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

Summary Reviewer 3

A 60-year-old female enrollee has requested authorization and coverage for 22870 and 22869 (insertion of stabilization device without compression). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the records document lumbar spinal stenosis with moderate to severe leg, buttock, groin, and back pain, sensory and motor dysfunction, and evidence of neurogenic claudication. She has tried and failed over six months of conservative treatment. The provider has advised a minimally invasive surgery consisting of insertion of a Superion interspinous process stabilization spacer, which is a less invasive indirect decompression procedure for patients who fail conservative treatment before undergoing a laminectomy and fusion. The patient is an appropriate candidate for this minimally invasive surgery. There are several treatment options for patients with lumbar spinal stenosis. These include the traditional invasive lumbar decompression and fusion and continued conservative care. When conservative care is not effective, the interspinous spacer decompression using the Superion device offers a minimally invasive procedure with documented good results for patients who fail conservative treatment. The Superion interspinous lumbar decompression is a minimally invasive, low-risk procedure for the treatment of lumbar spinal stenosis, which is safe and effective by maintaining sagittal alignment of the vertebrae at that level. This limits the possibility of device dislodgment or migration, and preserves the mobility and structural integrity of the spine. Thus, the requested CPT codes 22869 and 22870 (insertion of stabilization device without decompression) are likely to be more beneficial for treatment of the patients medical condition than any standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 46-year-old male 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 chronic hepatitis C virus genotype 1a. The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. This recommendation is 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. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. In this case, the patient has hepatitis C without evidence of cirrhosis on liver biopsy in 2011 or ultrasound in 2015. Although FibroScan in 2015 was consistent with cirrhosis, the patients aspartate-to-platelet ratio index (APRI) based labs on that date were not consistent with advanced fibrosis or cirrhosis. Therefore, the 12 week therapy recommendation should apply, rather than the 24 week duration recommended for patients with cirrhosis. Thus, a 12 week course of Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus. In conclusion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 55-year-old female with a history of hyperlipidemia. Per the medical records, she is intolerant to multiple statin medications. The submitted documentation noted coronary artery disease including prior coronary artery revascularization. On 12/14/17, low-density lipoprotein (LDL) level was 182 mg/dL. The patient has requested coverage for Praluent injection 75 mg/ml subcutaneous solution. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The submitted documentation supports the medical necessity of the requested medication. This patient has known obstructive coronary disease and marked hyperlipidemia. She is intolerant of several statin medications. Praluent is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter category. There is documented intolerance to several statin medications, and the use of ezetimibe alone would not be expected to achieve an LDL reduction to less than 70 mg/dL, the current goal in patients with documented obstructive coronary disease, such as this patient. PCSK9 inhibitors such as Praluent have been documented in several randomized controlled trials to be safe and effective at lowering LDL cholesterol and associated with improved outcomes. Thus, Praluent injection 75 mg/ml subcutaneous solution is medically necessary 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 Overturned

