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

Summary Reviewer

The patient is a 47-year-old female with a history of bed confinement with upper and lower extremity weakness and contractures with pain that prevents movement. On 11/30/16, the enrollee was transferred from Kindred Los Angeles Hospital to Cedars-Sinai Medical Center for follow-up appointment for cerebral arteriovenous shunt. The enrollee was monitored en route. The patient has requested reimbursement for the non-emergency ambulance service provided on 11/30/16. The Health Insurer has denied this request indicating that the service at issue was not medically necessary. This patients records do not include any clinical justification for the ambulance service provided on 11/30/16. The patient is bedridden but does not require medical transportation. The documentation suggests that the use of the ambulance was provided for patient convenience. Accordingly, the non-emergency ambulance service provided on 11/30/16 was not medically necessary for treatment of the patients medical condition. Based on the foregoing discussion, the service at issue was 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 44-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan of parathyroid gland provided on 7/19/16. The Health Plan has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees hyperparathyroidism. The physician reviewer found the traditional approach to parathyroid surgery consists of bilateral neck exploration with the goal of identifying and visually inspecting all four parathyroid glands. However, in the past few decades imaging studies have made it possible to localize parathyroid adenomas preoperatively (Mohebati and Shaha). More recently, the fusion of SPECT with x-ray based CT has proved to be more accurate and sensitive for localization of adenomas and may also help provide additional anatomic information to the surgeon pre-operatively (Liddy, et al). Therefore, the SPECT scan of parathyroid gland provided on 7/19/16 has been established as 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 diagnostic procedure 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 44-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan of parathyroid gland provided on 7/19/16. The Health Plan has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees hyperparathyroidism. The physician reviewer found that in the medical literature, Eslamy and Ziessman noted that the clinical diagnosis of primary hyperparathyroidism is based largely on serum laboratory test results, as patients often are asymptomatic. Given that approximately 90% of cases are due to a single parathyroid adenoma, the procedure of choice is the selective surgical excision of the hyperfunctioning parathyroid gland after its preoperative identification and localization at radiologic imaging. The authors noted that SPECT, when combined with CT, is particularly helpful for preoperative localization: The three-dimensional functional information from SPECT is fused with the anatomic information obtained from CT. In addition, knowledge of the anatomy and embryologic development of the parathyroid glands and the pathophysiology of primary hyperparathyroidism aid in the identification and localization of hyperfunctioning glands. In this case, the patient presented with a diagnosis of primary hyperparathyroidism complicated by the presence of thyroid nodules. In this clinical setting, the minimally invasive parathyroidectomy procedure is the standard of care. Medical literature supports the use of SPECT/CT scan for the preoperative localization of the tumor. As such, the SPECT scan of parathyroid gland provided on 7/19/16 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 diagnostic procedure 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 44-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan of parathyroid gland provided on 7/19/16. The Health Plan has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees hyperparathyroidism.The physician reviewer found the SPECT scan of parathyroid gland provided on 7/19/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is also ample literature to support its use in the surgical localization of parathyroid disease. The SPECT scan helps locate the anatomical abnormality and can enhance surgical precision, leading to better clinical outcomes for the patient, as well as help to shorten operative times. In conclusion, the diagnostic procedure 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 diagnostic procedure 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 




A 41-year-old male enrollee has requested reimbursement for computed tomography (CT) of the head without contrast performed on 9/08/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the evaluation of the enrollees headaches. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical evidence does not support CT scan of the head in this clinical setting.  The American College of Radiology Appropriateness Criteria is divided into several categories.  The one most closely reflects this patients presentation involves chronic headache, no new features, and normal neurologic examination.  The American College of Radiology states, In adult and pediatric patients with migraine, but without recent change in attack pattern, history of seizures, or other focal neurologic symptoms or signs, the routine use of neuroimaging is usually unwarranted.  The yield of CT or magnetic resonance imaging (MRI) in patients with headache but normal neurologic examination is generally quite low.  Douglas and colleagues noted most patients presenting with uncomplicated, non-traumatic, primary headache do not require imaging. When history, physical, or neurologic examination elicits red flags or critical features of the headache, then further investigation with imaging may be warranted to exclude a secondary cause.  All told, CT of the head without contrast performed on 9/08/16 was not medically indicated for the evaluation of this patient.  Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD), dysphagia and hiatal hernia. The physician reviewer found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other standard surgical anti-reflux procedures in the treatment of patients with GERD. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another evidence review found that further studies are required to determine its long-term outcomes and its relative efficacy as compared to other established treatments (Loh, et al). Adverse events, such as erosion through the esophagus, have been reported since U.S. Food and Drug Administration (FDA) approval (Bauer, et al). One peer-reviewed study reported that there are 11 cases of endoscopically-confirmed LINX erosion through the esophagus in the FDA Adverse Events database (Bielefeldt). Additionally, LINX has been associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al). The American College of Gastroenterology guidelines for the management of GERD also state that more evidence is needed before LINX can be recommended (Katz, et al). Based on current literature and clinical guidelines, the requested LINX procedure is not supported as medically necessary for the treatment of the patients medical condition. Based on the foregoing discussion, the requested procedure 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 


A 57-year-old male enrollee has requested authorization and coverage for Euflexxa injections. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees osteoarthritis of the bilateral knees. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Axe and colleagues report that intra-articular (IA) viscosupplementation using hyaluronic acid (HA) demonstrates anti-inflammatory, anabolic, and analgesic effects. The authors state Use of IA HA has also shown to delay total knee arthroplasty. Moreover, the literature review by Cheng and colleagues state We conclude that strong evidence supports the use of intra-articular knee injection as a valuable intervention in the continuum of management of arthritis between conservative treatment and knee surgeries. In this case, the clinical documentation submitted for review indicates the patient has osteoarthritis of the bilateral knees. The patient has been treated with Euflexxa injections and reported relief from 2011 until 2014. As such, additional injections would be medically necessary in this clinical setting. Based on the medical records submitted and the peer-reviewed literature, the request for Euflexxa injections are medically necessary for the treatment of the patients medical condition. For the reasons provided, 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 Upheld

