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

Summary Reviewer 

A 68-year-old male enrollee has requested authorization and coverage for eye medication/eye drops (latanoprost 0.005%, one drop twice daily). The Health Insurer has denied this request indicating that the requested medication dosage is not medically necessary for treatment of the enrollees primary open angle glaucoma. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication dosage. Latanoprost 0.005% is prescribed as once daily dosing. There is a lack of evidence demonstrating that twice daily dosing is more effective than once daily dosing. The medical evidence does not support the requested medication dosage in this clinical setting. Thus, eye medication/eye drops (latanoprost 0.005%, one drop twice daily) is not medically necessary for the treatment of this patient. Therefore, the requested medication dosage 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 Upheld

Summary Reviewer 

A 61-year-old female enrollee has requested reimbursement for neuropsychological testing performed on 12/28/14. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for treatment of the enrollees medical condition.The physician reviewer found that according to the American Academy of Clinical Neuropsychologys practice guidelines, distinctive features of neuropsychological evaluations and consultations in assessing brain function and dysfunction include the use of objective neuropsychological tests, systematic behavioral observations and interpretations of the findings based on knowledge of the neuropsychological manifestations of brain-related conditions. In this case, the symptom complex was consistent with affective illness and anxiety rather than a disease of neurocognition, such as delirium, dementia, frontotemporal degeneration, Parkinsons disease, prion disease, or Lewy body disease to name a few.  Psychosocially, the patient was relatively new to the community and involved in an emotionally convoluted relationship. In October 2014 she linked her memory issues and insomnia to her poorly controlled anxiety. During that appointment, the provider did not include specific examples of the memory decline or objective rating scales such as a Folstein Mini-Mental State Examination or a Montreal Cognitive Assessment. The patient was prescribed a trio of medications including temazepam, lamotrigine and quetiapine, each of which alone could cause cognitive dulling while the concomitant use of the three, particularly when combined with alcohol, commonly causes sedation. She did not follow through on the recommendation from the psychiatrist earlier in the year to reduce her quetiapine. Lastly, she was consuming alcohol and had reported previously drinking a bottle of wine nightly. During the most recent mental status examination from May 2015, the patients speech, thought process, insight and judgement were unimpaired, while her attention span and concentration were within normal limits. Neuropsychological testing is not medically necessary to diagnose anxiety or affective disorders. Further, the patient had not followed through with the recommended medication reductions and she continued to consume alcohol while facing several external stressors. Finally, the patient did not have evidence of a neurocognitive disorder while her most recent mental status examination was normal. In sum, the documentation submitted for review does not support the medically necessity for the neuropsychological testing performed on 12/28/14.Therefore, the testing at issue was 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 46-year-old female enrollee has requested authorization and coverage for CPT 19316 performed on 10/24/18. 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 the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had evidence of significant symptomatic macromastia, and she had failed conservative management. Based on the documentation provided, she was a candidate for bilateral breast reduction based on non-resolving functional impairment. She underwent this procedure on 10/24/18. The operative note was consistent with a standard breast reduction and not solely a mastopexy. Generally, standard breast reductions include a breast lift as an integral part of the procedure and would not be considered a separate procedure. Based on the documentation provided, this patient underwent a bilateral breast reduction and not solely a mastopexy. An additional mastopexy would not be considered as a separate procedure, but an integral portion to the breast reduction. Therefore, the Health Insurers denial was appropriate. Thus, mastopexy (CPT 19316) performed on 10/24/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 38-year-old female with a history of chronic left hip pain in the groin related to CAM type femoroacetabular impingement, with a small pincer and associated tear of the anterior-superior labrum. The patient has requested reimbursement for hip arthroscopy performed on 12/03/19. 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 there is sufficient support for the services at issue in this clinical setting. Femoroacetabular impingement is a common condition among young adults. Griffin and colleagues compared physical therapy and surgery for management of this condition. Among 348 participants, 171 participants were treated with hip arthroscopy and 177 were treated with hip physical therapy. Both treatments improved the quality of life. However, hip arthroscopy resulted in greater improvement than physical therapy. In this patientas case, the procedures performed at the time of hip arthroscopy were appropriate and are known to be beneficial. These included arthroscopic surgery on her left hip consisting of acetabular rim trimming, repair of the labral tear, femoral osteochondroplasty, and capsular plication. The operative report describes the deformity that was corrected. Physical therapy was not helping at three months, and surgery was medically indicated. Therefore, hip arthroscopy performed on 12/03/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 44-year-old male enrollee has requested authorization and coverage for Testim. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees testicular hypofunction. 
The physician reviewer found that low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue (Dandona and Rosenberg). For these reasons, many providers treat patients with hypogonadism when a patients testosterone level is less than 350 ng/dL (Nieschlag, et al). The general target level for testosterone ranges from 350 to 750 ng/dL, in androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal and the dose of testosterone replacement therapy should be adjusted accordingly (Rivas, et al). This patient has a history of hypogonadism, with documentation of low serum testosterone including levels of 275, 283, 300 ng/dL. Thus, the requested Testim is supported as medically necessary for treatment of this patients hypogonadism. 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 

