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

Summary Reviewer 2
A 69-year-old female enrollee has requested reimbursement for lipoprotein (a) testing performed on 2/09/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. At issue is whether the services at issue were likely to have been more beneficial for evaluation of the enrolleeas condition than any available standard therapy. The physician reviewer found that guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein (a) testing. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Therefore, lipoprotein (a) testing performed on 2/09/21 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 69-year-old female enrollee has requested reimbursement for lipoprotein (a) testing performed on 2/09/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. At issue is whether the services at issue were likely to have been more beneficial for evaluation of the enrolleeas condition than any available standard therapy. The physician reviewer found that there is a lack of support for the services at issue in this patientas case. The National Lipid Association stated that lipoprotein (a) testing is reasonable to refine atherosclerotic cardiovascular disease risk in adults with the following: first-degree relatives with premature atherosclerotic cardiovascular disease (less than 55 years of age in men; less than 65 years of age in women); a personal history of premature atherosclerotic cardiovascular disease; primary severe hypercholesterolemia (LDL of 190 mg/dL) or suspected familial hypercholesterolemia. This patient does not meet any of these criteria for lipoprotein (a) measurement. Therefore, lipoprotein (a) testing performed on 2/09/21 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 24-year-old female enrollee has requested reimbursement for intensive outpatient program services provided from 9/26/15 through 12/07/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patients eating disordered behaviors were intertwined with affective illness, psychosis and character pathology resulting in a complex episode of illness.  Based on the documentation provided, the patient remained ill and had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  During the disputed service, the patient was engaged in active treatment that included psychotherapy, nutritional counseling services, and psychiatric services including diagnostic evaluation and pharmacotherapy.  Despite these interventions, the patient continued to struggle with eating disordered behavior, poor self-esteem, mood symptoms and psychosis.  The record described an individual who had not optimized the skills needed to maintain weight and emotional stability in an outpatient based setting prior to the actual discharge date.  The patient remained at elevated risk for undue morbidity and admission to a higher level of care in the absence of intensive outpatient program level of care.   The disputed care was reasonably expected to improve her condition and prevent a more serious illness.  In sum, the intensive outpatient program services provided from 9/26/15 through 12/07/15 were 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 54-year-old male enrollee has requested reimbursement for high-intensity focused ultrasound (HIFU) performed on 6/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that HIFU has been increasingly been used for treatment of localized prostate cancer within the last decade. It has the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity. Potential candidates are patients with low to moderate risk prostate cancer. The available literature mainly consists of prospective case series and retrospective studies showing short-term to intermediate-term outcomes for localized prostate cancer. There is a paucity of controlled trials available for analysis, and a lack long-term survival data is available. American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology guidelines note clinicians should inform low-risk prostate cancer patients who are considering focal therapy or HIFU that these interventions are not standard care options because comparative outcome evidence is lacking. Therefore, HIFU provided on 6/28/16 was not likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 54-year-old male enrollee has requested reimbursement for high-intensity focused ultrasound (HIFU) performed on 6/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that the current medical evidence has not demonstrated the superior efficacy of the services at issue. At this time, there is a lack of data comparing the long-term results in a controlled or randomized protocol between HIFU and other standard treatments of prostate cancer, particularly in low stage and low grade disease where active surveillance is being used more commonly in patients. There is a lack of support for the services at issue in this patients case. In sum, HIFU provided on 6/28/16 was not likely to have been more efficacious than other treatment options. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 54-year-old male enrollee has requested reimbursement for high-intensity focused ultrasound (HIFU) performed on 6/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that HIFU for prostate cancer is relatively new procedure. The U.S. Food and Drug Administration (FDA) has approved this procedure to be safe for treatment of prostate ablation. However, there is no specific indication for treatment of prostate cancer. The safety and efficacy of this treatment is currently being evaluated. The medical evidence has not demonstrated that this form of treatment is superior to conventional treatment options. Thus, HIFU provided on 6/28/16 was not likely to have been superior over other treatment modalities. 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 12-year-old male enrollee has requested authorization and coverage for Omnitrope growth hormone therapy. 