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

Summary Reviewer 2


A 48-year-old female has requested reimbursement for Anser IFX testing performed on 9/04/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns colitis. The physician reviewer found there is a lack of support for the services at issue in this patients case.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, there are few well-controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  In sum, Anser IFX testing performed on 9/04/15 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 3


A 48-year-old female has requested reimbursement for Anser IFX testing performed on 9/04/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns colitis. The physician reviewer found the use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear Remicade levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there were a lack of standard guidelines defining a therapeutic strategy at the time of testing.  Based on the medical literature, Anser IFX testing performed on 9/04/15 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 38-year-old female enrollee has requested reimbursement and prospective authorization and coverage for substance use residential rehabilitation from 11/14/16 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.  This patient had a low risk of harm, as she denied any suicidal thoughts or plans, but occasionally had transient suicidal thoughts.  She had no prior suicide attempts.  Per the records, the patient had some moderate impairment in her functional status.  The documentation noted ongoing substance use despite negative consequences.  She also has comorbid general anxiety disorder.  The clinical notes indicates limited support.  The patient has maintained partial recovery for moderate periods of time, but only with strong professional and peer support.  Based upon the provided documentation, the patient appears to have had difficulties engaging in treatments at times.  However, recently she appears to be more motivated for treatment as her family and job are in jeopardy due to the patients current substance use.  Based on the American Association of Community Psychiatrists Level of Care Utilization System, the patient meets criteria for partial hospitalization program level of care.  In sum, substance use residential rehabilitation from 11/14/16 forward was not and is not medically indicated 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 

The patient is a 31-year-old male with a history of chronic right knee pain with associated instability, locking, catching, popping, numbness, swelling, night pain, and pain with activities. The patient has requested authorization and coverage for autologous cultured chondrocytes implantation, knee. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that this patient has severe knee pain due to a 2 cm x 2 cm focal chondral defect of the lateral patellar facet which has significantly impaired his quality of life. Matrix-induced autologous chondrocyte implantation is a procedure which cultivates the collagen membrane with harvested chondrocytes from a prior surgical procedure prior to implantation and is known to be highly successful for this indication. This patient has had a thorough physical examination and arthroscopic evaluation, and there is no question about the pain generator. The partial lateral meniscectomy was not effective in relieving his pain. Imaging studies were corroborated by the arthroscopic findings. Conservative management was tried prior to proceeding with arthroscopy. Chondral biopsies were obtained from the non-weight bearing zone of the articular surface of the femur. Based upon a review of the recent medical literature, this patient is an excellent candidate for the requested procedure. Therefore, the requested autologous cultured chondrocytes implantation, knee is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 36-year-old female who has a history of a right breast cancer.  The patient has requested authorization and coverage for Verzenio 150 mg tablets. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the patient. This denial is the subject of this appeal and determination.  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. In the trial by Johnston and colleagues, over 5,600 patients (just under one-half of whom were premenopausal women) with hormone receptor-positive, HER2-negative, high-risk early breast cancer who had completed surgery were randomly assigned to abemaciclib (Verbenio) with endocrine therapy or endocrine therapy alone. Although the studies preliminary results showed statistically significant improvement in invasive disease-free survival relative to the endocrine therapy alone group, there are no data yet available for overall survival. To date, the addition of abemaciclib to endocrine therapy in high-risk premenopausal women is not considered a standard of care. Therefore, Verzenio 150 mg tablets are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 52-year-old transgender female enrollee has requested reimbursement for CPT codes 67900, 20926, 21121, 40799, 30410, 21172 and 30520 performed on 10/15/19. 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 submitted documentation supports the medical necessity of the services at issue. The records document that the patient has a history of gender dysphoria. The World Professional Association for Transgender Health (WPATH) position statement notes, non-genital surgical procedures...notably facial feminization surgeryare often of greater practical significance in the patients daily life than reconstruction of the genitals. Ainsworth and Spiegel reported that facial feminization surgery, like genital surgery improved mental health-related quality of life. There is sufficient support for the services at issue in this clinical setting. Therefore, CPT codes 67900, 20926, 21121, 40799, 30410, 21172 and 30520 performed on 10/15/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 47-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In the clinical records submitted for review, there is no documentation of a manometry report or pH study. In addition, there is no comprehensive description of the patients symptoms. Given the lack of adequate data provided, the LINX procedure has not been established as 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 procedure 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 47-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).The physician reviewer found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Similarly, a best-evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). In addition, adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment such as surgical fundoplication (Sheu, et al; Ganz). The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the request for the LINX procedure 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 procedure 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 47-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).The physician reviewer found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient presents with documented GERD based on having developed Barretts esophagus. However, the records show that the patient has benefited to a significant degree from Dexilant treatment, and as such cannot be considered medically refractory to acid blocker drugs. Also, implantation of LINX in the clinical setting of Barretts esophagus must be approached with caution since LINX has not been adequately studied in patients with Barretts. Therefore, it cannot be concluded that LINX is likely to be more beneficial for treatment of the patients GERD than any standard therapy. All told, the request for the LINX procedure 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 procedure 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 Overturned

