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

Summary Reviewer 

A 60-year-old male enrollee has requested reimbursement for inpatient services (telemetry level of care) provided from 4/04/19 through 4/06/19. 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 patient had known coronary artery disease and multiple prior interventions. He was initially scheduled for elective catheterization when he presented to the outpatient office with low effort angina, and his medical regimen was appropriately adjusted at that time. However, in the subsequent days, he developed rest angina and was diagnosed with acute coronary syndrome. Patients presenting with rest angina and known complex coronary artery disease require hospitalization to rule out myocardial infarction, have cardiac telemetry monitoring and then are referred for cardiac catheterization and potential revascularization. Initially, the plan was for elective catheterization. However, the patients symptoms progressed rapidly, and he presented with an acute coronary syndrome in the setting of prior known severe coronary artery disease. Admission for acute coronary syndrome to rule out myocardial infarction, telemetry monitor, adjust his acute medical regimen and undergo subsequent catheterization and revascularization was medically appropriate and within the current standard of care. Therefore, inpatient services (telemetry level of care) provided from 4/04/19 through 4/06/19 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 29-year-old male enrollee has requested reimbursement for chiropractic modalities CPT codes (97012, 97110, 97140 and 99213) for the following dates: 1/22/16, 1/25/16, 1/27/16, 1/29/16, and 2/1/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck and upper back pain. The physician reviewer found the submitted records do not demonstrate the medical necessity of the services at issue. There is no high grade scientific evidence to support passive physical modalities such as traction and massage/myofascial release to neck and upper back complaints as indicated in this case. The patient did make functional change with objective measures such as neck disability index and upper extremity functional scale. However, there is no evidence that the patient would not have made functional changes with only the approved services and not the adjunct therapies. Treatment dependence on passive modalities such as massage should be avoided. Only when there is evidence of a lack of effectiveness should relaxation massage be offered. Physical modalities such as specific neck exercises for range of motion and strengthening are also recommended. There is strong evidence that exercise programs are superior to therapies that do not include exercise. For the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 53-year-old female enrollee has requested authorization and coverage for a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), including microprocessor, sensors, all components and accessories, custom fabricated. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the standard of rehabilitative care in the setting of severe functional impairments due to central nervous system pathology such as stroke is to endeavor to address impairments, mitigate risks of complications, and to optimize overall function in all relevant domains with the assistance of services, such as physiatry, occupational therapy, orthotists, assistive technology providers, social workers, independent living counselors and vocational counselors, as appropriate. Increased independence can be pursued and achieved in this clinical setting using equipment such as assistive speech technology, smartphones, adaptive utensils, nonskid plates, gait/mobility implements, other adaptive equipment and accessibility/environmental modifications, if appropriate.  When there are limits to function despite exhausting more direct interventions, or when efficiency or safety calls for it, caregivers may be called upon to otherwise meet a personas functional needs. There is no proven role of the MyoPro elbow-wrist-hand-finger orthosis in question in stroke management or rehabilitation.  The proposed device does not replace the role of conventional (i.e., passive, light and custom-fitted) orthoses, which can be employed as needed to manage the effects of tone, to reinforce therapeutic positioning, and to enhance functionality when applicable. There are some potential functional benefits theoretically of the device in question, but these benefits have not been demonstrated in a clinically relevant setting. There is a lack of proven health benefits that can be attributed to use of this device.  The available scientific evidence related to the type of orthotic device in question is limited to preclinical work and anecdotal literature. The potential benefits, importantly, have not been demonstrated to outweigh the potential adverse sequelae and safety issues. This type of device could potentially cause or exacerbate edema, skin injuries, musculoskeletal injuries or pain. Therefore, the requested powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), including microprocessor, sensors, all components and accessories, custom fabricated is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 53-year-old female enrollee has requested authorization and coverage for a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), including microprocessor, sensors, all components and accessories, custom fabricated. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested device in this clinical setting. Use of the myoelectric elbow-wrist-hand orthosis in chronic stroke patients with moderate and severe impairment in their upper extremities, such as this case, enables patients to use their affected upper extremities, facilitating increased function, independence and participation in valued activities inside and outside of home. Current quality evidence shows the use of the myoelectric elbow-wrist-hand orthosis increases gross manual dexterity and the quality of task performance. Moderately and severely impaired stroke survivors exhibit severely diminished ability to incorporate their affected upper extremities into daily activities and subsequently have limited treatment options. This limitation often necessitates prescription of compensatory strategies (e.g., one-handed techniques) and/or assistive devices (e.g., range of motion braces, splints) to maximize independence, with limited involvement from the paretic upper extremity. In contrast, current evidence supports that paretic arm disability may be significantly reduced while wearing a myoelectric elbow-wrist-hand orthosis, allowing for immediate use of the paretic arm and hand, with little device training. Thus, the requested powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), including microprocessor, sensors, all components and accessories, custom fabricated is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 53-year-old female enrollee has requested authorization and coverage for a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), including microprocessor, sensors, all components and accessories, custom fabricated. