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

Summary Reviewer 

The patient is a 31-year-old female with a history of vitiligo. She was previously treated with narrowband ultraviolet B (UVB) without success. The physician reviewer found that Vitiligo is an autoimmune disease, evidenced by circulating melanocyteaspecific antibodies, and association with other autoimmune diseases. At present, no medical treatment for repigmenting vitiligo has been approved by the U.S. Food and Drug Administration (FDA), and therefore treatments are used off-label. Topical treatments may be applied alone when small areas are involved or when other treatment modalities are not readily available. This patient has failed to repigment with topical treatment alone. Phototherapy combined with topical treatment is preferred when greater than 5-10% of the body surface area is affected. The use of targeted phototherapy, excimer laser, is preferred when there is limited disease, as this limits the exposure of the skin from unwanted side effects of total body ultraviolet treatment. Targeted narrowband UVB in the form of excimer laser is considered standard therapy. Therefore, CPT codes 96920, 96921 and 96922 (laser treatment for skin disease) are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 29-year-old female enrollee has requested authorization and coverage for compound medication of sirolimus cream 1%. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee, who has Klippel Trenaunay syndrome. The physician reviewer found that the treatment of rare vascular malformations is multidisciplinary, as this patient has been receiving. She has already been treated with laser and surgery and is still developing new blebs, placing her at risk for bleeding and infection. There is a lack of standard therapies for this disease. The use of topical sirolimus is likely to be more beneficial for the patient than the previous treatments she has tried. Promising results have been reported in preliminary studies. Therefore, compound medication of sirolimus cream 1% is likely to be of greater benefit than other available treatment options. Based upon the information set forth above, the requested medication is 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

A 29-year-old female enrollee has requested authorization and coverage for compound medication of sirolimus cream 1%. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee, who has Klippel Trenaunay syndrome. The physician reviewer found that the current medical evidence supports the requested medication in this patients case. The documentation noted venous malformations associated with bleeding and lymphatic drainage. She has had treatment previously with laser, interferon and sclerotherapy, without improvement. There is evidence in the medical literature indicating that sirolimus, both topical and oral, is effective for these symptomatic vascular lesions. This patient has a rare condition, and there is a lack of other treatment alternatives available. In sum, compound medication of sirolimus cream 1% is likely to be superior over other treatment options. Based upon the information set forth above, the requested medication is 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 29-year-old female enrollee has requested authorization and coverage for compound medication of sirolimus cream 1%. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee, who has Klippel Trenaunay syndrome. The physician reviewer found that Klippel Trenaunay syndrome is characterized by the triad of cutaneous capillary malformations, asymmetrical disturbed growth of soft tissues and/or bone, and venous and lymphatic malformations. Recent publications emphasize the potential interest of sirolimus, an inhibitor of mammalian target of rapamycin (mTOR) activity, as a treatment option for cutaneous vascular malformations and PIK3CA-related overgrowth spectrum (PROS). Sirolimus has been used successfully with a good safety profile. The requested medication is an appropriate medical treatment for bleeding induced by venous and lymphatic malformation associated with Klippel Trenaunay syndrome. Thus, compound medication of sirolimus cream 1% is likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested medication is 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 Upheld

