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

Summary Reviewer 

The patient is a 60-year-old male who has been diagnosed with moderate to severe ulcerative colitis (pancolitis). The patient has requested authorization and coverage for Remicade 10 mg/kg every six weeks for eight months. The Health Insurer has denied this request and reported that the requested medication dosage is not medically necessary for the treatment of this patient. The physician reviewer found that Remicade (infliximab) is FDA-approved and recommended for the treatment of ulcerative colitis. The increased dose requested in this case is commonly required during maintenance therapy with infliximab, and it can be effective. Large studies have shown that disease can be maintained in a majority of cases with increase of dose. American College of Gastroenterology guidelines for management of ulcerative colitis support the requested increase in Remicade dosage in patients with uncontrolled disease.  Additionally, American Gastroenterological Association guidelines for management of ulcerative colitis support the requested increase in Remicade dosage in patients with low Remicade level if anti-Remicade antibodies are absent or at a low level, as in this case. The American Gastroenterological Association guidelines for therapeutic drug monitoring state that a Remicade level of 5 ug/mL is recommended, and over 10 ug/mL is highly likely to be effective; the level in this case is significantly lower. Although the patient does not have frankly uncontrolled clinical disease, there is a history of dysplasia and of pseudopolyps, which place the patient at risk for colorectal cancer and severe disease flare.  For these reasons, an increase in dose to 10 mg/kg every 6 weeks is supported by current medical literature and guidelines. If therapy is continued at the current dose with low drug level, there is risk for a disease flare, uncontrolled disease, or uncontrolled disease manifesting as dysplasia and leading to colon cancer. Therefore, Remicade 10 mg/kg every six weeks for eight months is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a two-year-old female enrollee has requested authorization and coverage for the Synagis 100 mg/mL injection. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees heterotaxy syndrome and Shones complex which has required a single ventricle palliation. The physician reviewer found that the use of Synagis in this patient is not medically necessary. Since 1998, Synagis has been recommended under strict criteria so that its use maximizes patient benefit and efficacy. The most widely accepted guidelines for the use of Synagis are published by the American Academy of Pediatrics (AAP) Committee on Infectious Diseases and Bronchiolitis Guidelines Committee. The AAP guidelines indicate there is no established role for RSV prophylaxis after 24 months of age for any patient regardless of risk factors. The majority of hospitalizations associated with RSV occur in the first three months of life and are most commonly associated with prematurity. Functional or actual asplenia has not been shown in any studies to be associated with increased hospitalization due to RSV. At this time Synagis is only indicated in children under two years of age regardless of the presence of chronic heart, lung, or immune system disease. This prophylactic measure is not medically indicated for this patient. Accordingly, the requested Synagis vaccine is not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is an 18-year-old female with a history of major depressive disorder, recurrent severe without psychosis. The patient was admitted to an inpatient facility on 1/11/18 after reporting three weeks of worsening suicidal ideation and plan to jump off a bridge.  The patients history is significant for self injurious behavior from ages 12 to 15, an overdose attempt in June 2017 without hospitalization, an inpatient psychiatric hospitalization in August 2017 due to suicidal ideation, two months of intensive outpatient program treatment in October 2017, outpatient mental health treatment with a psychiatrist and therapist and medication trials of sertraline and escitalopram. During the patients recent inpatient admission, the patient was treated with venlafaxine ER, bupropion XL, mirtazapine, hydroxyzine, aripiprazole, and vortioxetine. She was discharged from the inpatient facility on 2/5/18 with plan to attend the Transitional Age Youth Intensive Outpatient Program. The patient has requested reimbursement for mental health inpatient stay from 1/29/18 through 2/5/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the patients behavioral health condition. This denial is the subject of this appeal and determination.  The submitted documentation supports the services at issue in this clinical setting. Based on a review of the medical records, the patient was not stabilized and remained symptomatic on 1/29/18. On 1/28/18, the patient was documented as refusing meals.  She was noted to have a flat affect and was withdrawn. The patient reported continued feelings of depression, guilt, and hopelessness with suicidal ideation.  On 1/29/18, the patient was documented as being depressed and withdrawn and feeling hopeless and helpless.  The patient endorsed continued suicidal ideation, isolated from peers, and was not fully participating in group activities. The patient continued to report depressive symptoms including recurrent suicidal ideation and anxiety symptoms up until the point of discharge at which time she reported improvement in her mood.  The patient had medication dose adjustments and changes to address her persistent symptoms. Research has shown that patients, with similar histories to the patient in this case, are at risk for early readmission especially if not stabilized at the time of discharge (Donisi, et al). The patients clinical status, in addition to current medical literature, support the mental health inpatient stay from 1/29/18 through 2/5/18 as medically necessary.  