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

Summary Reviewer 3


A 61-year-old male enrollee has requested authorization and coverage for intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures). The Health Insurer indicates that the requested services are investigational for the treatment of the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the requested services. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that the current medical evidence fails to demonstrate the superior efficacy of the requested services. There is a lack of support for intraoperative monitoring during a single-level lumbar fusion with pedicle screw placement. The cited articles discuss that the use of neural monitoring is associated with a higher cost without significant decrease in complication rate. Single-level lumbar fusion is below the spinal cord level, and neural monitoring is not recommended based on high-quality research. Therefore, intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures) is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 62-year-old male enrollee has requested reimbursement for homocysteine, Factor V Leiden and methylenetetrahydrofolate reductase (MTHFR) testing provided on 4/28/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees right lower extremity deep vein thrombosis (DVT). The physician reviewer found the DVT and pulmonary embolism may be caused by hereditary thrombophilias. Information regarding the increased risk is important especially in situations of prolonged immobility such as surgery, long car trips, or long airplane flights. These complications may be prevented by appropriate interventions and the avoidance of estrogens, which are prothrombic. The Prothrombin (F2) G20210A mutation increases risk of DVT about three-fold, but nearly 20-fold in compound heterozygous patients with Factor V Leiden (Emmerich, et al; Koeleman, et al). Similarly, patients with hyperhomocysteinemia and Factor V Leiden are at greatly increased risk for DVT (Ridker, et al). The most common genetic cause for hyperhomocysteinemia is the thermolabile variant of the MTHFR enzyme. This is due to homozygosity for the TT genotype at codon 677 (Kluijtmans, et al). Given that appropriate interventions should be taken if mutations are identified, the homocysteine testing, Factor V Leiden and MTHFR provided on 4/28/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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

A 62-year-old male enrollee has requested reimbursement for homocysteine, Factor V Leiden and methylenetetrahydrofolate reductase (MTHFR) testing provided on 4/28/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees right lower extremity deep vein thrombosis (DVT). The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Homocysteine testing is clinically indicated for idiopathic or recurrent venous thromboembolism. In this case, the patient has de novo DVT without provocative factor per se, and is at high risk for pulmonary thromboembolism. In addition, Factor V Leiden genetic testing was clinically indicated given the patients venous thrombosis with a family history of thrombotic disease. Moreover, there is growing evidence that MTHFR gene polymorphism testing has utility in this clinical setting. As such, the homocysteine, Factor V Leiden and MTHFR testing provided on 4/28/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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

A 62-year-old male enrollee has requested reimbursement for homocysteine, Factor V Leiden and methylenetetrahydrofolate reductase (MTHFR) testing provided on 4/28/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees right lower extremity deep vein thrombosis (DVT). The physician reviewer found the homocysteine, Factor V Leiden and MTHFR testing provided on 4/28/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. Patients with DVT have a high prevalence of inherited thrombophilic disorders and the testing at issue is recommended. In this case, the patient presented with spontaneous DVT of the right femoral and popliteal veins. In this clinical setting, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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 


An 18-year-old male enrollee has requested reimbursement for psychiatric residential treatment provided from 11/05/12 through 12/06/12.  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 the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was admitted after having felt stressed at his boarding school.  He did not feel he could fit in and cut and scratched himself from the stress.  Per the medical records, he was cooperative in his treatment program.  He had an episode of scratching when he felt stressed at the thought of returning to his old school.  The patient was given a discharge diagnosis of major depressive disorder, in remission, and attention deficit/hyperactivity disorder.  These conditions could have been safely treated at a lower level of care.  It appears that removing him from the stress of the boarding school was a main factor in his improvement, and this could have been accomplished in a setting other than residential treatment.  His scratching and cutting appear to be more stress relief and do not appear to be specific attempts at suicide.  All told, psychiatric residential treatment provided from 11/05/12 through 12/06/12 was not medically indicated for the treatment of this patient.  Therefore, 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 Overturned