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. The current medical evidence supports growth hormone therapy for children born small for gestational age, which is defined as birth weight or length two or more standard deviations below the mean for gestational age, who fail to manifest catch-up growth by two years of age, defined as height two or more standard deviations below the mean for age and sex. In this patients case, his height is close to the 50th percentile, and he has demonstrated catch-up growth. The growth velocity of 7.3 cm per year is normal. His predicted adult height is 59, which is the 50th percentile for a male in the United States. The predicted adult height is within two standard deviations of the mid-parental height of 72.1 inches. This patient does not meet the criteria for growth hormone treatment. Therefore, Omnitrope is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 37-year-old female enrollee has requested reimbursement for Butrans received on 10/3/15. The Health Insurer has denied this request indicating that the medication at issue was medically necessary for treatment of the enrollees medical condition. The physician reviewer found the patient presented with a history of chronic pain. The step wise WHO ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. (Raffa et al). In this patients case it does not appear all non-opioid treatment options had been utilized. Further, there was no plan in place to monitor this patients medications either historically and currently (Jamison et al). Moreover, it is unclear as to whether the diagnosis of chronic regional pain syndrome (CRPS) was supported. Based upon the information provided, the patient only appears to have met one of the criteria for such diagnosis and as noted in the medical records the patient has chronic pain syndrome and possibly fibromyalgia (Wurtman). Finally, multiple minimal requirements for opioid prescribing were not documented and the need to use Butrans to taper the patients opioid use is not supported. Pain specialists generally use taper medications that are not long-acting. Rather than using Butrans, buprenorphine oral form or methadone would be used for tapering purposes to get off another opioid. Moreover, there is no need to actually change opioids to taper; the physician can simply start decreasing the already prescribed opioids. As such, the medical necessity of the Butrans obtained on 10/3/15 has not been established. For the reasons set forth above, the medication at issue was 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 46-year-old female enrollee has requested authorization and coverage for Vascepa 1 gm capsule. 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 patient has a low, ten-year risk of cardiovascular disease at approximately 2%. He does have high triglyceride levels, which may require treatment, but a baseline low LDL cholesterol level. He does not have diabetes or known cardiovascular disease. He is not on statin therapy, as his LDL is low and he is not in a high cardiovascular risk group. Vascepa therapy has been approved and is indicated for use in patients with known cardiovascular disease or diabetes and two other cardiovascular risk factors as adjunctive therapy to high dose statin in these specific patients. It has not been shown yet to be indicated as monotherapy to lower isolated hypertriglyceridemia in low cardiovascular risk individuals unless other therapies (fibrates, Lovaza) have failed or are not tolerated. Although Lovaza has been implicated in possibly raising LDL levels in at-risk individuals, this patients LDL is already quite low at baseline. Although the patient may require therapy to lower his triglycerides, lifestyle modifications along with generic Lovaza or fibrate therapy would be reasonable first-line alternatives to lower triglyceride levels in the absence of established coronary artery disease or diabetes and additional multiple high-risk features for cardiovascular disease. Therefore, Vascepa 1 gm capsule is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 31-year-old male enrollee has requested reimbursement for the home sleep study provided from 9/20/15 through 9/22/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. There was no clinical indication for the home sleep study for this patient. The patient had a normal Epworth Sleepiness score and thus did not have daytime hypersomnia. Hypersomnia is the cornerstone for a diagnosis of clinically significant sleep apnea. In addition, he was not overweight or obese. There was no witnessed apnea. There was no documented elevated Mallampati score. Moreover, snoring is not an indication for a sleep study. For the reasons stated, the home sleep study provided from 9/20/15 through 9/22/15 was not medically necessary for evaluation of the patients medical condition. Given the above reasons, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 51-year-old male enrollee has requested reimbursement for air transport provided on 8/17/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition status post bicycle crash. The physician reviewer found that air medical transport is a service covered by the health plan when medically necessary. In order for air medical transport to be medically necessary, the documentation must include evidence that the patients condition was such that any form of transportation other than ambulance would have been medically contraindicated; the patients condition was such that the time needed to transport by ground posed a threat to the patients survival; the patient was transported to the nearest hospital with appropriate facilities for treatment; and the patient had a life-threatening medical condition. This patient sustained a brain and spine injury. He was transported from a facility in Hawaii to a facility in California for rehabilitation. However, there are adequate rehabilitation facilities located in Hawaii. Moreover, the transport did not occur to transition the patient to a higher level of care than could have been provided in Hawaii. Rather, the records suggest the patient was transferred to the rehabilitation center in California in order to be closer to home. As such, the air transport provided on 8/17/18 was not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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 64-year-old female enrollee has requested authorization and coverage for implantation of a nerve stimulator. