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

Summary Reviewer 2

The patient is a 64-year-old female who has been diagnosed with vertebral artery high-grade stenosis. In a letter dated 3/15/18, the provider noted the patient had a right carotid occlusion and a high-grade stenosis of the left carotid artery. The patient had presented with several transient ischemic attacks with complaints of dizziness, headaches and blurred vision. On 2/27/18, she underwent a left internal carotid artery angioplasty and stenting. The cerebral angiogram also noted a high-grade stenosis of the right vertebral artery of 70%. The patient then underwent a computed tomography (CT) perfusion to assess the blood flow to the posterior fossa. The CT perfusion on 3/07/18 revealed a decreased blood flow to the right occipital lobe, secondary to her right vertebral stenosis.  The provider recommended right vertebral artery angioplasty and stenting. The patient has requested coverage for vertebral artery angioplasty. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  The current medical evidence has not demonstrated the superior efficacy of the requested services. Angioplasty may be indicated for patients with severe vascular disease as indicated by greater than 50% stenosis and when there is severe disabling claudication or other severe disability from ischemia, critical limb ischemia or atheroembolic phenomenon. It is also appropriate for patients who have other physiologic changes requiring intervention. This patient has greater than 50% stenosis and dizziness. However, the records failed to establish that the patient had severe claudication or other severe disabilities from ischemia, critical limb ischemia or atheroembolic phenomenon. The records failed to establish physiologic changes were present to require intervention. The medical literature does not support that the performance of a vertebral artery angioplasty is superior to medical management. Further clinical trials are needed to establish superiority over medical management. Therefore, the requested vertebral artery angioplasty is not likely to be of greater benefit 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

The patient is a 64-year-old female who presented to the neurosurgery clinic after being diagnosed with a right carotid occlusion and high-grade stenosis of the left carotid artery.  She has a history of several transient ischemic attacks with complaints of dizziness as well as headaches and blurry vision. The patient underwent left internal carotid artery angioplasty and stenting on 2/27/18.  The angiogram noted high-grade stenosis of the right vertebral artery is 70%, and a computed tomography (CT) perfusion revealed decreased blood flow to the right occipital lobe. During the postoperative examination, she continued with symptomatic dizziness, and the recommendation was made for right vertebral artery angioplasty with stenting.  The provider noted she is at increased risk for stroke should she become dehydrated or hypotensive given the carotid occlusion and stenosis of the right vertebral artery. The patient has requested coverage for vertebral artery angioplasty. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  This patient has been recommended to undergo a vertebral artery angioplasty due to vertebral artery occlusion.  The patient underwent left internal carotid artery angioplasty and stenting on 2/27/18 and was noted to have a follow-up on 3/06/18 where she indicated she was doing well. She did complain of one episode of dizziness. While treatment with the requested surgical intervention may be appropriate in certain situations, it does not appear this patient is an appropriate candidate. There is lack of documentation indicating that the stenosis continues to make the patient symptomatic.  The follow-up note indicated the patient was doing well and only had one episode of dizziness.  Given the above, the requested vertebral artery angioplasty is not likely to be of greater benefit 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 6/01/15.  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.  As noted by Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Per Ciatto and colleagues, integrated two-dimensional and three-dimensional mammography improves breast-cancer detection and has the potential to reduce false positive recalls.  All told, digital breast tomosynthesis performed on 6/01/15 was likely to have been superior over 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 6/01/15.  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 in this patients case, the services at issue were likely to have been more effective than other available modalities.  The addition of the technique has gained worldwide popularity among radiologists due to an associated decrease in callbacks and increase in detection of small cancers.  Tomosynthesis helps in the elimination of confusing overlapping glandular tissue particularly in dense and heterogeneously dense breast tissue, which in turn allows for a more definitive assessment of the breast parenchyma.  Thus, digital breast tomosynthesis performed on 6/01/15 was likely to have been more beneficial 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 6/01/15.  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 Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this patients case, there were no problems to be solved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  There is a lack of support for the services at issue in this setting.  Thus, digital breast tomosynthesis performed on 6/01/15 was not likely to have been of greater benefit than other options for 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 25-year-old female enrollee has requested reimbursement for calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that the American College of Gastroenterology guidelines for the management of Crohns disease support the use of fecal calprotectin testing, stating, In patients who have symptoms of active Crohns disease, stool testing should be performed to include fecal pathogens, Clostridium difficile testing, and may include studies that identify gut inflammation such as a fecal calprotectin. The guidelines note, Fecal calprotectin and fecal lactoferrin measurements may have an adjunctive role in monitoring disease activityStudies have shown that both fecal lactoferrin and fecal calprotectin are sensitive markers of disease activity and correlate with a number of the endoscopic activity indices. Current medical literature, including prospective trials, support fecal calprotectin to assess disease activity, assess response to treatment, and predict disease relapse in patients with inflammatory bowel disease. Various studies have found that fecal calprotectin correlates with endoscopic finding of inflammation and serum markers of inflammation in Crohns disease. The test can assess for improvement in inflammation, such as in this patient undergoing induction with Entyvio and recent disease activity at the ileocecal valve. Therefore, calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 25-year-old female enrollee has requested reimbursement for calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that the fecal calprotectin is useful to assess disease activity in Crohns disease. Kawashima and colleagues conducted a study to clarify the predictability of fecal calprotectin level for predicting endoscopic remission. The authors noted that fecal calprotectin was more accurate for predicting endoscopic remission in Crohns disease than C-reactive protein, albumin, white blood cell count, and platelet count. DHaens and colleagues noted that fecal calprotectin levels correlate significantly with endoscopic disease activity in inflammatory bowel disease. There is sufficient support for the services at issue in this clinical setting. Therefore, calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 25-year-old female enrollee has requested reimbursement for calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found thant the submitted records fail to demonstrate the superior efficacy of the services at issue. Providers use the clinical history along with laboratory studies to obtain clues to ongoing inflammation related to the suspecting an underlying disorder of inflammatory bowel disease (IBD). In addition, radiographic studies and endoscopic evaluation are tools that can be used but carry their own potential risks. This patient underwent fecal calprotectin to assess the level of inflammation. An elevated fecal calprotectin is not specific for IBD. Any inflammatory process within the gastrointestinal tract will result in the activation of the innate immune response and release of calprotectin. Fecal calprotectin concentration has been shown in studies to be elevated in many conditions, including rheumatologic conditions. Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to cause significant increases in fecal calprotectin levels. Proton pump inhibitors (PPIs) have been associated with significantly elevated fecal calprotectin levels, regardless of reason for PPI. Therefore, calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 59-year-old female enrollee has requested authorization and coverage for Saxenda Pen injector. 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 according to the guidelines from the Endocrine Society, diet, exercise, and behavioral modification should be included in all obesity management approaches for patients with body mass index greater than or equal to 25 kg/m2. For patients with a body mass index greater than or equal to 27 kg/m2 with comorbidity or a body mass index over 30 kg/m2, pharmacotherapy may be used as an adjunct to behavioral modification. Drugs may amplify adherence to behavior change and may improve physical functioning, such that increased physical activity is easier in those who cannot exercise initially. Patients who have a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications. Saxenda (liraglutide) is a glucagon-like peptide-1 receptor agonist that has been successfully used in the treatment of type 2 diabetes for several years. Weight loss has been well-described as an additional benefit with liraglutide therapy, which prompted the manufacturer to evaluate and develop a higher dose formulation specifically for the treatment of obesity. Liraglutide 3 mg/day has been approved by the U.S. Food and Drug Administration for this indication. In this patients case, the records document a body mass index of 30.07 kg/m2. The current medical evidence supports the requested medication in this clinical setting. Therefore, Saxenda pen injector is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 21-year-old female enrollee has requested reimbursement for the Game Ready system provided on 9/10/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is support in the medical literature for the services at issue in this clinical setting. The study by Martimbianco and colleagues investigated the use of cryotherapy after arthroscopic knee surgery, finding that cold compression results in reduced pain 48 hours after surgery. In addition, Block states that cryotherapy and static compression is commonly used for acute injuries as this intervention is thought to be most effective if applied almost immediately after injury or at the conclusion of an operative procedure. Thus, there is benefit noted in the immediate post-operative period. As such, the services at issue provided after knee surgery were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Based upon the information set forth above, the 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 Upheld

