 through 5/20/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found there is a lack of support for the services at issue in this patients case.  She had no substance abuse problems.  She was engaged and an active participant in the treatment process.  She was independent in her activities of daily living, and there were no cognitive difficulties.  Her parents were active participants in the family process.  The patient did not require 24-hour supervision in the restricted setting of residential.  Although she required treatment, her medication management and other treatment could have been conducted at a lower level of care.  There was no documentation as to the patients response to medications or assessment for side effects.  There was no comprehensive intake, history and physical, or initial psychiatric evaluation.  Overall, the documentation was inadequate to support the medical necessity for 24-hour supervised care in a residential setting.  In sum, residential mental health treatment provided from 4/01/14 through 5/20/15 were not medically indicated 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 Overturned

Summary Reviewer 


A 46-year-old female enrollee has requested authorization and coverage for Epclusa. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients, based on clinical trials which showed a 99% cure rate and superiority to Sovaldi with ribavirin. A delay in treatment may result in decreased survival. All told, Epclusa is medically necessary in this patients case. Therefore, the requested medication is 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 

The representative of a deceased female enrollee has requested reimbursement for inpatient services provided from 8/17/17 through 9/11/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who has a history of cirrhosis of the liver. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. There is limited records to support an inpatient admission as of 8/17/17. The patient had stabilized as of 8/15/17. She did not require high-flow oxygen and was hemodynamically stable. She was working with therapy and did not have active infections. Her mental status was described as waxing and waning with mild confusion, which was expected for her medical condition. The laboratory studies were stable, with a stable hemoglobin, and she was tolerating oral medications. There was no documentation of active bleeding or respiratory distress. The records do not demonstrate that the patient required ongoing inpatient care during the dates of service in dispute. All told, inpatient services provided from 8/17/17 through 9/11/17 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 