Summary Reviewer 

The parent of a 16-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 11/07/18 through 11/15/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 2. The documentation indicates that the patient was not actively suicidal but did report she was passively suicidal on one occasion. In terms of functional status, the records support a score of 2. The patient has had some issues with level of function due to mental illness and relational issues but overall showed appropriate daily functioning while in treatment. In terms of comorbidity, the records support a score of 1. The patient did not have a history of past medical issues or substance use. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was noted to have a good relationship with her family. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents are involved in treatment. With regards to resiliency and treatment history, the records support a score of 3. The patient had a good response to a short period in the residential treatment center with minimal continued signs or symptoms of anxiety and depression. She was participating in therapy while on the unit and was not displaying serious or disruptive symptoms. In terms of acceptance and engagement of the patient, the records support a score of 2. The records documented that the patient participated in therapy. With regards to acceptance and engagement of the parent, the records support a score of 2. The patients parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 16. This score correlates with intensive outpatient services. Therefore, mental health residential treatment provided from 11/07/18 through 11/15/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 60-year-old female enrollee has requested reimbursement for the gene test (gene expression profiling) CPT 84999 performed on 12/29/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is insufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. According to the results of analysis of patients melanoma performed with DecisionDx melanoma, the tumor was classified as Class 1B with a low risk of near-term (within five years) metastatic disease, such as 90% metastasis free rate. According to the standard analysis of such risk, the lesions of 1-2 mm depth have a risk of 80-96%. Although DecisionDx melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. Therefore, the gene test (gene expression profiling) CPT 84999 performed on 12/29/16 was 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 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 2

A 60-year-old female enrollee has requested reimbursement for the gene test (gene expression profiling) CPT 84999 performed on 12/29/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that in this clinical setting, the standard protocol for an intermediate thickness tumor does not include a work-up with molecular genetic testing. Although gene expression testing has shown some impressive results in predicting risk of metastasis, there is no set change in treatment protocol based on the findings. The standard of care in this clinical setting would be a wide local excision and a sentinel node biopsy and the decision to pursue medical treatment would be based on the results of these tests. There are no clinical studies at this time that show that the results of the molecular testing will make a difference in the treatment of the patient. As such, the gene test (gene expression profiling) CPT 84999 performed on 12/29/16 was 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 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 60-year-old female enrollee has requested reimbursement for the gene test (gene expression profiling) CPT 84999 performed on 12/29/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the gene test (gene expression profiling) CPT 84999 performed on 12/29/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx Melanoma Gene assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the treatment of the patients melanoma. Thus its usage is not expected to impact the treatment or outcome of the patients melanoma. For the reasons provided, the testing at issue was 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 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 35-year-old female enrollee has requested reimbursement for (CPT code 86343) leukocyte histamine release test (LHR) dated on 10/20/15. The Health Insurer has denied this request indicating that the requested procedure are considered investigational for treatment of the enrollees chronic idiopathic urticaria The physician reviewer found in contrast to acute urticaria, many cases of chronic urticaria have identifiable causes.  According to current management guidelines for chronic urticaria, chronic autoimmune urticaria can be differentiated from idiopathic urticaria by the presence of auto-antibodies to IgE receptors, also named chronic urticaria index.  The Chronic Urticaria (CU) Index is available from reference laboratories. Patients with a chronic urticaria and a positive functional test result for autoantibody to the immunoglobulin E (IgE) receptor, likely have an autoimmune basis for the diagnosis. The evaluation for an autoimmune process is necessary to identify non-allergic triggers for her symptoms.   The implication of such distinction has direct impact on the choices of treatment, as to include immune modulating or suppressor agents in addition to the conventional antihistamines for the treatment of chronic urticaria. The presence of urticarial symptoms in this patient has been greater than two months and is considered chronic urticaria. Furthermore, the treating provider also determined that the cause of her chronic urticarial symptoms was unlikely to be allergic. Therefore, an evaluation for autoimmune causes is clinically reasonable and necessary. In conclusion, the service in review (CPT code 86343 - leukocyte histamine release test) is likely to be more beneficial for treatment of the enrollees medical condition than any available standard of care. Based upon the information set forth above, the services at issue were 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 35-year-old female enrollee has requested reimbursement for (CPT code 86343) leukocyte histamine release test (LHR) dated on 10/20/15. The Health Insurer has denied this request indicating that the requested procedure are considered investigational for treatment of the enrollees chronic idiopathic urticaria The physician reviewer found the clinical utility of LHR is not well established and there are currently no national Allergy and Immunology or Dermatology guidelines recommending routine use of this test. LHR is a test that consists of basophil histamine release assay.  This assay is used to detect anti-Fc-epsilon-RI-alpha antibodies. Some concerns with LHR is that there is evidence against a pathogenic role of autoantibodies to IgE or Fc-epsilon-RI and they are not specific to CU.  Anti-Fc-epsilon-RI-alpha antibodies have been identified in healthy normal people and those with other autoimmune diseases.  The level of these antibodies do not appear to change with the clinical disease activity. The presence of these antibodies do not appear to predict refractory disease. In this patients case, her symptoms are consistent with chronic idiopathic urticaria. Her evaluation to include LHR have all been negative.  As such, (CPT code 86343) leukocyte histamine release test (LHR) that was rendered on 10/20/15 was not likely to have been more effective than current standard therapy for evaluation of this patient. Therefore, for the reasons stated 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.