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

Summary Reviewer 1

The patient is a 19-year-old female with a history of multiple congenital anomalies and borderline intellectual disability. She has a history of coarctation of the aorta with Shone complex and unbalanced atrioventricular canal defect. She had early developmental delays. Intelligence quotient (IQ) testing revealed a full scale IQ of 74. She has executive functioning and memory problems. She also has a history of hypothyroidism. Examination was significant for height at 143.5cm, high and broad forehead with mild temporal sparseness, somewhat broad nasal bridge, slightly upslanting palpebral fissures, narrow and posteriorly-rotated ears with over folded helices and large lobules, short neck, mild scoliosis, brachydactyly with flattened fingertips and shortening of the 4th and 5th metacarpals, and small feet. The patient underwent genetic testing. She has requested reimbursement for FirstStepDX Plus test rendered on 4/14/17. The Health Insurer has denied reimbursement noting that the services at issue were considered investigational for the evaluation of the patients medical condition.  Chromosomal microarray (CMA) is recommended by the American College of Medical Genetics (ACMG) as a first-tier test for patients with developmental delays, intellectual disability (ID), autism spectrum disorders, and/or multiple congenital anomalies (MCA). The yield of CMA in patients with ID or MCA is estimated to be around 10 percent. While findings on CMA may not alter treatment of ID or MCA features themselves in all patients, CMA has become the standard of care for diagnosis in patients with these conditions. Increasing numbers of patients with ID and/or MCA have been found to have underlying copy number variations. As such, it is possible that some copy number variations have also been associated with specific neuropsychological treatments or medications that have been shown to be more efficacious in patients with ID due to that underlying cause. Additionally, copy number variations on CMA may inform or identify other complications and medical risks, some of which can be screened for and treated. A 2014 study showed that the majority of those with abnormal CMA had findings that directly affected or altered management.  In sum, the FirstStepDX Plus test rendered on 4/14/17 was likely to have been of greater benefit for evaluating this patients medical condition when compared to other options for the treatment and evaluation of this patient. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The patient is a 19-year-old female with short stature, congenital heart disease, multiple minor malformations, and borderline intellectual disability. A specific diagnosis could not be recognized.  Chromosomal microarray was performed to investigate the etiology of the patients medical issues, in order to direct the patients medical care more specifically. The patient has requested reimbursement for FirstStepDX Plus test rendered on 4/14/17. The Health Insurer has denied reimbursement and reported the services at issue were investigational for the evaluation of the patients medical condition.  Array-based comparative genomic hybridization (CGH, or chromosomal microarray) has become standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or multiple congenital anomalies.  Formerly, it was a diagnostic test that was employed when the first-line investigation of karyotype (chromosome analysis) returned normal; however, currently it is considered a first-line investigation.  The yield of this test is approximately 8 to 17% and varies with the degree of cognitive impairment, the presence of dysmorphic features, and the presence of congenital anomalies. The cited references indicate that this test has become an important and mainstream tool in the practice of clinical genetics.  As early as 2007, its utility had been convincingly demonstrated, such that experts in the field were recommending its inclusion in the evaluation of any child with intellectual disability.  More recently, its clinical utility has been confirmed in a study by Henderson and colleagues where 12.7% of patients meeting referral criteria had a pathogenic copy number variant identified on microarray, and that half of those results influenced management (including pharmacological treatment, cancer-related screening or exclusion of screening, identifying contraindications, and referrals for further evaluation).  Medical literature has shown that microarray results affect clinical management, at rates, which are similar to other genetic testing. Given the potential to influence management, microarray is an appropriate test to perform in this clinical scenario. Accordingly, the FirstStepDX Plus test rendered on 4/14/17 was likely to have been more effective for the evaluation of this patients medical condition than the other available modalities.  Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The patient is a 19-year-old female who has been recognized to have a number of inherited disorders, including intellectual disability, multiple congenital anomalies including, coarctation of the aorta and small left ventricles unbalanced atrioventricular canal defect and short stature. The patient underwent genetic testing in order to obtain additional information and to best guide medical management of her care. The patient has requested reimbursement for FirstStepDX Plus test rendered on 4/14/17. The Health Insurer has denied the request for reimbursement. Per the Health Insurer, the services at issue were investigational.  There is support in the medical literature for the efficacy of the tests performed in April 2017. The provider ordered testing to gather additional information that could affect the care and treatment of this patient. The records show that the patients clinical presentation is not specific to a well delineated syndrome and she has two or more major malformations. As such, targeted genetic testing is relevant as a rationale pursuit of information that could potentially alter treatment services. All told, the FirstStepDX Plus test rendered on 4/14/17 was likely to have been more efficacious for evaluating this patients medical condition when compared to other available standard options. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 63-year-old female with a history of breast cancer. The patient has requested reimbursement for acute hospital admission from 6/04/21 through 6/06/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that outpatient management with oral analgesic medication and incentive spirometry is reasonable for rib fractures involving less than three ribs. The patient is at increased risk for complications, such as flail chest, pneumonia, pulmonary contusions or respiratory failure, when there are three or more ribs fractured. There is an increased risk of complications in individuals who are older than 65 years.  The presence of six or more rib fractures increases the risk for serious complications.  Pain control, pulmonary hygiene and mobility are the goals of care for individuals with severe rib fractures. The submitted documentation fails to demonstrate the medical necessity of the services at issue. Inpatient care is necessary when the patientas signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient had three rib fractures but was admitted in stable condition with minimal pain. The objective data supported that she was stable. While close monitoring was appropriate, she could have been treated at a lower level of care. Therefore, acute hospital admission from 6/04/21 through 6/06/21 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 38-year-old male enrollee has requested authorization and coverage for sirolimus cream. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. Tuberous sclerosis is a rare genetic disease, and there are not enough patients to have double blind, placebo-controlled studies for the treatment of the associated facial angiofibromas. Topical rapamycin or sirolimus is considered standard of care for the treatment of these lesions.  The International Tuberous Sclerosis Complex Consensus Statement also recommends the use of this medication for treatment of facial angiofibromas in tuberous sclerosis. Therefore, sirolimus cream is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 38-year-old male enrollee has requested authorization and coverage for sirolimus cream. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that topical sirolimus offers superior benefit for the control and resolution of angiofibromas in tuberous sclerosis complex. There is robust evidence supporting the efficacy and safety of topical sirolimus, which targets the etiology of this rare genetic disorder. The alternative therapies of hyfrecation, shave removal or laser ablation all carry risks of permanent scarring and are less effective than topical sirolimus. All told, sirolimus cream is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3
A 38-year-old male enrollee has requested authorization and coverage for sirolimus cream. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient has facial angiofibromas, which is a finding in his genetic disorder called tuberous sclerosis complex. These angiofibroma are at risk of bleeding and growing. Treatment options have mainly consistent of laser ablation, which at times could mean increased risks due to general anesthesia due to the sheer number of lesions and scarring. This medication is an accepted treatment option for facial angiofibromas, as evidenced by the medical literature. Thus, sirolimus cream is likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 63-year-old male enrollee has requested authorization and coverage for Repatha SureClick. 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 this patient has an intermediate 10-year cardiovascular risk of approximately 8.4%. He also has other risk factors which increase his cardiovascular risk independent of those measured by the clinical cardiovascular calculator, including a family history of cardiovascular disease and a markedly elevated coronary calcium score. He is a candidate for statin therapy based on published guidelines. He has done lifestyle modification but has a documented intolerance to two statin medications. He was started on ezetimibe per guidelines. The patient had a moderate reduction in his LDL to 125, but this is still not at goal. In a patient with elevated risk and intolerance to multiple statin medications who is already on ezetimibe and is still not at LDL goal, the addition of the proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor Repatha SureClick is reasonable and medically indicated to achieve the guideline directed LDL goal. Therefore, Repatha SureClick is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 35-year-old male enrollee has requested authorization and coverage for jaw surgery.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the medical literature documents mixed results in attempting to correct moderate to severe obstructive sleep apnea with jaw surgery.  The surgical goal is to advance the jaws to increase the size of the pharyngeal airway space.  It was stated that a mandibular repositioning appliance, found to be effective in treatment of mild obstructive sleep, was not an option due to the patients orthodontic treatment.  These appliances work on the premise that advancement of the mandible will cause a resultant increase in the pharyngeal space by moving soft tissue obstruction, thus opening the airway.  It is thus counterintuitive that a setback of the mandible as prescribed would allow effective treatment of the obstructive sleep apnea as the movement of the jaw is opposite to that of the mandibular advancement appliance.  All told, the requested jaw surgery is not medically indicated 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 