Summary Reviewer 1

A 26-year-old female enrollee has requested reimbursement for laboratory services (CPT code 83993) performed on 10/5/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees structuring ileocolic Crohns disease. The physician reviewer found that various studies have found that fecal calprotectin correlates with endoscopic finding of inflammation and serum markers of inflammation in Crohns disease (Mao, et al; Kopylov, et al). Further studies have found that fecal calprotectin is useful to assess disease activity in Crohns disease (Walsham, et al). The test allows non-invasive assessment of Crohns disease. The American Gastroenterological Association (AGA) guidelines for the management of Crohns disease recommend fecal calprotectin to assess disease activity in patients with Crohns disease. For these reasons, the laboratory services (CPT code 83993) performed on 10/5/17 was likely to be more beneficial for evaluation of this patients Crohns disease than any available standard therapy. Based upon the information set forth above, the testing at issue was 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

A 26-year-old female enrollee has requested reimbursement for laboratory services (CPT code 83993) performed on 10/5/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees structuring ileocolic Crohns disease. The physician reviewer found that fecal calprotectin, elaborated by neutrophils, is elevated when there is inflammation within the lumen of the gastrointestinal tract. In the setting of post-operative Crohns, a progressive rise is usually indicative of disease recurrence. Following serial measurements is a reasonably strategy rather than subjecting the patient to serial colonoscopy exams to assess disease activity. Performance of serial post-operative fecal calprotectin levels can be considered a standard of care strategy. Accordingly, the laboratory services (CPT code 83993) performed on 10/5/17 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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

A 26-year-old female enrollee has requested reimbursement for laboratory services (CPT code 83993) performed on 10/5/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees structuring ileocolic Crohns disease. The physician reviewer found that persistent disease activity is associated with a poor prognosis in inflammatory bowel disease (IBD). Therefore, monitoring of patients in this clinical setting with intent to suppress subclinical inflammation has emerged as a reasonable community standard treatment goal. As endoscopic monitoring is invasive and resource intensive, identification of valid markers of disease activity has been a priority. Calprotectin, when measured in feces, is now used in clinical practice to differentiate between non-organic and inflammatory intestinal disorders, especially to identify IBD. Fecal calprotectin may also be useful, as has been proposed for this patient, to monitor patients with IBD under treatment and to predict the risk of recurrence of active disease prior to clinical relapse (Burri and Beglinger). Given this support, the laboratory services (CPT code 83993) performed on 10/5/17 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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

