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

Summary Reviewer 


A 39-year-old male enrollee has requested reimbursement for lumbar spine surgery performed in Germany.  The Health Insurer has denied this request indicating that the services at issue were not emergent or urgent and were not medically necessary for treatment of the enrollees advanced degenerative disc disease. The physician reviewer found that per the submitted documentation, the surgical intervention performed in Germany was not emergent or urgent.  A program of conservative care allowing for return to the United States and resumption of follow-up with treating surgeons in the United States was possible, and there is no documentation of accepted indications for emergent surgery such as acute cauda equina syndrome with abrupt bowel and bladder change. Additionally, the current medical evidence fails to support the medical necessity of the services at issue.  In the context of the need for treatment of postoperative infection or mechanical failure of the total disc arthroplasty device, there is a unique and high risk of vascular injury or injury to the ureters in management of these complications.  The studies do not adequately reflect likely long-term complications of implantation of metal and metal methyl methacrylate devices in the spine.  After implantation of metal and metal methyl methacrylate devices in the knee and hip, it has been demonstrated that the patients are exposed to particulate debris.  This particulate debris consisting of abrasive wear and adhesive contact wear between the components of the device elicit a chronic inflammatory reaction including a giant cell tissue response.  The effect of this exposure may vary from patient to patient, but all patients will be exposed to the consequences of wear.  In total joint arthroplasty at the hip and the knee, problems of subsidence and loosening are known to be associated in some patients with this phenomenon.  It is unlikely that the long-term effects of total disc arthroplasty will be any different than metal to plastic arthroplasty in other locations in the body. Van Den Eerenbeemt and colleagues performed a systematic review of the literature of total disc replacement.  The authors reviewed three randomized controlled trials and 16 prospective cohort studies comparing total disc replacement with lumbar fusion.  The authors concluded that high-quality randomized controlled trials with relevant control groups and long-term follow-up is needed to evaluate the effectiveness and safety of total disc replacement.  In summary, the patients experience of pain while in Germany did not provide an indication for emergent or urgent surgery, and a delay with pain management techniques would have allowed additional patient education and the possibility of a positive symptomatic response to conservative care.  The lumbar spine surgery performed in Germany was not medically indicated for the treatment of this patient.  Therefore, the services at issue were not emergent or urgent and 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 


A 29-year-old male enrollee has requested reimbursement for assistant surgeon services provided on 7/17/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the Center for Medicare and Medicaid Services (CMS) provide direction relative to the typical medical necessity of assistant surgeons. The CMS has revised the list of surgical procedures which are eligible for assistant-at-surgery. For the surgery at issue, CPT code 20680, an assistant surgeon is not necessary. In addition, the study by the American College of Surgeons indicates that for CPT code 20680, an assistant at surgery is sometimes needed. Thus, the medical practice indicates that an assistant surgeon is not generally indicated for a hardware removal surgery. In addition, there was no indication in the operative report that the procedure performed was a complex procedure, or that the assistant surgeon played a significant active role in the performance of the surgery. In sum, there is no compelling rationale provided to support the medical necessity of an assistant surgeon on 7/17/15. 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 

The patient is a 16-year-old male with idiopathic short stature. He presented to his endocrinologist at the age of 8 years 6 months with height at approximately the third percentile. The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication. Based on the bone age of 13 years, the calculated predicted adult height is 187 cm or 73.6 inches. Based on the bone age of 13.5 years, the calculated predicted adult height was 182.4 cm or 71.8 inches. These are based on values per Greulich and Pyle method. The U.S. Food and Drug Administration has approved the use of growth hormone therapy for idiopathic short stature or non-growth hormone-deficient short stature defined as height standard deviation less than or equal to -2.25 or less than or equal to 1.2nd percentile for age and gender. In 2016, Pediatric Endocrine Society came out with guidelines and recommendations for growth hormone use and noted that the decision to treat idiopathic short stature should be made on case-by-case basis. The above patient had a history of short stature with height being at 1.2 percentile and poor growth velocity. He has been treated with growth hormone therapy. His predicted adult height of 71.8 to 73.6 inches is higher than the 66.5 inches of mid-parental height by a good margin. His current height is 64.8 inches and he is likely to achieve his mid-parental height. At this point, continued growth hormone therapy is not medically necessary. Therefore, Norditropin Flexpro 10 mg/1.5 mL pen injector is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of an 11-year-old female enrollee has requested authorization and coverage for Nutropin.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  There is insufficient information provided to determine the medical necessity of continuation of growth hormone therapy.  As the case material includes a growth chart with only one data point, it is not possible to determine if this patient experienced poor growth velocity prior to growth hormone treatment.  In addition, no data are provided about pre-treatment IGF-1 or insulin-like growth factor binding protein 3 (IGFBP-3) levels, or pre-treatment laboratory work-up to rule out other causes of growth fall-off.  All told, Nutropin is not medically indicated for the treatment of this patient.  Therefore, the requested medication 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 Upheld