The patient is a 65-year-old female whose tumor was sent for FoundationOne CDx testing. Magnetic resonance imaging (MRI) of the brain showed multiple brain metastases, and a positron emission tomography (PET) scan was negative. 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. This patient underwent next generation sequencing prior to initiation of systemic therapy, despite molecular targets found on biopsy, estrogen and HER2. The use of next generation sequencing continues to be the subject of ongoing clinical trials and use outside of a clinical trial at this time is not indicated. Therefore,
FoundationOne CDx Testing performed on 4/17/19 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 22-year old female with a history of bipolar I, posttraumatic stress disorder, gender dysphoria, and an eating disorder. The record notes that the patient failed several medications and had four prior psychiatric hospitalizations. The patient is currently taking lamotrigine and lurasidone. The patient underwent genetic testing for medication guidance. The patient has requested reimbursement for genotype testing performed on 11/10/15.  The Health Insurer denied the request for reimbursement noting that the services at issue were investigational for the evaluation of this patient.  There is a lack of support in the medical literature for the use of genetic testing for medication guidance. A study by McIntye states, In some circumstances in clinical practice, phenotyping of cytochrome P450 enzymes may be relevant. However, sufficient high-quality, replicated, and controlled studies demonstrating that pharmacogenetics and pharmacogenomics reliably improve health outcomes are not yet available.  Other studies have found that genetic testing may not even be reporting relevant clinical information. There are some circumstances when genetic testing is done for safety reasons, like to test for possible Stevens Johnson syndrome or toxic epidermal necrolysis. However, there is a lack of head to head comparisons proving that genetic studies are of clinical benefit in this patients case. Currently, there is not enough evidence to show improved health outcomes due to genetic testing. In sum, genotype testing performed on 11/10/15 was not likely to have been more efficacious than the standard options for the evaluation of this patients medical condition. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 36-year-old male enrollee has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request indicating that the device at issue was considered investigational for evaluation of the enrollee, who reported palpitations. The physician reviewer found that the patient is a 36-year-old male with a history of hypertension and diabetes. He reported palpitations. Per the records, the patient underwent a 30-day external event monitor which revealed a symptomatic, but single episode, of atrial fibrillation lasting approximately 30 seconds. He was referred for implantable loop recorder to further assess atrial arrhythmic burden. The patient has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request and reported that the device at issue was investigational for the evaluation of this patient. The patient has symptoms of palpitations and would be at higher risk for embolic stroke if he had a significant burden atrial fibrillation associated with these episodes. He would then likely require lifelong anticoagulation. He was first assessed appropriately with an external 30-day event monitor which revealed one episode of symptomatic, although short-lived, atrial fibrillation. A single 30-second episode of atrial fibrillation may not be a definite indication to commit this patient to lifelong anticoagulation, but more sustained or frequent episodes may be an indication for lifelong anticoagulation. In this setting, an implantable recording device is a reasonable next step to assess the full burden of atrial fibrillation prior to starting anticoagulation. Therefore, implantable ambulatory event monitor provided on 12/28/17 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the device 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 Upheld