Summary Reviewer 

The parent of a 13-year-old male enrollee has requested authorization and coverage for Genotropin 12 mg cartridge. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved the use of growth hormone therapy for idiopathic short stature or non-growth hormone-deficient short stature, defined as height standard deviation less than or equal to -2.25 or less than or equal to 1.2nd percentile for age and gender and who are considered unlikely to reach a normal adult height. In 2016, the Pediatric Endocrine Society came out with guidelines and recommendations for growth hormone use and indicated the decision to treat in idiopathic short stature should be made on case-by-case basis. The guidelines also suggested a follow-up assessment of benefit in height standard deviation and psychosocial impact 12 months after growth hormone initiation and dose optimization. This patient has a very low growth velocity of 2.75 cm per year. He has a poor height prediction of less than 160 cm, which is below the -2.25 standard deviation for the U.S. adult male population. Based on the records, this patient meets the criteria for idiopathic short stature and meets the FDA criteria for treatment with growth hormone therapy. Therefore, Genotropin 12 mg cartridge is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 47-year-old female enrollee has requested authorization and coverage for Lyrica. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees peripheral neuropathy. The physician reviewer found the submitted documentation establishes the medical necessity of the requested medication. This patient presents with neuropathy with neuropathic pain. It is well-established that diabetic neuropathy is a model for many types of neuropathy. Nearly half of all neuropathies have no clear cause, but for the most part, the pain noted with neuropathy has a final common pathway, and similar response to treatment. There are a number of studies in the medical literature showing Lyrica is effective in a variety of neuropathic pain. Furthermore, Lyrica is widely prescribed by providers for neuropathic pain outside of diabetic peripheral neuropathy. In this case, the patient has tried and failed standard therapies including gabapentin and amitriptyline and has found Lyrica to be the most effective without side effects. As such, Lyrica is medically necessary for treatment of this patients painful peripheral neuropathy. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 13-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intensive behavior therapy (IBT) services provided from 2/02/16 through 8/02/16. 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 autism.   The physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue.  ABA addressed social skills deficits, communication problems and adaptive delays.  Per the submitted records, this patient has autism spectrum disorder and has been making progress with ABA therapy.  In this patients case, 25 hours of ABA therapy per week is medically appropriate and standard of care.  Additionally, one hour of supervision for every eight to ten hours of direct ABA is medically indicated.  In sum, the records demonstrate the medical necessity of a portion of the services at issue in this patients case.  Therefore, a portion of the services at issue was and is 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 

A 59-year-old female enrollee has requested reimbursement for CPT codes 81201-90, 81210-90, 81211-90, 81282-90, 81295-90 and 81298-90 provided on 2/19/18. 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 understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing to predict candidates for specific mutation-driven treatment holds promise but is not yet ready for routine clinical use. Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of next generation sequencing, such as with FoundationOne testing, continues to be the subject of ongoing clinical trials. Therefore, CPT codes 81201 and 81210 provided on 2/19/18 were not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 61-year-old male enrollee has requested authorization and coverage for radiofrequency ablation (code 50592). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The records document a small, localized, renal cell tumor, for which surgical resection is the standard of care (likely, in the form of partial nephrectomy). This is stated in the National Comprehensive Cancer Network guidelines, and is justified by much higher local recurrence rates for radiofrequency ablation or microwave ablation as compared with resection. Therefore, the more minimally invasive approaches, such as radiofrequency ablation and microwave ablation, are reserved for patients who would not tolerate surgery, either by virtue of being poor surgical candidates, or for patients in whom removal of a kidney or part of it may result in renal failure. There is a lack of support for the requested services in this clinical setting. Thus, radiofrequency ablation is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 37-year-old male enrollee has requested reimbursement and prospective authorization and coverage for assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the role of fecal calprotectin has been extensively studied in many areas of inflammatory bowel disease (IBD) patients management. There is emerging evidence that fecal calprotectin is a useful surrogate marker of inflammation in the post-operative setting, as it correlates with the presence and severity of endoscopic recurrence according to Rutgeerts score and can predict the subsequent clinical recurrence and response to therapy in CD patients. There is sufficient medical literature showing the usefulness of following fecal calprotectin levels serially. All told, the assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing was and is 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 and is 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 Upheld

Summary Reviewer 2

A 37-year-old male enrollee has requested reimbursement and prospective authorization and coverage for assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that calprotectin, when measured in feces, is commonly used in clinical practice to differentiate between non-organic and inflammatory intestinal disorders, especially to identify inflammatory bowel disease (IBD). Fecal calprotectin may also be useful to monitor patients with IBD under treatment and to predict the risk of recurrence of active disease prior to clinical relapse (Burri and Beglinger). While one time fecal calprotectin testing may have clinical utility, a series of calprotectin assays does not (Bourdillon, et al). In this case, the patient underwent a total of nine serial testing of fecal calprotectin from 12/7/15 through 12/26/16. This serial testing has not proven adequately correlative with the patients other inflammatory markers. For the reasons provided, the assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing was not and is not 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 not and is 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 37-year-old male enrollee has requested reimbursement and prospective authorization and coverage for assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that fecal calprotectin has not been definitively established for the management of Crohns disease, and may be redundant with other tests. A meta-analysis of the utility of fecal calprotectin to determine disease activity in adults with inflammatory bowel disease found poor specificity in Crohns disease (Lin, et al). In Crohns disease, studies have demonstrated that calprotectin above 150 ug/g had poor specificity (43%), and therefore poor positive predictive value in predicting relapse (Pardi and Sandborn; Costa, et al). Another meta-analysis of inflammatory bowel disease markers reported that the relatively poor specificity of fecal calprotectin in Crohns disease is a concern, as a false positive test could lead to treatment of a patient without endoscopically active disease (Mosli, et al). Use of calprotectin levels to guide therapy has not definitively been shown in controlled studies to improve clinical outcomes in patients with Crohns disease. Therefore, assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing was not and is not 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 not and is 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 Overturned

