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

Summary Reviewer 


A 55-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees neck pain. The physician reviewer found the submitted records support the medical necessity of the requested services. This patient has had symptoms for a prolonged period of time, with no apparent relief, and now has been referred for additional cross-sectional imaging as well as to an orthopedist for consultation.  For the first study for patients with chronic neck pain with or without a history of previous trauma, the American College of Radiology does not recommend computed tomography (CT) and states that an MRI is usually not appropriate.  However, the American College of Radiology considers MRI to be the appropriate next imaging modality for patients with radiographs which show degenerative changes when neurologic signs or symptoms present.  In this case, the patient has numbness and tingling extending to her fourth and fifth fingers.  Her symptoms are more than just neck pain.  The localization of symptoms to her fourth and fifth fingers are typical for a C8 dermatome.  In this setting, MRI of the cervical spine is considered the most appropriate next imaging modality. This patient has already had a trial of anti-inflammatory medications.  All told, the requested MRI of the cervical spine is medically necessary for the evaluation of this patient. Therefore, the requested services are medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 27-year-old male enrollee has requested reimbursement and prospective authorization and coverage for outpatient psychological services provided from 6/6/17 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 enrollees anxiety, depression, intrusive and recurrent thoughts, and migraines. The physician reviewer found that although weekly individual psychotherapy may be medically necessary for treatment of this patients medical condition, based on the documentation provided, the services in dispute were not and are not medically necessary. The criteria for PTSD, anxiety disorder, obsessive compulsive disorder, functionally impairing depression or specific phobia have not been established in the medical records. In addition, the treatment plan from August 2017 did not include critical elements such as the implementation of validated rating scales to guide treatment or the articulation of specific, measurable, attainable, relevant and timely patient-generated goals. Considering the diagnostic uncertainty and chronicity of symptoms, the records lack an updated psychological assessment and comprehensive outpatient treatment plan to determine the patients diagnoses, current clinical status and treatment needs. Depending on the evaluation, an evidence based psychotherapy and/or particular treatment modality may be deemed reasonably expected to improve the patients condition and prevent a more serious episode of illness based on the diagnosis. However, based on the documentation provided for review, the outpatient psychological services provided from 6/6/17 forward were not and are not medically necessary for treatment of this patients medical condition. Based on the above discussion, the services at issue were not and are 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 63-year-old male enrollee has requested reimbursement for computed tomography (CT), lower extremity, without contrast material performed on 9/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees ankle pain. The physician reviewer found that determining when a fracture is healed is a routine part of orthopedic clinical care. Typically, serial radiographs are utilized to assess nonunion of a fracture. There is significant variability in the determination of fracture healing radiographically. CT is superior to radiography in the assessment of fracture union. According to the American College of Radiology, CT may be appropriate for the evaluation of ankle fracture in the setting of suspected osteochondral defect. In this case, the patients provider suspected an osteochondral lesion, which is better evaluated with CT or MRI, which can often be occult on radiographs. The provider also suspected nonunion, as the patient had continued pain five months after the injury, which was more than was expected. CT is an appropriate imaging examination in this clinical setting. Thus, CT, lower extremity, without contrast material performed on 9/26/18 was medically necessary for the evaluation of this patient. Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 56-year-old male enrollee has requested reimbursement for an endoskeletal left transtibial prosthesis provided on 1/03/19. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a lack of outcomes data available from controlled clinical trials published in the peer-reviewed literature to substantiate the safety and marginal effectiveness of microprocessor-controlled ankle-foot prosthetic componentry over designs lacking microprocessor aid. The available data are from small pilot studies, which, on balance, have not demonstrated clinically significant advantages of these components over conventional ankle foot components. A small study by Agrawal and colleagues noted no significant differences in work between microprocessor-controlled devices and conventional devices in individuals with an amputation when negotiating stairs.  Bai and colleagues noted potential for improvements with negotiation of slopes using a prosthesis with a microprocessor-controlled ankle-foot, but there were no demonstrated differences in comparison to a conventional ankle-foot mechanism that were statistically significant. Overall, there are no proven clinical or functional advantages of this type of componentry that would offset their heavier weights and significantly increased bulk. In addition, concerns related to potential adverse effects on the socket-limb interface have been raised. It is also unclear what happens if the electronics on this type of prosthetic componentry fails, either due to mechanical failure or battery power loss. Therefore, the endoskeletal left transtibial prosthesis provided on 1/03/19 was not likely to have been more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 56-year-old male enrollee has requested reimbursement for an endoskeletal left transtibial prosthesis provided on 1/03/19. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that in lower limb loss rehabilitation, the prosthetic ankle-foot mechanism is the most common major component needed to restore function. All individuals that undergo a lower limb amputation at or proximal to the ankle joint will require a prosthetic ankle-foot mechanism to walk with minimal gait deviations and have stability and proper alignment of knees, hips and spine. Evidence-based clinical practice guidelines state that patient age or amputation etiology is not the primary consideration in prosthetic foot type selection. Evaluation of functional status and mobility needs of the patient is crucial to determine what type of prosthetic foot is needed. There are five categories of K3-level prosthetic ankle-foot mechanisms currently available. The categories include microprocessor ankle-foot (MPF) mechanisms and four that are classified as non-microprocessor. The MPF utilizes a microprocessor and series of sensors to measure the patientas gait cycle and then respond according to the required output for optimal stepping With the exception of two currently available commercial MPF, these feet are primarily adaptive in nature, using small motors to adjust hydraulic or pneumatic resistance to forces but do not generate power at the ankle. MPF allows greater mobility than the other four available types since it is the only one that utilizes sensors to read and subsequent motors to respond to various tasks faced by the user, given it is the most analogous function to the human neuromuscular system. The evidence-based clinical guidelines inform decision making in determining the most appropriate prosthetic foot type for individuals with lower-limb amputation in consideration of their clinical presentation. This patient in this case has experienced major lower-limb amputation (i.e., ankle-disarticulation level or proximal), has experienced adequate healing at the primary wound site to permit prosthetic fitting, and has the demonstrated ability to ambulate with a prosthesis. Current high-quality research supports the use of endoskeletal transtibial prosthesis in this case. All told, endoskeletal left transtibial prosthesis provided on 1/03/19 was likely to have been more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 56-year-old male enrollee has requested reimbursement for an endoskeletal left transtibial prosthesis provided on 1/03/19. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient has requested reimbursement for a microprocessor controlled foot/ankle. There are many studies that discuss the use of a microprocessor controlled foot/ankle. Many of the studies described some improvement in physiologic/kinematic parameters, such as residual knee moment, increased stance phase dorsiflexion, and vertical ground reaction forces. However, these studies did not identify how these improvements translated into real world functional benefit, such as improved walking endurance, reduction in falls/instability, or reduction in skin friction/breakdown on the residual limb. The physiologic/kinematic benefits do not always correlate with clinical improvement. Hahn and colleagues noted, aWhile the perception of benefits regarding the negotiation of uneven terrain and slopes is very high, the correlation to product preference is moderate.a Users identified 80-90% improvement with walking on uneven ground, ascending, and descending ramps. However, only 40% of users preferred the microprocessor controlled foot. As such, it can be difficult to extrapolate findings regarding isolated physiologic/kinematic benefits to patient preference, let alone extrapolating that data to sustained functional improvement. As another example, many of the studies focused on an isolated point in time intervention in a gait lab or other clinical setting. As such, these studies had participants perform tasks in a clinical setting and did not evaluate whether the use of this device in a real world home setting would offer similar functional gains. Patients frequently have unexpected responses to adaptive equipment, as evidenced by a study by Lamers and colleagues. This study demonstrated that despite the microprocessor-controlled ankle behaving similarly for each user, there were marked differences in individual responses. The authors noted, aFor instance, two users switched from a forefoot landing pattern with the microprocessor-controlled ankle locked at neutral angle to rearfoot landing when the microprocessor-controlled ankle adapted to the slope, while two maintained a forefoot and three maintained a rearfoot landing pattern across conditions.a As such, it can be difficult to extrapolate benefits from a clinical setting to the real world day-to-day environment. Thus, the endoskeletal left transtibial prosthesis provided on 1/03/19 was not likely to have been more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

An 18-year-old male enrollee has requested reimbursement for psychiatric residential treatment center services from 2/05/19 through 3/07/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the 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. With regard to risk of harm, the records support a score of 2. The patient did not endorse specific suicidal ideation/plan during his stay, but his history included two previous suicide gestures including fashioning a noose on an exercise bar in his home and contemplating hanging himself. In terms of functional status, the records support a score of 4. The patient had significant withdrawal, dysphoria, and inability to play as a jazz pianist, a role that appeared vital to his self-identity at the time. With regard to comorbidity, the records support a score of 4. The records noted possible PANS, POTS and mild sleep apnea, with unspecified elevation in autoimmune markers, with his hand/forearm nerve compression injury compromising his functioning, in addition to persistent depressive disorder with intermittent major depressive episodes, obsessive-compulsive disorder with poor insight, somatic symptom disorder, severe, and parent-child relational problems. In terms of level of stress of the recovery environment, the records support a score of 3. The patient did not appear to feel close to family members. With regard to level of support of the recovery environment, the records support a score of 2. The patients family appeared supportive and participated in therapy, although the dynamics were not optimal. In terms of resiliency and treatment history, the records support a score of 3. The patient has a high overall IQ, although there were personality characteristics concerning for depressive and avoidant personality traits, with self-defeating features. With regard to acceptance and engagement, the records support a score of 3. The patient appeared to continue to externalize blame to his physical/medical concerns, pointing to limited therapeutic engagement. In sum, the patient has a composite score of 21. However, the patient had scores of 4 in both functional status and comorbidity. Thus, residential treatment was indicated in this patients case. Therefore, psychiatric residential treatment provided from 2/05/19 through 3/07/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 43-year-old female enrollee has requested authorization and coverage for immune globulin injection 500 mg (Gamunex-C). 