Summary Reviewer 2


A 21-year-old female enrollee has requested reimbursement for the Game Ready system provided on 9/10/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there are few published data of cryotherapy devices with respect to health or functional outcomes in the setting of musculoskeletal conditions, including following knee surgery.  Hubbard and Denegar reported that, Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury.  There is some limited published literature related to hip and knee surgery. The medical literature does not indicate, however, that the use of these cooling devices is necessary in the postoperative period outside of the hospital, particularly when a patient is ambulatory. There is also insufficient high quality evidence that establishes that the use of cooling devices results in better outcomes over the use of topical ice pack application. All told, the Game Ready system provided on 9/10/15 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 21-year-old female enrollee has requested reimbursement for the Game Ready system provided on 9/10/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the Game Ready cryocompression device provides icing and compression for an extremity after surgery. Although both compression and icing are beneficial for the patient after surgical intervention, there is a lack of evidence in the peer-reviewed literature that the supports use of the Game Ready cryocompression device as more beneficial than standard therapies in this clinical setting. Most of the medical literature suggests benefit for patients after joint replacement surgery. All told, there is a lack of peer-reviewed literature that supports the Game Ready cryocompression device as likely to be more beneficial for this patient than icing and wrapping. 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.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a seven-year-old male enrollee has requested authorization and coverage for Nutropin AQ Nuspin 10. 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 fails to demonstrate the medical necessity of the requested medication. This patient has a low body mass index, even for DiGeorge syndrome. There is no evidence that the poor weight gain has been addressed properly, as this can lead to growth failure. There is no evidence of what the bone age is on the present notes. This patient had an actual growth velocity of 4 cm per year in the last year, which is reassuring. Patients with DiGeorge syndrome can have hypothyroidism which can also lead to short stature. There is no evidence from the current notes that this has been ruled out. At this time, the medical records do not establish that Nutropin AQ NuSpin 10 is medically indicated. Therefore, Nutropin AQ NuSpin 10 is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 58-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis. 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 American Urologic Association guidelines note that the clinical indications for the use of MRI in the management of prostate cancer are rapidly evolving. Mowatt and colleagues noted owing to the relative paucity of reliable data, further studies are required. The authors noted that prospective studies are required in men with suspected prostate cancer and elevated PSA levels but previously negative biopsy comparing the utility of the MRI with both a magnetic resonance-guided/-directed biopsy session and an extended 14-core TRUS-guided biopsy scheme against a reference standard of histopathological assessment of biopsied tissue obtained via saturation biopsy, template biopsy or prostatectomy specimens. At this time, standard transrectal ultrasound and guided biopsy of prostate remains the initial diagnostic modality. Therefore, the requested MRI of the pelvis is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 55-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 1/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees melanoma. The physician reviewer found that the records document an early stage melanoma. The National Comprehensive Cancer Network guidelines states while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of this testing was not likely to have altered treatment and surveillance recommendations. Thus, DecisionDx-Melanoma assay performed on 1/26/18 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.