The patient is a 58-year-old female who was evaluated in the emergency department on 12/22/19. The patient has requested reimbursement for emergency room physician services provided on 12/22/19. The Health Insurer has denied this request and reported that the services at issue were not required on an emergent basis. The physician reviewer found that at issue in this case is whether a prudent layperson in the patientas circumstances would believe he or she was experiencing an emergency medical condition. California law defines an aemergency medical conditiona as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patientas health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patient presented with the sudden onset of low back pain. There was no recent trauma, and the patient did not have a history of low back pain. She had tried over-the-counter pain medication, without relief. Her symptoms continued to worsen over the course of the next day. The patientas lumbar CT scan and MRI revealed multilevel degenerative changes. Despite intravenous pain medication, the patient was still unable to ambulate and was unable to be discharged. The sudden onset of severe low back pain that does not respond to over-the-counter pain medication with the inability to ambulate meets prudent layperson criteria for an emergency. A prudent layperson in these circumstances would reasonably expect the absence of emergency care to jeopardize her health. Therefore, this patientas symptoms on 12/22/19 met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 63-year-old female enrollee has requested authorization and coverage for Harvoni. 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 that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Therefore, the requested medication is 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 


A 60-year-old female enrollee has requested authorization and coverage for bronchoscopic thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees moderate to severe persistent asthma. The physician reviewer found that currently, the three initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed. Cox and colleagues reported that patients with moderate to severe asthma demonstrated improved control at one-year follow-up following treatment with bronchial thermoplasty. Further, Pavord and colleagues found short-term worsening in symptoms, but evidence of improved long-term control of asthma with the procedure. Finally, the Castro and colleagues compared bronchial thermoplasty with a sham procedure and followed the patients for one year. The authors noted that the thermoplasty group had fewer exacerbations and improved quality of life when compared to the sham group. Overall, the data supports the short- and long-term benefits of bronchial thermoplasty for well selected patients. This patient has undergone a thorough evaluation and is on an aggressive regimen. However, her symptoms have persisted despite her current medical therapy and she has continuously required systemic steroids. Given these findings, the requested bronchoscopic thermoplasty is supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested procedure 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 36-year-old female enrollee has requested authorization and coverage for intravenous immunoglobulin therapy. The Health Insurer has denied this request indicating that the requested therapy 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 therapy.  While there are a variety of criteria for common variable immunodeficiency, virtually all of these require significant reduction in levels of IgG, typically to values of 400 mg/dL or less.  Additionally, criteria also require impaired response to immunizations and documentation of severe and frequent sinopulmonary infection.  This patient does not have a low total level of IgG.  The subclass values are of unknown significance, but not generally considered clinically important.  Response to pneumococcal immunization here may be slightly reduced, but does not meet usual criteria for impaired response.  Documentation of severe recurrent sinopulmonary infection is not present.  The patient has had symptoms of facial fullness but a normal sinus CT.  All told, the requested intravenous immunoglobulin therapy is not medically indicated for the treatment of this patient.  Therefore, the requested therapy 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 49-year-old male enrollee has requested reimbursement for the chiropractic services (CPT codes 98941, 98943, 97110, and 97012) provided on 12/14/16, 4/21/17, 5/17/17, 6/9/17, and 7/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck and shoulder pain. The physician reviewer found that the patient has a chronic condition and has received extensive chiropractic care. However, there is no clear objective documentation on functional improvement or specific goals with chiropractic treatment. The records suggest that the treatments have been provided as supportive care. Chiropractic maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong or enhance the quality of life, or therapy is that is performed to maintain or prevent deterioration of a chronic condition. As noted by the Centers for Medicare and Medicaid Services (CMS), when further clinical improvement cannot reasonably be expected from continuous ongoing care, the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is considered maintenance therapy and not considered medically necessary. Therefore, the chiropractic treatments with ancillary treatments provided on 12/14/16, 4/21/17, 5/17/17, 6/9/17, and 7/6/17 were 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 62-year-old female has requested reimbursement gene testing performed on 11/01/15. 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 molecular profiling is an assay to detect genomic or molecular abnormalities or gene overexpressions in an individuals cancer cells, with the hope that this information will guide therapy.  However, there is a lack of convincing evidence that such assays add to our decision-making ability.  There are a variety of non-randomized studies exploring the value of molecular profiling that have as yet not yielded evidence of significant benefit to such assays.  Therefore, the superior efficacy of gene testing performed on 11/01/15 has not been established.  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.