Therefore, for the reasons stated above, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a seven-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy, eight hours per month of supervision and six hours for the contract period for re-assessment provided from 11/9/16 through 5/9/17. 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. The physician reviewer found the correlation between treatment outcomes and treatment intensity is well documented. Ample research has shown that intensive applied behavior analysis (ABA) treatment produces robust outcomes for individuals with autism spectrum disorder (ASD). (Linstead, et al). Linstead and colleagues studied 726 children (ages 1.5 to 12) to evaluate the relationship between treatment intensity and treatment outcomes. The study showed a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the patient continues to demonstrate significant delays that place him at an increased risk for injury, and also makes it difficult for him to be successful in more generalized environments. Based on the documentation submitted for review, the request for 40 hours per week of direct ABA therapy, eight hours per month of supervision and six hours for the contract period for re-assessment provided from 11/9/16 through 5/9/17 were and are medically necessary for treatment of the patients medical condition. Therefore, 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 63-year-old female enrollee has requested authorization and coverage for an iris prosthesis. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that traumatic aniridia can lead to photophobia and disfigurement, both of which need to be addressed. The main options are contact lens or an iris prosthesis. In this case, the patient has already tried contact lens. There is sufficient support for the use of an iris prosthesis in this setting, and these services have been approved by the U.S. Food and Drug Administration (FDA). In this patientas case, an iris prosthesis is likely to be more beneficial than contact lens. A contact lens does not fully restore cosmesis and carries a risk of infection. Therefore, the requested iris prosthesis is likely to be more beneficial for the treatment of this patient than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 63-year-old female enrollee has requested authorization and coverage for an iris prosthesis. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the records support the requested services in this patientas case. There is evidence in the medical literature that the device is safe and effective. Since traumatic aniridia is not a widespread phenomenon, there are not robust clinical trials for such a device. Nonetheless, there are numerous smaller trials and investigational studies for this device that have demonstrated safety and efficacy for treating this disease. Treatment with contact lenses, corneal tattooing, or tinted spectacles are not adequate treatments for the patientas disease. Therefore, the requested iris prosthesis is likely to be more beneficial for the treatment of this patient than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 63-year-old female enrollee has requested authorization and coverage for an iris prosthesis. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the medical records state that the patient has advanced glaucoma. The patient says that she has a glare from her traumatic aniridia. She also states that she desires to undergo this procedure to improve the cosmetic appearance of her abnormal eye. In this patientas case, placement of an iris prosthesis is unlikely to improve her functional vision; there is a greater chance that significant complications may result. She currently uses a custom contact lens, without apparent complications. Therefore, the requested iris prosthesis is not likely to be more beneficial for the treatment of this patient than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The parent of a 14-year-old female enrollee has requested authorization and coverage for colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report, procedure code 91117, and associated one day inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollee, who has a history of bowel incontinence. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. The requested services are likely to further help in her care and potentially change her management.  Her provider needs this information before deciding on whether this patient needs surgery. Therefore, the requested colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report, procedure code 91117, and associated one day inpatient admission is likely to be of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the requested services are likely to be 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 parent of a 14-year-old female enrollee has requested authorization and coverage for colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report, procedure code 91117, and associated one day inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollee, who has a history of bowel incontinence. The physician reviewer found that colonic manometry is indicated for the planning of surgical interventions in patients with constipation refractory to medical therapy. These interventions may include, but are not limited to, appendicostomy and cecostomy for antegrade enemas. Appendicostomy has been specifically mentioned as a consideration for this patients care. The utility of colonic manometry for this purpose has been described in the clinical literature. In sum, colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report, procedure code 91117, and associated one day inpatient admission are likely to be superior over other methods of evaluating this patient. Based upon the information set forth above, the requested services are likely to be 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 parent of a 14-year-old female enrollee has requested