Summary Reviewer 

A 27-year-old male enrollee has requested reimbursement for vitamin D testing performed on 1/15/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the clinical manifestations of vitamin D deficiency depend upon the severity and duration of the deficiency. The majority of patients with moderate to mild vitamin D deficiency are asymptomatic. With severe vitamin D deficiency, there can be hypocalcemia, which leads to bone disorders.   Patient groups who are at risk for vitamin D insufficiency includes patients who are obese, those taking medications that accelerate the metabolism of vitamin D, hospitalized or institutionalized patients or individuals who have limited effective sun exposure. Other people at high risk include those with osteoporosis or malabsorption, including inflammatory bowel disease and celiac disease. Screening of the general population is not recommended. Normal-risk adults do not need assessment. In this case, the patient did not have any chronic medical conditions that would cause vitamin D deficiency. Therefore, vitamin D testing performed on 1/15/20 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 19-year-old female with a history of low back pain. The patient has requested authorization and coverage for anterior lumbar fusion, allograft synthetic cage and associated inpatient stay. 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 the submitted documentation supports the medical necessity of the requested services. Anterior lumbar interbody fusion is associated with higher fusion rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine, including those with instability.  There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone anterior lumbar interbody fusion has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. This patient has not responded to conservative treatment and is likely to benefit from the anterior lumbar interbody fusion. As such, the requested anterior lumbar fusion, allograft synthetic cage and associated inpatient stay are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 22-year-old female who was transferred by air ambulance from Swedish Medical Center (SMC) in Englewood, Colorado, to St. Josephs Hospital (SJH) in Phoenix, Arizona, on 9/26/19. The patient has a medical history significant for mild autism, attention deficit/hyperactivity disorder, and non-epileptic seizures. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. In order for air ambulance transportation to be medically necessary, specific criteria should be met. First, the patients condition must be such that any form of transportation other than ambulance would be medically contraindicated. Additionally, the patients condition must be such that time needed to transport by ground poses a threat to the patients survival. Also, the patient should be
transported to the nearest hospital with appropriate facilities for treatment, and there should be a medical condition that is life-threatening. When transporting from one facility to another, the above criteria must be met, and the first hospital must not have the required services and facilities to treat the patient.
In this patients case, she had nonepileptic seizures, or psychogenic nonepileptic spells. Psychogenic nonepileptic spells (PNES) or psychogenic nonepileptic episodes (PNEE) are terms used to describe events that appear to be epileptic seizures but in fact do not represent the manifestation of excessive synchronous cortical activity that defines epileptic seizures. They are not a variation of epilepsy, but are of psychiatric origin. These terms reinforce the idea that the events are not seizures of any type, and PNES is used as a synonym for pseudoseizures. Distinguishing PNES from epileptic seizures may be difficult at the bedside even to experienced observers. In theory, almost any recurrent behavior may represent epileptic seizures. The simultaneous utilization of video and EEG recordings are key to diagnosis, as was the case here. This patient had PNES, and she was under the care of a neurologist at SMC. Her condition was stable. Had there been a need for higher level of care, SJH in Phoenix, Arizona was not the closest facility capable of providing that care. Indeed, the patients family requested transport to Arizona so that the patients mother would be able to oversee her care and make medical decisions for the patient. Therefore, air ambulance transportation provided on 9/26/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 
The patient is a 56-year-old female with a history of relapsing multiple sclerosis, type 1 diabetes, and hypothyroidism. The patient has requested authorization and coverage for Acthar (corticotropin injection gel 80 units/mL). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found standard therapy for acute exacerbations of multiple sclerosis has been high-dose corticosteroid therapy.  Adrenocorticotropic hormone (H.P. Acthar gel) has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of exacerbations of multiple sclerosis in adults.  Other therapies include plasmapheresis and intravenous immunoglobulin (IVIG). Plasmapheresis is generally reserved for treatment of relapses that are severe or refractory to treatment with high-dose corticosteroids. IVIG is sometimes used in patients for whom high-dose corticosteroids are contraindicated or not tolerated, but there is a lack of consistent evidence for its use in relapse management. Per Ross and colleagues, adrenocorticotropic hormone gel may be considered as an alternative treatment of multiple sclerosis relapses and is generally used as an alternative to high-dose corticosteroids. The authors noted, that the reasons for using adrenocorticotropic hormone include a lack of benefit established with corticosteroids, inability to tolerate corticosteroids or adverse effects, and poor intravenous access. Its efficacy has been studied in several published investigations, and treatment outcomes may be comparable to those seen with corticosteroids. Bell and colleagues performed a randomized, open-label, crossover study that evaluated 18 patients with multiple sclerosis treated with subcutaneous H.P. Acthar gel and intravenous methylprednisolone. Preliminary results suggest that fewer drug-related adverse effects occurred with Acthar gel than intravenous methylprednisolone for treatment of multiple sclerosis exacerbations. Kutz performed a retrospective review of patients with multiple sclerosis exacerbations and diabetes treated with Acthar gel. The data suggested that Acthar gel may be a well-tolerated and effective treatment option for patients with diabetes experiencing a multiple sclerosis relapse. In this case, the patient has multiple sclerosis with uncontrolled exacerbations and has failed conventional therapy with high-dose corticosteroid therapy. She also has diabetes and developed uncontrolled blood sugars with corticosteroid treatment. She seeks approval for Acthar gel for treatment of acute exacerbations. Acthar gel is an FDA approved therapy for multiple sclerosis exacerbations and is used for patients who fail corticosteroids and patient who are unable to tolerate corticosteroids or their side effects, both of which apply in this case. Therefore, Acthar (corticotropin injection gel 80 units/mL) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 31-year-old male enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) level of care services provided from 3/1/16 and 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 medical condition status post right hip revision surgery.  