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that a review of the literature reveals that there are few studies on the myoelectric elbow-wrist-hand orthosis, and the outcomes of the studies are inconsistent. The literature reveals that further studies with larger numbers of participants are needed that show consistent improvements in relevant outcome measures. Additionally, the studies performed were inconsistent with variations between the trials in the intensity, duration, and amount of training; type of treatment; participant characteristics; and measurements used. A literature review by Carey evaluating the differences in myoelectric and body-powered upper limb prostheses revealed conflicting evidence in terms of the relative functional performance of body-powered and myoelectric prostheses. The authors noted, aBody-powered prostheses have been shown to have advantages in durability, training time, frequency of adjustment, maintenance, and feedback; however, they could still benefit from improvements of control. Myoelectric prostheses have been shown to improve cosmesis and phantom-limb pain and are more accepted for light intensity work.a The authors reported that the current evidence is insufficient to conclude that either system provides a significant general advantage. Additionally, this study indicates that there is a lack of empirical evidence regarding functional differences in upper-limb prostheses. McCabe and colleagues indicated that a small retrospective chronic stroke study did reveal gains made on a measure of upper limb motor control. This study was limited by inconsistent timing of testing and variability in treatment dose. The authors noted that additional measurements across multiple domains are necessary to further elucidate how the device impacts patient care and functional performance. All told, the requested powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), including microprocessor, sensors, all components and accessories, custom fabricated is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 77-year-old female enrollee has requested reimbursement and prospective authorization and coverage for substance use inpatient rehabilitation from 7/11/16 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 behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  There was no evidence of an acute psychiatric syndrome, grave disability or a medical crisis.  The patient had completed a safe detoxification.  She had a supportive spouse and safe housing.  Further, her relapse was prompted by a significant identifiable external stressor.  Prior to that, she was stable on an antidepressant medication and had sustained several months of sobriety in the absence of chemical dependency programming, such as community services, anti-craving medication, sober living environments, intensive outpatient programming or partial hospitalization. This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. Thus, substance use inpatient rehabilitation from 7/11/16 forward were not and are not medically necessary for the treatment of this patient. Therefore, 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 27-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential mental health treatment provided from 6/14/16 through 1/31/17. 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 behavioral health condition. The physician reviewer found considering the extent of the patients thought disorder and the common practice of utilizing the residential setting as a step-down level of care, the initial admission was consistent with current practice standards. The patient showed fairly prompt signs of improvement. On 6/29/16, the patient was in a good mood. He was gaining insight, and his judgment was improving. His thought processing was linear. On 7/8/16, he was in good spirits and his psychotic symptoms were subsiding. On 7/14/16, his thought content was devoid of suicidality. His responses were appropriate. He was euthymic and organized with improving insight and judgment. The patient was medication adherent and self-administering his paliperidone and l-mehtylfolate. The patient was functioning independently, and by 7/14/16 had been in an inpatient setting for nearly three months. Based on the documentation provided, the patient warrants ongoing comprehensive specialty care including antipsychotic therapy, assertive community treatment, family psychoeducation, cognitive remediation, cognitive behavioral therapy, and supportive housing and employment. However, these services could have been delivered in a community-based setting while the patients illness burden no longer demanded placement in a 24-hour supervised setting as of 7/14/16. As such, discharge to a less restrictive setting by 7/14/16 would have been safe, appropriate and consistent with good medical practice. Thus, the residential mental health treatment provided from 6/14/16 through 7/13/16 was medically necessary.Therefore, 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 31-year-old female with multiple medical problems who has had years of pelvic pain and dysfunctional uterine bleeding. The patient has tried conservative treatment with oral contraceptive pills, intrauterine device, progesterone, and Depo-Lupron. The patient received genetic counseling and indicates that she has no desire for future fertility. She has not had a surgical diagnosis of endometriosis; however, her clinical presentation is suggestive of endometriosis. Her provider has recommended hysterectomy as the best treatment option for the management of this patients symptoms.
