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

Summary Reviewer 2


A 22-year-old female enrollee has requested authorization and coverage for spine nerve treatment, procedure codes 64634 and 64633. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Manchikanti and colleagues discuss the effectiveness of medial branch blocks in systematic reviews and randomized trials. Thoracic spine was noted to have evidence with controlled blocks Level II-1, moderate to strong evidence lasting from months to a year with level II-2 to II-3. Thoracic facet joint nerve blocks showed improvement in 71% of the patients at 6 months, 76% at 12 months, 71% at 24 months, and 69% at 36 months. Thus, the requested services are successful in treating lumbar spine pain in repeated fashion. In this case, given she has had successful cervical and thoracic rhizotomies in the past, the requested services are 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 requested services are 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 Overturned

Summary Reviewer 3


A 22-year-old female enrollee has requested authorization and coverage for spine nerve treatment, procedure codes 64634 and 64633. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that spine nerve treatment, procedure codes 64634 and 64633 are likely to be more beneficial for treatment of the enrollees medical condition. The majority of peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected. Tzaan and colleagues performed a retrospective study to assess the value of percutaneous radiofrequency facet rhizotomy. The authors concluded that the procedure is simple and safe in patients with disabling spinal pain that fail to respond to conservative treatment. In this case, the physical exam and MRI is significant for multi-level spondylosis and facet mediated pain. Per the provider notes the patient has had significant relief with prior radiofrequency of the thoracic facet. Therefore, the requested services are 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 requested services are 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a three-year-old female enrollee has requested reimbursement for speech therapy provided from 1/06/15 through 5/28/15.  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 the submitted documentation supports the medical necessity of the services at issue.  As noted by Nelson and colleagues, the identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Law and colleagues noted that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient has moderate expressive language delay negatively impacting her ability to communicate effectively and express her wants and needs.  The literature supports the efficacy of speech and language therapy in this clinical setting.  All told, speech therapy provided from 1/06/15 through 5/28/15 was medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition.  The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a six-year-old male enrollee has requested authorization and coverage for Nutropin AQ. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has normal stature, normal growth velocity, normal bone age, and normal IGF-1.  Provocative growth hormone testing showed a peak growth hormone response of 14.1 ng/mL, with a normal result being a peak growth hormone level greater than 10 ng/mL on at least one sample obtained after two provocative growth hormone tests.  Thus, the patient does not meet auxological or biochemical criteria for growth hormone deficiency.  Growth hormone therapy is not an indicated treatment for fatigue/somnolence in the absence of auxological or biochemical evidence of growth hormone deficiency.  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 

A 45-year-old male enrollee has requested authorization and coverage for Otezla 10-20-30 milligram tablets, starter therapy pack. 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 is requesting coverage for Otezla for the treatment of chronic plaque psoriasis. The records document that he has tried and failed therapy with Clobex spray and azithromycin. The Health Insurer has denied the request as not medically necessary as the patient has not tried and failed the formulary preferred agents. The submitted records do not indicate a treatment trial or contraindications to the use of methotrexate, cyclosporine, Humira, Enbrel, Cosentyx or Stelara. Thus, there are effective, alternative, formulary preferred agents available for use. Therefore, Otezla 10-20-30 milligram tablets, starter therapy pack is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The patient is a 58-year-old male who presented with invasive breast, cT2N1M1, estrogen receptor (ER) positive, progesterone receptor (PR) positive, Her2 negative with a single bone metastases in the right acetabulum. He is being evaluated for stereotactic body radiotherapy (SBRT) for the single bone metastases. The patient has requested authorization and coverage for SBRT. The Health Insurer has denied this request indicating that the requested services are considered investigational. In some cases, patients with certain histologies with limited metastatic disease are considered good candidates for treatment with SBRT (Hanna and Landau; Tree, et al). There is convincing medical evidence that suggests that patients with breast cancer with an oligometastatic presentation benefit from SBRT. This patient has several features that portend a good prognosis for treatment to the oligometastatic site, including the patients age, bone only metastases, and the presence of only a single site of metastatic disease (Wong, et al). Therefore, the requested SBRT is 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 requested services are 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 Overturned