authorization and coverage for colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report, procedure code 91117, and associated one day inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollee, who has a history of bowel incontinence. The physician reviewer found that this patient has been diagnosed with Phelan-McDermid syndrome. Patients with this condition have a wide range of medical, intellectual and behavioral challenges. Gastrointestinal issues are common and include reflux, vomiting, diarrhea, constipation and hypotonia. Manometry studies help in understanding the pathophysiology of the defection disorders in these children. Studies have shown that surgical interventions in these patients, as guided by manometric findings, have led to improvement in patient outcome and quality of life. The requested services are an appropriate next step for this patient with intractable constipation and stool incontinence. Thus, colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report, procedure code 91117, and associated one day inpatient admission are likely to be more effective than other methods of evaluating this patient. Based upon the information set forth above, the requested services are likely to be 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 


A 54-year-old female enrollee has requested reimbursement for acute inpatient psychiatric treatment from 11/18/16 through 12/4/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions The physician reviewer found that there is a lack of support for the medical necessity of the services at issue in this clinical setting. On 11/17/16, although the patient continued to endorse depression and anxiety, her suicidal ideation was passive in nature and there was no intent.  She denied homicidal ideation.  She was no longer a danger to herself, and she was not a danger to others.  She was cognitively intact.  She was able to care for herself and adequately perform activities of daily living.  She was not gravely disabled.  Beyond that date, she continued to report depression, anxiety, poor sleep, somatic preoccupation, and preoccupation with family finances. These states appear to be her baseline.  The record notes that her medication changes were tolerated well and were not of a complicated nature that required inpatient level of care.  She was participating in therapies and groups offered. It should be noted that dialectic behavior therapy is typically an outpatient modality. The issues this patient was working on, emotional regulation, improvement of mood, decrease feelings of being overwhelmed, increase structure, identification of triggers of suicidal thoughts, and building coping skills, could have continued in PHP. Based on the documentation, this patient could have been stepped down on 11/18/16. As such, inpatient psychiatric services from 11/18/16 through 12/4/16 were not medically necessary. Therefore, for the reasons stated above the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 53-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulator.  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 submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has failed therapy for obstructive sleep apnea, including trials of conservative management and prior surgical intervention.  The case file for the re-review includes added data regarding the three years outcome results of the STAR trial.  This was a study that was fully designed and funded through Inspire Medical.  As noted by Certal and colleagues, further studies comparing hypoglossal nerve stimulation with conventional therapies are needed to definitively evaluate outcomes.  All told, the requested hypoglossal nerve stimulator 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 parent of a five-year-old male enrollee has requested authorization and coverage for the SleepSafe bed with bedding. The Health Insurer has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation supports the requested equipment in this clinical setting.  The records indicate that the patient no longer fits in his current crib, and he as at a high risk of fall.  The medical records document the need for the requested SleepSafe bed in this clinical setting.  It is medically indicated for the patient to have medical equipment designed to improve personal safety.  All told, the requested SleepSafe bed with high rails and padded bumpers is medically indicated for the treatment of this patient.  Therefore, the requested equipment 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 parent of a 12-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential mental health treatment services from 7/1/15 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 condition. The physician reviewer found the residential treatment services provided from 7/1/15 forward were not and are not medically necessary for treatment of the patients medical condition. The patient presents with a complex mental health history which is complicated by loss of parents at an early age, living in an orphanage and international adoption. The patient has been diagnosed with major depressive disorder, dysthymic disorder (pervasive depressive disorder) and disruptive mood dysregulation disorder, which are potentially treatable with psychopharmacology. In this case, the patient has had a trial of Zoloft and Trileptal and is currently taking Lamictal. Given that the patient presents with treatable mental health conditions, psychopharmacological intervention needs to be more intensive. In addition, the primary focus of RAD related disorder is corrective emotional experience and intensive and dynamic family therapy. By placing the patient out of state, this aspect of the intervention is significantly comprised. In this clinical setting based on all of the documentation presented for review, the patient can be safely and effectively managed at a lower level of care in a less restrictive setting. 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.