The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. There is support in the documentation provided for the requested services in this clinical setting.  While this patient does not have a surgical diagnosis of endometriosis, her symptoms are strongly suggestive of endometriosis. The association between endometriosis stage at surgery and severity of pelvic symptoms has been marginal.  Thus, a diagnostic procedure would add little to the management of this patients pain. In this case, it is reasonable to assume that the patient has endometriosis.  Given the presumptive diagnosis of endometriosis, long standing pelvic pain with menstrual dysfunction and a lack of desire for future fertility, it is reasonable for the patient to proceed with definitive treatment of hysterectomy. This request is supported by the American College of Obstetricians and Gynecologists Practice Bulletin on endometriosis. Accordingly, based on the documentation provided as well as the medical literature, the requested hysterectomy for treatment of this patients medical condition is supported as medically necessary.  Therefore, based on the information noted above, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 57-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma test performed on 8/17/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state 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 services at issue were not likely to have altered patient management. Therefore, DecisionDx-Melanoma test performed on 8/17/17 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 57-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma test performed on 8/17/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add to these statistics. DecisionDx-Melanoma is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 (with a 90 to 92% distant disease free survival at five years), or class 2 (with a 65 to 80% rate). Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node sampling. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear whether the assay can be used to make treatment decisions. Therefore, DecisionDx-Melanoma test performed on 8/17/17 was not likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 57-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma test performed on 8/17/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that there is a lack of support for the services at issue in this patients case. DecisionDx-Melanoma is a 31-gene expression profile test for predicting the risk of recurrence of skin melanoma. The National Comprehensive Cancer Network guidelines note that while there is interest in newer prognostic molecular techniques, such as gene expression profiling, routine prognostic genetic testing of primary cutaneous melanoma before or after sentinel node biopsy is not recommended outside of a clinical trial. The current medical evidence has not demonstrated that the test is more beneficial than standard of care. Thus, DecisionDx-Melanoma test performed on 8/17/17 was not likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1
A 50-year-old female enrollee has requested reimbursement for breast tomosynthesis imaging performed on 2/10/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented for her annual breast examination. The physician reviewer found that there is evidence-based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol on 2/10/17 was likely to have been more effective than had her examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service at issue was likely to be more beneficial for the 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 50-year-old female enrollee has requested reimbursement for breast tomosynthesis imaging performed on 2/10/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented for her annual breast examination. The physician reviewer found that the digital mammography screening has been proven to decrease mortality related to breast cancer. Standard or two dimensional (2-D) mammography has significant limitations, namely obscuration of cancers within areas of overlapping or dense tissue, as well as false positive recalls due to overlapping breast tissue, which must be confirmed with additional imaging. Digital breast tomosynthesis addresses both of these issues as it increases the cancer detection rate. It does this by allowing the radiologist to scan through slices of breast tissue rather than seeing the breast tissue superimposed on itself. This technology is especially beneficial in patients with dense breast tissue, where the mammogram is already limited in the detection of cancer. According to the American College of Radiology position statement on breast tomosynthesis, it specifically states: To be clear: tomosynthesis is no longer investigational. Tomosynthesis has been shown to improve key screening parameters compared to digital mammography. As digital breast tomosynthesis has been proven to increase cancer detection in the screening setting, as well as decrease false positive recall rates, this patient would benefit from breast cancer screening utilizing tomosynthesis. As such, current medical literature supports that this modality is superior to standard 2-D mammography. Therefore, in this case, breast tomosynthesis imaging performed on 2/10/17 was likely to have been more beneficial for the evaluation of the patients condition than the available standard imaging.  Based upon the information set forth above, the service at issue was likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.