Summary Reviewer 2

The patient is a 58-year-old male with a left-sided clinical stage IV invasive breast cancer that is estrogen receptor (ER) positive, progesterone receptor (PR) positive, Her2 negative, and grade 3. He has a single bone metastasis in the right acetabulum. He was treated with neoadjuvant chemotherapy followed by mastectomy with sentinel lymph node biopsy. Pathology showed a good response to chemotherapy with negative margins. Repeat positron emission/computed tomography (PET/CT) showed uptake limited to the right acetabulum. The patient has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Insurer has denied this request indicating that the requested services are considered investigational. After review of available studies, the requested SBRT is likely to be more beneficial for the patients solitary bone metastasis secondary to breast cancer than conventional treatment consisting of conventionally fractionated radiotherapy. The current data demonstrates superior and more durable local control with SBRT for oligo-bone metastases with low toxicity. Chow and colleagues performed a systematic review of several different regimens of conventionally fractionated radiotherapy and demonstrated an overall response rate of approximately 60% with SBRT. Owen and colleagues reported on 74 patients with oligometastatic non-spine bony metastases of varying histologies that were treated with SBRT resulted in a one year local control rate of 91%. In this clinical scenario, it would be advantageous to provide a treatment for this patients bone metastasis with an expected response rate greater than 60%. Thus, the requested SBRT is 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 requested services are 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 Overturned

Summary Reviewer 3

The patient is a 58-year-old male with history of left-sided invasive breast cancer, clinically staged as cT2N1M1, stage IV, estrogen receptor (ER) positive, progesterone receptor (PR) positive, and grade III. The patient is noted to have a single osseous metastasis in the pelvis located in the right acetabulum. The provider noted this is a case of oligometastatic breast cancer. The patient has been treated with neoadjuvant chemotherapy followed by mastectomy and sentinel lymph node biopsy, revealing good treatment response. Given the low disease burden on computed tomography (CT), the provider has recommended treatment with stereotactic body radiotherapy (SBRT). The patient has requested authorization and coverage for SBRT. The Health Insurer has denied this request indicating that the requested services are considered investigational. SBRT is a treatment that couples a high degree of anatomic targeting accuracy and reproducibility with very high doses of precise, externally generated, ionizing radiation, thereby maximizing the cell-killing effect on the target(s) while minimizing radiation-related injury in adjacent normal tissues. This patient has breast cancer that was treated aggressively and has responded nicely. He has single metastatic lesion in acetabulum which needs aggressive treatment for durable local control. The current literature has demonstrated that aggressive treatment of limited metastases improves local control and slows progression beyond that expected with standard radiation therapy. All told, the requested SBRT is 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 requested services are 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a seven-year-old female enrollee has requested reimbursement for tonsillectomy and adenoidectomy performed on 9/25/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees sleep disordered breathing, recurrent tonsillitis, and adenotonsillar hypertrophy. The physician reviewer found that removal of tonsils and adenoids is a safe, effective surgical method to resolve breathing obstruction, throat infections and manage recurrent childhood ear disease. Tonsillectomy is performed commonly in combination with adenoidectomy, and has demonstrated efficacy as the primary treatment option for most children with obstructive sleep apnea syndrome. The medical literature suggests that obstructive sleep apnea syndrome is a risk factor for growth failure in children. A significant number of children with obstructive sleep apnea concurrent with growth failure are noted to benefit from tonsillectomy and adenoidectomy to recover and normalize their growth rate. This patient had clinically evident obstructive sleep apnea and growth failure as well as recurrent infections. Therefore, the tonsillectomy and adenoidectomy performed on 9/25/17 were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 50-year-old female who presented to her provider on 8/14/19. She reported back pain, shoulder pain and neck pain with bra strap grooving. The physician reviewer found that the American Society of Plastic Surgeons (ASPS) has indicated the decision to perform reduction mammoplasty should be based on patient symptoms and a surgeons assessment of the likelihood of benefit as opposed to the amount (weight) of breast tissue to be removed. It has been indicated by others, however, that the ASPS position is largely based on observational studies, which are un-blinded, lack randomized control groups and have potential for selection bias, and expert opinion. The more common and accepted guidelines use a measurement of body surface area and weight removed to determine medical necessity. The gold standard for this determination is the study by Schnur and colleagues. This article does not establish a defined lower weight for breast resection. Rather, it establishes a range. In this patients case, the resection would qualify the procedure as medically necessary according to weight. The photographs documented significant breast hypertrophy, consistent with the qualified weight resection. All told, breast reduction surgery performed on 12/11/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