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 there is a lack of support for the requested services in this clinical setting. The medical evidence does not support the use of intravenous, intramuscular, or subcutaneous immune globulin as a treatment to prevent recurrent spontaneous abortion in pregnant women. The American College of Obstetricians and Gynecologists does not support the requested services for the treatment of this patient. The use of intravenous immune globulin for pregnancy loss prevention has not been demonstrated by large scale, prospective clinical trials to have superior outcomes compared to existing therapies. Therefore, immune globulin injection (Gamunex-C), 500 mg is not likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 43-year-old female enrollee has requested authorization and coverage for immune globulin injection 500 mg (Gamunex-C). 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 there is limited high-quality data on the management of recurrent pregnancy loss. Currently, therapeutic recommendations are largely based upon clinical experience and data from observational studies. This patients provider seeks to treat her recurrent pregnancy loss thought to be of autoimmune nature with intravenous immune globulin (IVIG). The studies cited by the provider are observational and pre-date current systematic reviews. Systematic reviews have consistently found no beneficial effect of immunotherapy for treatment of recurrent pregnancy loss. Wong and colleagues performed a systematic review of 20 trials of high-quality. The authors noted that immunotherapy did not result in a statistically significant improvement in live births compared to untreated controls. Treatment with intravenous immune globulin was included in this study. In sum, immune globulin injection (Gamunex-C), 500 mg is not likely to be superior over other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 43-year-old female enrollee has requested authorization and coverage for immune globulin injection 500 mg (Gamunex-C). 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 fails to demonstrate the superior efficacy of the services at issue. The records document a history of recurrent spontaneous pregnancy loss. Per the provider, the patient has been diagnosed with polyclonal hypergammaglobulinemia, white blood cell disorder, and coagulation disorder hereditary thrombophilia. She is currently pregnant, and her provider has recommended intravenous immune globulin (IVIG) (Gamunex-C) to prevent fetal loss. The current literature does not support the services at issue in this patients case. The treatment of IVIG has not been shown to improve pregnancy outcomes. Thus, immune globulin injection (Gamunex-C), 500 mg is not likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 53-year-old female enrollee has requested authorization and coverage for PET scan (78816). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The avidity of fluorodeoxyglucose (FDG) uptake can be helpful in differentiating between benign and malignant solid nodules. Given the resolution limitations of PET, tracer avidity cannot be reliably assessed for nodules with solid components measuring less than 8 mm. The nodules on this patient are 6 mm and below. Thus, the requested PET scan is unlikely to be of utility. Therefore, that PET/CT scan of the whole body with CT scan attenuation (78816) is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 




A 30-year-old female enrollee has requested reimbursement for the intensive outpatient program (IOP) treatment provided from 5/26/16 through 6/2/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bulimia nervosa and alcohol abuse. The physician reviewer found that the records provided for review support the medical necessity of IOP services from 5/26/16 through 5/27/16. On 5/25/16, the patient was continuing to have thoughts of bingeing and purging. She was also struggling with body dysmorphia in the context of rigid and perfectionistic cognitive schemas which fueled anxiety and guilt-based self-criticality. The patient was absent on 5/24/16 and 5/26/16, but based on the longitudinal illness burden and her clinical status on 5/23/16, it was reasonable to have the patient come in to the program on 5/27/16. On that date, the patient continued to have a reluctance to increasing her dietary choices, and expressed guilt for certain meal selections. However, she was willing to increase her food variety, gain weight and address her food fears. By that date, she was tolerating her meal plan, her weight and appearance were healthy, and there was no mention of alcohol use. She was stable on her medications while her most recent mental status examination was unremarkable and included a euthymic mood with linear thought processing. Considering the patients improvement and motivation coupled with a three-month course of specialty care in supervised settings, transition to the outpatient level of care after completing services on 5/27/16 would have been safe, appropriate and consistent with good medical practice. Thus, the services in dispute were medically necessary from 5/26/16 through 5/27/16, but not thereafter. Based on the foregoing discussion, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 36-year-old female who presented on 7/11/16. The records noted hormone imbalance. She was started on low dose birth control pills. The patient ultimately developed headaches on the birth control pills, which limited further use. On 11/07/16, the records noted major depressive disorder and generalized anxiety disorder.  She was started on Viibryd. On 11/18/16, the records noted painful periods. On 12/30/16, endometrial ablation was performed. The Health Insurer has denied reimbursement for the services at issue. Per the Health Insurer, endometrial ablation was investigational for the treatment of this patient.  The submitted documentation fails to demonstrate the superior efficacy of the services at issue. The submitted records do not include a complete blood count to attempt to document the anemia of heavy cycles. There is no documentation of sampling of the endometrium, such as endometrial biopsy or dilation and curettage (D&C). In this patients case, addressing her issues of mood disorders (which can have a strong effect on perception of pain) and offering a trial of medical management was reasonable. Although progesterone only may have worsened her mood disorders, but this would not be the case with Mirena. If the patient had a relatively normal complete blood count, she could have benefitted from the use of nonsteroidal anti-inflammatory drugs with or without progesterone. If the patient had contraindications to these management options, then an endometrial ablation may have been an appropriate next step. However, an endometrial biopsy should have been done before the ablative procedure was contemplated. Therefore, endometrial ablation was not likely to have been more effective than other available treatment options. Based upon the information set forth above, the services at issue were 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.