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested authorization and coverage for applied behavioral analysis (ABA) services for 30 hours per week. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder. The physician reviewer found that this patient is reported to be on the autism spectrum. However, the records provided for review do not provide details regarding the frequency of challenging behaviors, nor his response to previous ABA therapy. Some of the goals being addressed in the proposed ABA therapy plan provided are more consistent with goals addressed with occupational or vocational therapy than directly addressing the patients autism spectrum disorder. These goals include completing chores and using utensils. In the medical literature, Orinstein and colleagues reviewed the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder and found no correlation between the number of hours provided per week and outcomes. The authors noted that the age at which ABA therapy was started and duration of treatment was correlated with outcome. Luiselli and colleagues reached similar conclusions. Thus, the Health Insurers approval for 15 hours per week of direct ABA therapy is appropriate to address this patients current needs as documented in the records reviewed. Accordingly, the requested ABA services for 30 hours per week is not supported as medically necessary. Based on the foregoing discussion, the requested services 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 

The patient is a 40-year-old female who was evaluated with a lactulose breath test on 7/31/19. The patient has requested authorization and coverage for Xifaxan. The Health Insurer has denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. This patient has small intestinal bacterial overgrowth. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. This medication had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, fluoroquinolones, and penicillins. Results are sustained for several weeks after treatment. Therefore, Xifaxan is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 48-year-old female enrollee has requested authorization and coverage for Gamunex-C (immune globulin (human) intravenous or subcutaneous solution, 10 gm/100 ml. 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 dermatomyositis is an idiopathic inflammatory myopathy. In this case, the patient has been diagnosed with dermatomyositis. Her treatment has included prednisone alone. Initial therapy for individuals diagnosed with this disorder includes high-dose glucocorticoid therapy with a taper to the lowest effective dose. Generally, a glucocorticoid-sparing agent is used in combination with glucocorticoid therapy. Treatment includes prednisone in combination with methotrexate, azathioprine or CellCept. In this case, the patient has only been treated with prednisone, and the requested medication is not considered a first-line medication. There is no documentation that she has failed treatment with a glucocorticoid-sparing agent, such as methotrexate, azathioprine or CellCept, which are considered first-line medications. The requested medication, Gamunex-C is not medically indicated. Therefore, Gamunex-C (immune globulin (human) intravenous or subcutaneous solution, 10 gm/100 ml) is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 16-year-old male with diagnoses of other specified anxiety disorder, cannabis use disorder, severe, and parent-child relational problem. He started using marijuana in eighth grade, and was using daily by the end of eighth grade. 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 3. The patient had a significant risk of harm, due to binge or excessive use of alcohol or other drugs, resulting in potentially harmful behaviors. In terms of functional status, the records support a score of 3. The documentation indicated moderate functional impairment, due to conflict with parents, recent sobriety and stabilization of mood achieved in a structured and protected setting (wilderness treatment program). With regard to comorbidity, the records support a score of 3. The documentation indicated significant comorbidity due to significant anxiety symptoms contributing to substance use. In terms of level of stress of the recovery environment, the records support a score of 1. The patient had a minimally stressful environment, due to the absence of difficulties in his life circumstances. With regard to environmental support, the records support a score of 2 due to his parents active participation in treatment and ability to meet patients material needs. In terms of resiliency and treatment history, the records support a score of 3 due to maintenance of abstinence and mood stability in the structured environment of the wilderness program, with no prior attempts at outpatient treatment. With regard to the patients acceptance and engagement, the records support a score of 2 due to his active participation in treatment at the wilderness program. Thus, the patient has a composite score of 17. This is consistent with an intensive outpatient or partial hospital program. There is no evidence that this level of care had been tried for this patient. Therefore, mental health residential treatment provided from 5/06/19 through 12/31/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 55-year-old female enrollee has requested authorization and coverage for tremfya 100 mg/mL syringe. 