The patient is a 19-year-old female with a history of mood disorder and attention deficit/hyperactivity disorder. The patient was admitted to a residential treatment center on 2/04/15 due to worsening anxiety, family disturbances, low self-esteem, and depression. The patient was treated with individual, group, and family therapy along with medication management of fluoxetine. The patient has requested reimbursement for psychiatric residential treatment provided from 2/04/15 through 11/30/15. 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 Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The patient met the following criteria based on the submitted records. In terms of risk of harm, the records support a score of 1. The patient did not have a history of suicide attempts. She did not have suicidal or homicidal ideation. With regards to functional status, the records support a score of 3. The patient was struggling to maintain good grades. The patient was able to maintain her activities of daily living. With regards to comorbidity, the records support a score of 3. The patient had comorbidities of attention deficit/hyperactivity disorder and borderline traits which adversely affected her mood.  In terms of environmental stress of the recovery environment, the records support a score of 3. The patient had interpersonal struggles in the home. This has had a significant impact on her living environment.  With regards to environmental support, the records support a score of 2. The patients parents were supportive of the patient and were willing to participate in treatment. In terms of resiliency, the records support a score of 3. The patient was seeing a therapist for a year. She had an equivocal response to therapy. With regards to acceptance and engagement, the records support a score of 2. The patient was cooperative with staff and would engage in treatment. Thus, the records support a composite score of 17.  Based on these criteria, the patient met criteria for an intensive outpatient program and could have been treated in a less restrictive environment. Thus, psychiatric residential treatment provided from 2/04/15 through 11/30/15 were not medically necessary for the treatment of this patient. Therefore, 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 39-year-old male enrollee has requested reimbursement for ambulance transportation provided on 6/26/18. 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 submitted documentation fails to demonstrate the medical necessity of the services at issue. The Health Insurer denied prior authorization for ambulance transportation to University of California San Diego Medical Center. The reason cited was that there were other facilities closer to Cincinnati, Ohio which were capable of performing pulmonary thromboendartectomy. The alternative plan was to transfer the patient by ground to Cleveland, Ohio. The records noted that the patient and his provider selected University of California San Diego Medical Center because it performs many pulmonary thromboendartectomy procedures and has a low mortality rate. This patient was not transferred on an emergency basis. The patient was medically stable at Christ Hospital. He was appropriate to be discharged home. The patients vital signs were stable at the time of transfer. There were medical facilities closer to Cincinnati, Ohio which were capable of performing pulmonary thromboendartectomy. Therefore, ambulance transportation provided on 6/26/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 40-year-old female enrollee has requested authorization and coverage for spinal fusion.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has been diagnosed with lateral recess stenosis at L4-5 and severe foraminal stenosis at L5-S1. The physician reviewer found there is sufficient support for the requested services in this patients case.  Evidence-based medical guidelines support lumbar fusion in the setting of degenerative spondylolisthesis with symptomatic radiculopathy or spinal stenosis when nonoperative treatment has failed.  Lumbar fusion is also supported in the setting of wide decompression with anticipated intraoperative instability.  This patient presents with persistent worsening low back pain radiating into the left lower extremity to the calf consistent with a left L5 radiculopathy.  Significant functional difficulty is documented in ambulation and activities of daily living.  Detailed evidence of a comprehensive nonoperative treatment protocol trial and failure has been submitted.  Clinical examination findings were consistent with imaging evidence of lateral recess stenosis at L4-5 and severe foraminal stenosis at L5-S1.  There is radiographic evidence of spondylolisthesis at L4-5 exaggerated in extension and reduced in flexion.  The treating provider has planned complete facetectomy and foraminotomy to achieve adequate nerve root decompression which would result in temporary intraoperative instability and necessitate fusion. Thus, the requested spinal fusion is medically indicated for the treatment of this patient.  Therefore, the requested services 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 63-year-old female with Crohns disease.  She is noted to have joint pain, and has failed Cimzia and methotrexate.  Per the provider note dated 1/24/17, she was noted to have Crohns disease flares and sharp abdominal pain since stopping Cimzia.  She was also noted to have ongoing chronic joint pain. The patient has requested authorization and coverage for Stelara injections for the treatment of Crohns disease.  The Health Insurer has denied the request as not medically necessary. Per the Health Insurer, there is no documentation that Stelara will not be used concomitantly with other biologic disease modifying antirheumatic drugs.  This denial is the subject of this appeal and determination. The current medical literature supports the use of Stelara in this patients case. A large randomized controlled trial by Sandborn and colleagues demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, as in this patients case.  Kopylov and colleagues showed a 73% response in patients with anti-TNF-resistant Crohns disease. A significant majority of these patients were able to discontinue steroids. Stelara is more appropriate than immunosuppressants and corticosteroids in this patients case. The American College of Gastroenterology guidelines for induction of remission of Crohns disease state that immunosuppressants may not induce remission in adults with active Crohns disease with use up to 17 weeks; therefore, they are not recommended. For maintenance of remission, immunosuppressants (such as azathioprine, 6-mercaptopurine, and methotrexate) are given a weak recommendation. Corticosteroids are not an appropriate long-term primary therapy for Crohns disease.  Cimzia and methotrexate have been discontinued.  For these reasons, the requested Stelara injections are 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 32-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 9/24/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Prognostic gene expression profiling (GEP) testing to differentiate melanomas at low versus high risk for metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive result, GEP testing should not guide clinical decision making in this group. This patient has a small good prognosis lesion based on pathology. Commercially available GEPs, such as DecisionDx-Melanoma testing, are marketed as being able to classify cutaneous melanoma into separate categories used on risk of metastasis. However, it remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known cliniopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Various (mostly retrospective) studies of prognostic GEP testing suggest its role as an independent predictor of worse outcome, although not superior to Breslow thickness or sentinel lymph node status. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Therefore, DecisionDx-Melanoma testing performed on 9/24/19 was not likely to have been more beneficial than other available standard therapy.