The physician reviewer found the medical records support the medical necessity of the continued treatment at a SNF as of 3/1/16 as recommended by this patients medical providers for the management of complex issues of T11 level paraplegia and a complex intratrochanteric fracture of the right hip requiring revision hemiarthroplasty and complex ORIF techniques. Multiple comorbidities are likely to be improved with decisions as to transfer to a lower level of care once the patient has achieved stated goals. The totality of medical care reasonably includes care at a SNF until such time as risks of decubitus, bladder infection, loss of fracture stability, and avoidance of hip dislocation have all been addressed to the satisfaction of the patients providers. All told, the SNF services at issue from 3/1/16 and forward are medically necessary for treatment of this patients medical condition. For these reasons, the services at issue were and are 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 40-year-old female with abnormal uterine bleeding thought to be secondary to her known uterine fibroids. The patient has requested authorization and coverage for laparoscopy, surgical ablation of uterine fibroids including intraoperative ultrasound guidance and monitoring radiofrequency. 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 the requested procedure is a minimally invasive radiofrequency ablation treatment that reduces fibroid-related symptoms by reducing fibroid volume. The procedure is performed through a laparoscopic approach. Alternative standard therapy to the procedure includes more aggressive interventions, such as hysterectomy or myomectomy. Interventional radiology embolization procedures are only successful in a certain patient population with fibroids in specific locations. The procedure is done as an outpatient basis, with return to normal activity within approximately one week. Using ultrasound guidance to identify the fibroid, a conductive needle array punctures the fibroid and transmits radiofrequency energy, which causes coagulative necrosis. An ultrasound probe is used to monitor the tissue effect until the bulk of the fibroid is treated. Over subsequent months, fibroids are reabsorbed with a decrease in fibroid volume and a resultant reduction in fibroid-related symptoms. This is directed therapy and allows for treatment in the proper candidate within a minimally invasive surgical approach. There is sufficient support for the requested services in this clinical setting. Therefore, laparoscopy, surgical ablation of uterine fibroids including intraoperative ultrasound guidance and monitoring radiofrequency is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 53-year-old female who has a history of breast cancer, Helicobacter pylori infection, hyperlipidemia, hypertension, murmur, and obesity. The patient has requested reimbursement for 53 units of anesthesia services provided on 2/11/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. The patient has morbid obesity, based on BMI over 35 kg/m2, with attendant health risks. According to the American Society of Anesthesiologists guideline for anesthesia care during endoscopic procedures, judgment of the need for monitored anesthesia care requires consideration of procedure requirements and potential risks. Wani and colleagues found higher risk for sedation-related complications with BMI over 30 and even higher with BMI over 35 during endoscopic procedures. Per the most recent American Society for Gastrointestinal Endoscopy guideline for sedation and anesthesia in endoscopy, elevated body mass index is an independent risk factor for hypoxemia during endoscopic procedures. In this patientas case, she had an extended procedure with both esophagogastroduodenoscopy and colonoscopy, and did not tolerate moderate sedation in the past. Based on current medical literature, this patient was at an increased risk for sedation-related complications. Therefore, 53 units of anesthesia services provided on 2/11/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 34-year-old female enrollee has requested reimbursement for homocysteine testing performed on 6/10/20 and 9/23/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. At issue is whether the services at issue were likely to have been more beneficial for evaluation of the enrollees condition than any available standard therapy. The physician reviewer found that Hyperhomocysteinemia has been associated with vascular disease, venous thromboembolism, obstetric complications, osteoporosis, dementia and cognitive impairment in Parkinsons disease. Homocysteine levels are generally measured if an individual is suspected of having homocystinuria. Lowering homocysteine levels has not been shown to prevent cardiovascular events, prevent dementia or decrease thrombotic events. Some individuals with Hashimotos thyroid disease have an undiagnosed mutation in the MTHFR gene, causing high homocysteine levels. However, routine testing of homocysteine levels is not recommended, as treatment of this disorder has not shown to decrease the incidence of thrombosis or cardiovascular events. In this case, the patient has a history of Hashimotos thyroid disease. In October 2019, she had comprehensive testing showing normal B12, folate and homocysteine levels. There is a lack of support for repeat homocysteine testing in this setting. Therefore, homocysteine testing performed on 6/10/20 and 9/23/20 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 34-year-old female enrollee has requested reimbursement for homocysteine testing performed on 6/10/20 and 9/23/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. At issue is whether the services at issue were likely to have been more beneficial for evaluation of the enrollees condition than any available standard therapy. The physician reviewer found that the current medical evidence does not support the services at issue in this clinical setting. The records do not document a medical indication for the services at issue. It has no pertinent clinical usefulness, especially in a patient with normal thyroid function and normal hemoglobin levels. The records do not indicate that the patient was on immunosuppressive medications. The literature does not support the use of homocysteine level in this clinical scenario. Therefore, homocysteine testing performed on 6/10/20 and 9/23/20 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 34-year-old female enrollee has requested reimbursement for homocysteine testing performed on 6/10/20 and 9/23/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. At issue is whether the services at issue were likely to have been more beneficial for evaluation of the enrollees condition than any available standard therapy. The physician reviewer found that the medical records support a portion of the services at issue. The patient had borderline low B12 levels in April 2020. Testing for intermediates in vitamin B12 and folate metabolism (i.e., homocysteine) can be useful in cases in which initial test results for vitamin B12 are borderline. Because of potential inaccuracies in the measurement of vitamin B12 levels, the diagnosis can be confirmed by testing for methylmalonic acid (MMA) and homocysteine. In this case, testing for homocysteine on 6/10/20 was reasonable in order to confirm or exclude the diagnosis of vitamin B12 deficiency. However, there is a lack of support for repeat testing performed on 9/23/20, as this testing would have no bearing on the treatment plan and would not have changed the course of care. Therefore, homocysteine testing performed on 6/10/20 was likely to have been more beneficial than other methods of evaluating this patient. Homocysteine testing performed on 9/23/20 was not likely to have been more beneficial than other methods of evaluating this patient.