Summary Reviewer 2
A 36-year-old male enrollee has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request indicating that the device at issue was considered investigational for evaluation of the enrollee, who reported palpitations. The physician reviewer found that the patient is a 36-year-old male who reported palpitations. He was evaluated with a 30-day event monitor which demonstrated an episode of atrial fibrillation lasting 30 seconds. The patients provider recommended an implantable loop recorder to assist with treatment planning given the risks of bleeding if anticoagulation was initiated. The patient has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request and reported that the device at issue was investigational for the evaluation of this patient. There is a lack of support for the device at issue in this patients case. The medical evidence does not support an implantable loop recorder for monitoring for atrial fibrillation burden in this clinical setting. The use of an implantable loop recorder is supported if the patient has had cryptogenic stroke or recurrent syncope and has had negative results of external electrocardiogram monitoring. This patient was shown to have a 30-second episode of atrial fibrillation on the initial event monitor performed. In sum, the implantable ambulatory event monitor provided on 12/28/17 was not likely to have been superior over other available methods of evaluating this patient. Based upon the information set forth above, the device at issue was 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 36-year-old male enrollee has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request indicating that the device at issue was considered investigational for evaluation of the enrollee, who reported palpitations. The physician reviewer found that the patient is a 36-year-old male with a history of hypertension and diabetes. The records noted a history of intermittent palpitations. An echocardiogram performed on 11/20/17 revealed normal left ventricular systolic function.  A 30-day event monitor reported one episode of atrial fibrillation lasting 30 seconds which was associated with palpitations.  Anticoagulation was not started at that time. An implantable loop recorder was placed on 12/28/17 to help determine burden of atrial fibrillation in order to help guide treatment. The patient has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request and reported that the device at issue was investigational for the evaluation of this patient. In this case, the records documented palpitations which were determined to be due to atrial fibrillation by external event monitoring.  In this circumstance, if further monitoring for recurrent atrial fibrillation were thought to be necessary, then additional external event monitors that are either patient activated or auto-triggered should be sufficient as an initial step in identifying atrial fibrillation. There is no documentation to indicate the patient is unable to manage external monitoring devices or that these have been tried and failed. In this setting, recurrent atrial fibrillation could be adequately identified using a combination of symptoms and additional external event monitors, if needed. The implantation of a loop recorder in this circumstance has not been demonstrated to improve cardiac outcome and is not recommended in current guidelines. Thus, the implantable ambulatory event monitor provided on 12/28/17 was not likely to have been more efficacious than other methods of evaluating this patient. Based upon the information set forth above, the device at issue was 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 60-year-old female enrollee has requested reimbursement for the positron emission tomography (PET) scan provided on 5/10/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary for evaluation of the enrollees Stage IV ovarian cancer. The physician reviewer found that The findings on the PET/CT from 2/2/16 raised the possibility of tumor and the interpreting provider recommended a follow-up study. Thus, the PET/CT was indicated and complied with the National Comprehensive Cancer Network (NCCN) guidelines which state that PET/CT scan is an accepted tool for use in this clinical setting based upon questionable imaging results. Thus, the PET scan performed on 5/10/16 was medically necessary for further evaluation of this patients possible tumor in the setting of known metastatic ovarian cancer. Based on the foregoing discussion, the diagnostic procedure at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 64-year-old male enrollee has requested reimbursement for injection, immune globulin, Gammagard liquid, non-lyophilized, (e.g., liquid) 500 mg from 11/2/15 through 11/6/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees anti-GM1 polyneuropathy and Sjogrens syndrome. The physician reviewer found the medical literature support the superior efficacy of the services at issue in this clinical setting. Polyneuropathy can be idiopathic or can be traced to specific etiologies. Dysimmune neuropathies, with antibodies to gangliosides GM1 and GD1a can present in an acute or a chronic fashion. Patwa and colleagues stated the following, IVIG is effective and should be offered in the long-term treatment of chronic inflammatory demyelinating polyneuropathy (Level A). This patient has had sensory-motor polyneuropathy confirmed, and with associated autoimmune markers. He has tried and failed prednisone and medications for symptom management. IVIG has been administered with benefit, and he has had relapse when not treated. This patient was responsive to treatment with IVIG. As such, injection, immune globulin, (Gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg from 11/2/15 through 11/6/15 was shown to be more effective than standard therapy for treatment of this patient. Based upon the information set forth above, the services at issue were 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 64-year-old male enrollee has requested reimbursement for injection, immune globulin, Gammagard liquid, non-lyophilized, (e.g., liquid) 500 mg from 11/2/15 through 11/6/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees anti-GM1 polyneuropathy and Sjogrens syndrome. The physician reviewer found the current literature supports IVIG treatment in this clinical setting. As with most neuropathies, the cause of the neuropathy is thought to be autoimmune in nature. The use of IVIG is considered standard therapy in the treatment of neuropathies. Therefore, according to the current standard of care, the injection, immune globulin, (Gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg from 11/2/15 through 11/6/15 was likely to be more effective than other therapies available for treatment of this patient. Based upon the information set forth above, the services at issue were 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 64-year-old male enrollee has requested reimbursement for injection, immune globulin, Gammagard liquid, non-lyophilized, (e.g., liquid) 500 mg from 11/2/15 through 11/6/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees anti-GM1 polyneuropathy and Sjogrens syndrome. The physician reviewer found that although IVIG is not a first line therapy for all patients with polyneuropathy, there is solid research evidence supporting its use for patients with chronic inflammatory demyelinating polyneuropathy, autoimmune neuropathies, and anti-GM1 neuropathies.  In this case, the patient had significant symptoms including impaired balance, numbness and pain.  In addition, the patient had a previously documented, very positive response to the IVIG treatment. Undertreated autoimmune neuropathies frequently cause significant disability, weakness, pain, and numbness.  To this end, the use of IVIG in this particular case was highly effective.  In sum, injection, immune globulin, Gammagard liquid, non-lyophilized, (e.g. liquid) 500 mg from 11/2/15 through 11/6/15 was likely to result in a superior clinical outcome when compared to other standard forms of therapy for treatment of this patient.