An 18-year-old male enrollee has requested reimbursement for residential treatment center services from 1/20/12 through 12/3/12. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the residential treatment center services from 1/20/12 through 12/3/12 were not medically necessary for treatment of the patients medical condition. The additional documentation submitted for review demonstrates that the patient benefited from living in a sober living environment, in which he was drug free. However, these records do not indicate that within that environment he received any specialized medical or nursing treatment that was medically necessary for 24-hour residential treatment level of care. He had monthly psychiatric treatment, as well as group and individual therapy. He was at least minimally cooperative with his treatment, as documented every month by his attending psychiatrist. He did not require any special treatments, and was not documented to be suicidal, homicidal or psychotic. Based on the additional records submitted for review, this patient could have been treated in a less restrictive setting, such as a therapeutic boarding school with treatment provided through outpatient services. In addition, the neuropsychological performed in September 2012 assessed the patient with conduct disorder and stated that he does not have anxiety or depression. Moreover, the second evaluation, performed in 2013 also failed to find current evidence of a depressive disorder, and only stated that the patient has a history of major depressive disorder and oppositional-defiant disorder. In summary, the additional records submitted for review do not provide evidence that placement in a residential treatment center was medically necessary. 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 

A 55-year-old transgender female enrollee has requested authorization and coverage for facial feminization surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that gender reassignment traditionally includes psychotherapy, hormonal therapy, and surgery.  This has been demonstrated as the most effective treatment for patients with gender dysphoria. The World Professional Association for Transgender Health has published guidelines and standards of care, including what they consider eligibility criteria for surgery. In this patients case, the records do not document a comprehensive psychiatric evaluation. Further, in studying the quality of life of transgender male to female individuals, one large scale study by Ainsworth and Spiegel suggested that facial feminization did not have a statistically significant outcome in mental health features in these patients. Therefore, the requested facial feminization surgery is not medically necessary for the treatment of this patient. Therefore, 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 




A 22-year-old female enrollee has requested authorization and coverage for Botox injections. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees lymphatic malformation. The physician reviewer found botox injections have been established as medically necessary for treatment of the patients medical condition. The application of Botox to the healthy side of the face in patients with long-standing facial paralysis has been shown to be a minimally invasive technique that improves facial symmetry at rest and during facial motion. In addition, since this patient developed facial paralysis after treatment for a lymphatic malformation, surgery to treat the facial asymmetry would be considered reconstructive. Moreover, treatment with Botox should be considered medically necessary to improve the patients facial asymmetry. All told, Botox injections are medically necessary for treatment of the patients medical condition.  Therefore, the requested service is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 30-year-old female enrollee has requested authorization and coverage for Ocrevus injection, 300/10 mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees multiple sclerosis. The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the requested medication.  The records document that the patient is unable to tolerate Copaxone. Based on this patients side effect profile to Copaxone, Glatopa will cause similar side effect issues. The study by Kappos and colleagues compared Rebif to Ocrevus and demonstrated a relative reduction in new enhancing lesions achieved by Ocrevus.  However, there is no evidence of superiority of Ocrevus compared to the Health Insurers alternative Gilenya in comparative studies. Since the proposed treatment has not been demonstrated to be superior to all of the offered preferred agents, the medical necessity of the requested medication has not been established. All told, Ocrevus injection, 300/10 mL is not medically necessary 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 54-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay provided on 2/5/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx melanoma assay tests the tissue genetics of the melanoma to help stratify whether a thin melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Further, there is a paucity of literature to support its use in the care of patients with thin melanomas to effect health outcomes. The test is currently not standard of care, has not been demonstrated to provide a beneficial effect on health outcomes, and is not recommended by the NCCN guidelines. Overall, there is not enough published data to support its routine use. There needs to be clinical trials to determine the utility of the results of the test. Since this test does not provide a benefit more than established tests on outcomes, the DecisionDx melanoma assay provided on 2/5/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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.