An 18-year-old male enrollee has requested reimbursement for substance use residential treatment from 5/16/15 through 6/29/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The records failed to demonstrate that less restrictive interventions targeting the patients substance use during the episode of illness had either been unsuccessful or would have more than likely been inappropriate.  Upon admission, the patient was engaging and motivated for treatment with a strong desire to succeed.  He reported no history of withdrawal symptoms.  He had no acute psychiatric comorbidity or unresolved medical issues.  Although many of his decisions were self-defeating, he did not pose an imminent threat to self or others.  Prior to admission, the patient was engaged in neither specialty treatment services nor community programming.  He had not pursued trusted treatment interventions for cannabis use disorder that can be safely and effectively delivered in the outpatient setting, such as motivational enhancement therapy, cognitive behavioral therapy, twelve-step facilitation, contingency management or family therapy, which was identified at presentation as an intervention of critical importance in this particular case.  In sum, there was no evidence to suggest that comprehensive specialty services provided at a lower level of care, such as partial hospitalization or intensive outpatient programming either at home or in a sober living environment would have been unreasonable or consistent with inadequate care.  Thus, substance use residential treatment from 5/16/15 through 6/29/15 was not medically indicted 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 56-year-old male enrollee has requested reimbursement for positron emission tomography (PET) scan performed on 1/19/16.  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 there is sufficient support for the services at issue in this clinical setting.  This case demonstrates the limitations of the standard bone scan agent, technetium in the detection of bone metastases in some individuals with prostate cancer.  This difference has been extensively reported in the literature.  There is significant data which supports the use of PET scans in patients that are at high-risk for skeletal metastases from prostate cancer, such as this patient.  It is very reasonable to use the same pharmaceutical agent that has been successful in the identification of metastatic disease in the past in order to provide an accurate comparison in this high risk patient with rising prostate-specific antigen and a history of prostate cancer.  All told, the PET scan performed on 1/19/16 was 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 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 56-year-old male enrollee has requested reimbursement for positron emission tomography (PET) scan performed on 1/19/16.  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 patients case.  The records indicate that the patient has metastatic prostate cancer.  The PET scan performed on 1/19/16 was likely to have been more efficacious than other methods of evaluation.  The medical literature supports this modality as superior to bone scan with regards to detection of prostate cancer bone metastases within the spine.  The PET scan performed is the most reliable investigational tool when there is high index of suspicion for osseous metastases.  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 56-year-old male enrollee has requested reimbursement for positron emission tomography (PET) scan performed on 1/19/16.  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 following the diagnosis and initial treatment for prostate cancer, it is conventional to obtain sequential prostate-specific antigen levels every six to twelve months for five years.  With a failure of the prostate-specific antigen levels to fall to undetectable levels, or with progressive increases in prostate-specific antigen levels, imaging or biopsies may be indicated.  These additional studies will generally dictate future treatment options.  However, routine technetium bone scans will occasionally not be diagnostic and scanning with PET scans has been developed as a second line scanning technique.  In this patients case, the routine bone scan was not diagnostic.  The results of the PET scan performed on 1/19/16 were likely to have a major impact on the choice of treatment.  Thus, the PET scan performed on 1/19/16 was likely to have been of greater benefit than 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 38-year-old female enrollee has requested authorization and coverage for Tysabri.  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 this patient has been diagnosed with relapsing-remitting multiple sclerosis. Treatment is indicated to reduce attacks.  She has been prescribed Tysabri, and the current medical evidence supports the requested medication in this clinical setting.  Guidelines and clinical experience show reduction of relapse rates and progression, with generally favorable tolerability. Compliance with once monthly regimen is high.  This patient did not tolerate Copaxone.  There is sufficient support for the requested medication in this patients case.  All told, Tysabri is medically indicated for the treatment of this patient.  Therefore, the requested medication is 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 40-year-old female enrollee has requested reimbursement for fetal sex chromosome analysis, circulating cell-free fetal DMA in the maternal blood provided on 6/13/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient underwent prenatal testing on 6/13/19. She was pregnant at 11 weeks 2 days gestation at the time of services. This was her second pregnancy, and an earlier pregnancy ended in a spontaneous miscarriage. Noninvasive prenatal screening by cell-free DNA is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is a sensitive screen for aneuploidy. It is more sensitive than sequential screening, but does not require the invasive procedure of chorionic villus sampling or amniocentesis. This is the case for both younger women and for women of advanced maternal age. Offering diagnostic testing via chorionic villus sampling or amniocentesis is considered standard accepted practice in women over 35 years at the time of delivery, and noninvasive prenatal screening by cell-free DNA testing should also be considered standard. Therefore, fetal sex chromosome analysis (CPT 81599) performed on 6/13/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 40-year-old female enrollee has requested reimbursement for fetal sex chromosome analysis, circulating cell-free fetal DMA in the maternal blood provided on 6/13/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that screening for the most common sex chromosome aneuploidies is controversial because these individuals have fewer serious physical abnormalities than those with trisomy 21, 18, or 13, and the phenotypic features are much more variable. The American College of Medical Genetics and Genomics (ACMGG) does not recommend use of cell-free DNA to screen for autosomal aneuploidies other than those involving chromosomes 13, 18, and 21. The Harmony Noninvasive Prenatal Testing offers screening for traditional aneuploidies (13, 18 and 21), which is evidence-based and standard of care. However, the test also offers screening for common sex chromosome aneuploidies, which is not recommended by the ACMGG and does not reflect standard of care. Therefore, fetal sex chromosome analysis (CPT 81599) performed on 6/13/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 40-year-old female enrollee has requested reimbursement for fetal sex chromosome analysis, circulating cell-free fetal DMA in the maternal blood provided on 6/13/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient was 11 weeks and 2 days pregnant when she underwent prenatal testing with Harmony Noninvasive Prenatal Testing. The testing combined both noninvasive prenatal testing (CPT codes 81507) and sex chromosome analysis for gender determination (CPT code 81599). According to the American College of Genetics and Genomics, Providers should make efforts to deter patients from selecting sex chromosome aneuploidy screening for the sole purpose of biologic sex identification in the absence of a clinical indication for this information. In this case, the patients clinical records do not suggest a specific concern for sex chromosome aneuploidies. Sex chromosome analysis via cell-free DNA methods was not clearly indicated in this case. In addition, without a specific indication, management of the pregnancy would not change by having this information. Sex chromosome analysis is not indicated via cell-free DNA for general screening at this time. Thus, fetal sex chromosome analysis (CPT 81599) performed on 6/13/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 29-year-old female enrollee has requested reimbursement and prospective authorization and coverage for eating disorder residential treatment center services provided from 4/09/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation. With regards to functional status, the records support a score of 2 due to some difficulty meeting obligations but overall ability to maintain meaningful relationships. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to stable medical issues and no substance use. With regards to level of stress of the recovery environment, the records support a score of 2 due to some performance pressure at work and leave from work. In terms of level of support of the recovery environment, the records support a score of 2 due to positive relationship with family but some struggles with her relationship with her mother. With regards to treatment and recovery history, the records support a score of 3 due to successful recent residential treatment with significant weight gain but incomplete resolution of eating disorder symptoms. In terms of engagement and recovery status, the records support a score of 2 due to good cooperation in treatment and insight into the need for treatment. Thus, the patient has a composite score of 14. This score of correlates with a high intensity community-based services. Therefore, eating disorder residential treatment center services provided from 4/09/19 forward were not and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 30-year-old female enrollee has requested reimbursement for emergency department services received on 10/30/17. The Health Insurer has denied this request on the basis that the services were not emergent. The physician reviewer found that review of the submitted documentation reveals the patient complained of a cough that had been present for one week. She denied wheezing, chest pain, fever, or leg swelling. There is no notation made that the patient was feeling short of breath. The patient was described as "in no distress." Her vital signs were normal. Mild wheezing with good air movement was noted. All testing that was performed was normal. The patient received two inhaled beta agonist treatments and oral medication. She declined any intravenous medications. This patient's symptoms were not acute in onset nor were they severe. All told, the patients symptoms on 10/301/7 did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health. Therefore, the Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 22-year-old male enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) provided from 9/21/16 forward. The Health Insurer has denied this request indicating that the service at issue was not and is not medically necessary for treatment of the enrollees major depressive disorder. The physician reviewer found in this case, continued TMS was and is medically necessary for treatment of the patients medical condition. The Clinical TMS Society recommends considering continuation or maintenance TMS therapy when other established methods of maintenance antidepressant therapy fail to provide a satisfactory sustained pattern of clinical benefit or a patient has a history of frequent relapse (Perera, et al). In addition, several naturalistic studies have demonstrated good tolerability and clinical efficacy of TMS therapy for treatment courses at long-term follow-up (Dunner, et al; Janicak, et al). In this case, the patient has had multiple relapses. He had trialed many medications and psychotherapies with no improvement. He had responded well to TMS maintenance therapy and the treatment was recommended by his treating clinical providers. Thus, it is reasonably expected that the patient will continue to benefit from TMS sessions. Further, there is no evidence suggesting that ongoing TMS would be unsafe. Based on the medical literature, TMS sessions not to exceed two per week for a period of six months and then clinical re-evaluation is appropriate. As such, TMS provided from 9/21/16 forward was and is medically necessary for treatment of the patients major depressive disorder.  Therefore, the service at issue was and is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.