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees moderate obstructive sleep apnea (OSA). The physician reviewer found that the Inspire device is a U.S. Food and Drug Administration (FDA) approved device for the treatment of OSA. The records provided for review indicate that this patient has not had a thorough evaluation for nasal obstruction. The examination note reports a slightly deviated septum, but no nasal endoscopy is documented to see if posterior deviation is present. Standard therapy options have not been exhausted for the patients possible nasal obstruction or pharyngeal wall collapse. With an AHI of 20.5, conventional proven therapy addressing nasal or pharyngeal collapse is likely to benefit the patient. Thus, the requested implantation of a nerve stimulator is 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 requested service is 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 2

A 64-year-old female enrollee has requested authorization and coverage for implantation of a nerve stimulator. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees moderate obstructive sleep apnea (OSA). The physician reviewer found that in the peer-reviewed medical literature, Certal and colleagues noted that, that hypoglossal nerve stimulation therapy may be considered in selected patients with OSA who fail medical treatment. Further studies comparing hypoglossal nerve stimulation with conventional therapies are needed to definitively evaluate outcomes. In this clinical case, the patient meets some of the criteria for implantation of upper airway stimulation to improve the symptoms. However, the patient has not undergone standard methods of management including improvement of the nasal airway with turbinate reduction and possible nasal septal reconstruction. Although the standard methods have not been shown to improve OSA, they can improve tolerance to nasal CPAP therapy. Additionally, the patient did not present any other physical examination information to decide whether other surgery such as uvulopalatopharyngoplasty or maxillary-mandibular advancement could offer any additional improvement of the symptoms. Accordingly, the requested implantation of a nerve stimulator is 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 requested service is 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 64-year-old female enrollee has requested authorization and coverage for implantation of a nerve stimulator. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees moderate obstructive sleep apnea (OSA). The physician reviewer found that Hypoglossal nerve stimulation is a new and emerging treatment for OSA. However, the current literature does not provide sufficient evidence of efficacy. While sleep endoscopy is frequently utilized for evaluation, there are no standard parameters to determine optimal candidates for hypoglossal nerve stimulation, nor have the findings of the original studies been replicated, which is a standard within medical research. Given the inability to support conclusions on efficacy and patient outcomes, the requested implantation of a nerve stimulator is 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 requested service is 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 


An 18-year-old female enrollee has requested reimbursement for residential mental health treatment for children and adolescents from 8/13/15 through 12/31/16. 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 submitted documentation does not support the services at issue in this clinical setting. Upon admission to the residential facility, the record did not contain notations as to frequent suicidal or homicidal ideation, aggression, self-injurious behavior, abnormal vital signs, documentation of withdrawal from substances, urges to use substances, non-response or adverse response to medications, frequent medication changes,  or difficulty with attending to activities of daily living.  During the admission at the residential facility, the patient was documented as having an anxious and low mood at times.  However, she was more frequently documented as having an appropriate mood and attitude with cooperative behavior. Individual progress notes indicated that the patient had no suicide or self-harm risk.  She was noted to be engaged and participated in group.  Per the psychiatric progress note dated 10/19/15, the patient record noted depression and an episode of self-harm. Subsequent psychiatric progress notes documented the patient as having a good/appropriate mood, no suicidal ideation, and no reports of self-harm. There was a lack of documentation to indicate significant adverse effects to the medications and there were few documented medication changes.  The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP, 2014).  The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services.  According to the patients clinical history and documentation as outlined above, at the time of admission to the residential facility, the patient met CASII criteria for intensive outpatient services and not residential level of care treatment services. As such, residential mental health treatment from 8/13/15 through 12/31/16 was not medically necessary for treatment of this patients medical condition. (Marshall, et al; AACAP; Mee-Lee and Shulman).