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 the submitted documentation supports the medical necessity of the requested medication. The American College of Rheumatology/National Psoriasis Foundation published updated guidelines in 2019. Severe psoriasis is defined as disease affecting greater than 5 to 10% body surface area or disease affecting the face, palms or soles of feet. The National Psoriasis Foundation considers Tremfya a first-line therapy when ultraviolet B therapy is not available. The American Academy of Dermatology and the National Psoriasis Foundation issued a joint position statement in April 2019. Currently, there are 11 biologic agents on the market or in clinical trials for the treatment of psoriasis. Tremfya was approved by the U.S. Food and Food Drug Administration in July 2017 for use in psoriasis. Tremfya is recommended as a monotherapy treatment option in adult patients with scalp, nail, and plaque-type palmoplantar psoriasis. In this case, the patient has severe psoriasis with involvement of the scalp, foot and hands over 15% body surface area. The patient has tried and failed topical steroids, oral steroids, cyclosporine A, and Taltz (not tolerated). Given the scenario of failure of standard therapies for severe psoriasis, it is reasonable to consider a trial of biologics. The requested medication is medically appropriate in this clinical setting. Therefore, Tremfya 100 mg/mL syringe is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The patient is a 63-year-old male who has been diagnosed with a squamous cell carcinoma of the thymus. In May 2015, he had resection of gross tumor, but was found to have very locally extensive cancer. The surgery was followed by four cycles of chemotherapy along with radiation therapy. This therapy ended in November 2015. He was noted to have progression of disease approximately in October 2016 and was retreated with chemotherapy at that time. As of September 2017, he was relatively stable. A tissue sample was sent for FoundationOne assay. The patient has requested reimbursement for the FoundationOne testing performed on 12/28/16. Per the Health Insurer, the services at issue were investigational for evaluation of this patients medical condition. There is a lack of support for the services at issue in this clinical setting.  FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician, nor yields a result that is reliably clinically beneficial. There are various non-randomized studies exploring the value of molecular profiling but these studies are not definitive or compelling as to the efficacy of the assay. A randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. Finding a mutation does not guarantee that a treatment directed at that mutation will produce a clinically meaningful response. All told, the FoundationOne testing performed on 12/28/16 was not likely to have been more efficacious than other methods of evaluating this patients medical condition.   Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial sho
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The patient is a 63-year-old male with metastatic thymic cancer, stage IV with pleural dissemination. He was initially diagnosed in November 2014. On 4/29/15, he underwent an anterior mediastinal mass core biopsy and the results were suggestive of a thymic carcinoma. He underwent thymic mass resection and completed four cycles of chemotherapy. Other treatments included radiation and additional chemotherapy with cisplatin, epirubicin, and etoposide when he recurred. He had progression of the disease and his tumor was sent for FoundationOne testing to help guide treatment decision making. The patient has requested reimbursement for FoundationOne testing performed on 12/28/16. The Health Insurer denied this request and reported that the services at issue were investigational for the evaluation of this patients medical condition. Thymic carcinomas are rare epithelial malignancies with no clear therapeutic guidelines beyond first line therapy. Molecular profiling such as with FoundationOne testing offers molecular profiling that can differentiate thymic carcinomas from thymomas by identifying c-KIT mutations. The presence of a c-KIT mutation in thymic cancers has shown benefit to treatment with sunitinib or sorafenib. Molecular profiling can also help to differentiate thymic cancers from lung cancers as pathologically they are similar. As such, molecular profiling with FoundationOne testing performed on 12/28/16 was likely to have been more effective than any available standard therapy for evaluating the patients medical condition.  Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overtu
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The patient is a 63-year-old male with thymic carcinoma. He initially presented in November 2014 with dyspnea. A computed tomography scan showed an anterior mediastinal mass, which was biopsied. The pathology showed this was a thymic carcinoma. He had surgical resection in May 2015. The mass involved the left upper lung lobe, pericardium, parietal and visceral pleura, and diaphragmatic and mediastinal lymph nodes. He received four cycles of chemotherapy and radiotherapy. The patient has minimal residual disease. The tumor was submitted for mutational testing. The patient has requested reimbursement for FoundationOne testing performed on 12/28/16. The Health Insurer denied this request on the basis that the services at issue were investigational for the evaluation of this patients medical condition. There is support for the efficacy of the services at issue in this clinical setting. This patient was diagnosed with a very rare tumor, thymic carcinoma, which is metastatic.  Combination chemotherapy had induced a significant response but with progressive disease FoundationOne testing was the next step. A study of 86 patients by Von Hoff and colleagues of the progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial had very significant results for patients with stage IV tumors. Therefore, the molecular profiling such as with FoundationOne testing performed on 12/28/16 was likely to have been more beneficial than any available standard therapy for evaluating the patients medical condition.  Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 27-year-old female enrollee has requested reimbursement for inpatient level of care provided on 5/20/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient presented with symptoms consistent with urinary tract infection. At the time of admission, she was afebrile and hemodynamically stable. She did not have significant pain at the time of admission. She was tolerating oral hydration and could be treated with oral antibiotics.  There was no evidence of urinary tract obstruction. The inpatient admission was not medically necessary for this patient. She could have been treated at a lower level of care. Therefore, inpatient level of care provided on 5/20/19 was not medically necessary for the treatment of this patient.