Summary Reviewer 


A 62-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 hepatitis C. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin 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.  For these reasons, Harvoni is medically indicated for the treatment of this patient.  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 Upheld

Summary Reviewer 

The patient is a 49-year-old female with a history of ex pleomorphic adenoma of her right lacrimal gland. The patient has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that per the current peer-reviewed medical literature, there are insufficient high-quality clinical outcomes reported to allow one to make definitive conclusions regarding the relative safety/efficacy of proton beam radiotherapy for management of the patientas head and neck cancer, as compared to standard of care photon-based radiation therapy. In this patientas setting, proton radiation therapy has the ability to reduce the volume of low dose radiation exposure to surrounding normal critical tissues, but it cannot reduce the high dose exposure. Since it is the volume of high dose normal tissue exposure that has traditionally been correlated with radiation-induced morbidity, it remains unclear as to whether the use of proton beam radiation therapy would offer clinically meaningful improvements in outcomes in this patientas case. The treating provider has not supplied a detailed slice-by-slice proton/photon plan comparison in color format to justify the need for proton beam radiation therapy. Typically, a photon-based plan would be associated with a high level of safety/efficacy, and this is supported by high-quality outcomes published in the peer-reviewed medical literature. There are not any extenuating circumstances present in this case that would necessitate the use of proton beam radiation therapy, such as prior receipt of radiation to the same site or genetic/comorbid condition, which increases normal tissue radiosensitivity.  The records do not demonstrate that this patient could not be treated safely and effectively with photon-based radiation therapy in the form of intensity modulated radiation therapy. Therefore, proton beam therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 20-year-old male enrollee has requested reimbursement for acute detoxification treatment provided from 12/31/15 through 1/4/16. 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 according to the documentation submitted for review, the patient presented with a history of alcohol use which included blackouts and withdrawal symptoms. He was drinking heavily on a daily basis. He was also having significant intrapsychic and psychosocial distress in context of underlying anxiety and depression. Considering these factors, the patient was at-risk for a complicated withdrawal syndrome thus the admission for supervised detoxification was initially medically necessary. While hospitalized, the primary detoxification modality was a benzodiazepine taper, which is standard of care.  On 1/1/16, the patients blood pressure was 144/100. His Clinical Institute Withdrawal Assessment for alcohol scale tallied 11 out of 67 (scores of 10 or less usually do not require medication therapy). On 1/2/16, the patient was normotensive. He was improving.  He was euthymic. There were no significant withdrawal or acute psychiatric symptoms noted. The patient was active in discharge planning. A family session was planned for 1/3/16. He did not want to attend intensive outpatient or residential programming, but intended to resume Alcoholics Anonymous. A follow-up appointment was arranged for 1/7/16. On 1/3/16, the patients tremor had resolved. He reported feeling well physically. Based on the documentation provided, as of 1/3/16 the patient had improved clinically. He had no history of complicated or protracted withdrawal. He had aftercare services in place. Thus, discharge on 1/3/16 to a less restrictive setting would have been safe, appropriate and consistent with good medical practice. All told, the acute detoxification treatment provided from 12/31/15 through 1/2/16 was medically necessary for treatment of the patients medical condition. 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 Upheld

Summary Reviewer 


The parent of a 13-year-old male enrollee has requested authorization and coverage for growth hormone therapy (Humatrope).  The Health Plan has denied this request indicating that the requested therapy is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  This patient has been treated with growth hormone therapy, and has apparently had a very good response in terms of increased height velocity.  Based on the medical records, this patients height velocity is consistent with simple constitutional delay.  As to the diagnosis of idiopathic short stature, he does not have absolute height standard deviation score more than 2.25 standard deviations below normal for age.  In terms of mid-parental height, the records indicate that he was 1.96 standard deviations below mid-parental height.  This patients bone age is not delayed.  Importantly, constitutional delay need not be treated with growth hormone supplementation.  There is a lack of support for the requested therapy in this clinical setting.  All told, the requested growth hormone therapy (Humatrope) is not medically indicated in this clinical setting.  Therefore, the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 21-year-old female enrollee has requested reimbursement for the outpatient papanicolaou smear testing performed on 7/17/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees abnormal and showed atypical squamous cell of undetermined significance (ASC-US) and high risk human papilloma virus (HPV) test.   The physician reviewer found that the Pap smear performed on 7/17/15 was indicated and consistent with current guidelines for the management of an ASC-US and positive HPV Pap smear. Since the Pap smear in 2014 was abnormal, these findings required specific management planning. The ASC-US Pap smear posed a risk of representing underlying disease and needs to be clinically managed the same as a patient is in the 21-24 age category. The guidelines for management of an ASC-US and HPV positive Pap smear is to either proceed with colposcopy evaluation or to repeat the Pap smear in one year. The Pap smear done in 2015 was done as the recommended repeat study. Thus, the Pap smear performed on 7/17/15 was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.