Summary Reviewer 


A 31-year-old female enrollee has requested authorization and coverage for HyQvia. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypogammaglobulinemia. The physician reviewer found that HyQvia Ig, dosed at once per month infusion intervals, meets the medical necessity criteria for this patient, who has a diagnosis of blood clotting disorder and hypogammaglobulinemia. In the case of this patient, her blood clotting disorder places her at an increased baseline risk for thromboembolic events. Thus, it is clinically reasonable that less frequent dosing intervals would place her at a lower risk for thromboembolic events. It is also clinically reasonable that a less concentrated Ig product, such as HyQvia, poses less of a risk for thromboembolic event. The peer-reviewed literature does support the use of Ig replacement in special circumstances, such as with this patient. The literature advises also for adequate hydration pre-Ig infusions, slowed infusion rates, and use of antiplatelet therapy for patients at risk. Given this patients clinical presentation and history, the requested HyQvia is medically necessary. Based on the foregoing discussion, 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 


A 45-year-old female enrollee has requested reimbursement for the hip arthroscopy with femoroplasty performed on 6/21/17. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees right hip pain.    The physician reviewer found that in the medical literature, Hellman and colleagues reviewed five approaches for surgical management of femoroacetabular impingement syndrome, including arthroscopy. The authors reported that femoroacetabular impingement was a common pathologic disorder of the hip that caused pain and had been implicated in the development of early osteoarthritis in young adults. When nonsurgical treatment methods fail, surgical options were recommended, but there was a lack of long-term outcome data to support one method over another. Harris and colleagues concluded that the outcomes of operative treatment of femoroacetabular impingement are significantly better than nonsurgical management. Nationally recognized evidence based medical guidelines recommend surgery for femoroacetabular impingement for patients with symptomatic hip pain and dysfunction resulting from a defined injury with duration less than 18 months, failure of a minimum of three months of conservative treatment, symptoms including decreased range of motion, limp, and/or sexual difficulties, physical findings of hip tenderness and increased pain with extremes or motion or crepitation, MRI and radiographs show classic pincer and/or cam lesions, absent or minimal arthritic changes and hip joint space greater than 2 mm and no subchondral cysts, and pain relief should be demonstrated with a diagnostic intra-articular anesthetic injection in questionable or borderline cases. In this case, the patient presented with low back pain, right hip pain, and right SI joint pain. Functional difficulty was reported in activities of daily living. Evidence of reasonable and/or comprehensive non-operative treatment protocol trial and failure was submitted. Clinical examination was reported to be generally consistent with hip impingement. However, there was no corroborating x-ray or imaging evidence. Pelvic MRI documented no osseous or soft tissue abnormality. Right hip MR arthrogram demonstrated tearing versus sub-labral sulcus of the right acetabular labrum anteriorly with no osseous pathology. Overall, the evidence based medical criteria were not met for the right hip arthroscopy with femoroplasty performed on 6/21/17 given the absence of corroborating imaging evidence of a cam or pincer lesion, and ongoing signs or symptoms of lumbar radiculopathy and right SI joint dysfunction. All told, the hip arthroscopy with femoroplasty performed on 6/21/17 was not medically necessary for treatment of the patients medical condition. Based on the foregoing discussion, the surgery at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.