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

Summary Reviewer 

The parent of a 17-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment provided from 6/28/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Psychiatric Association treatment guidelines for eating disorders recommend either an inpatient unit or residential treatment facility when lower levels of care have been tried and failed. Additionally, the presence of comorbid conditions is an important factor to consider when deciding on the appropriate level of care. This patients comorbidities include major depressive disorder with suicidal ideation. Brewerton and Costin noted that for patients with anorexia nervosa there were statistically significant improvements in mean body mass indexThe great majority of patients completing treatment showed significant improvement at discharge from intensive residential treatment. This patient is experiencing a disturbance in mood, affect or cognition resulting in disordered eating behavior that could not be safely managed in a less restrictive setting. Therefore, residential treatment is in accordance with generally accepted standards of medical practice. Thus, mental health residential treatment from 6/28/19 forward was and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 44-year-old female enrollee has requested reimbursement for positron emission tomography (PET) scan performed on 3/04/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  Assessment of the response to treatment of metastases is crucial in daily oncological practice and clinical trials. For soft tissue metastases, this is done using CT scanning, magnetic resonance imaging (MRI) or PET scanning using validated response evaluation criteria.  While PET/CT scanning may not be indicated when the recent CT scans or MRI scans are positive, this is less convincing when the recent CT or MRI scans are negative.  In this patients case, the negative CT scans of the chest, abdomen, and pelvis were a reasonable indicator that the patient does not have metastatic disease.  However, breast carcinoma often spreads to the bones, and the bones had not been specifically evaluated.  PET/CT scans offer the ability to image the entire body as opposed to routine CT scans which must be directed to specific body regions.  This patient is at a high-risk for developing metastatic disease, and a baseline PET/CT scan may help to further direct or continue what will be a second-line chemotherapy.  All told, the PET scan performed on 3/04/16 was medically indicated for the evaluation of this patient.  Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the services at issue in this patientas case. Beckmann and colleagues concluded that their results asupport the clinical application of arthroscopic arthroplasty as a procedure that enhances cartilage repair as an alternative to far more complex procedures that have gained popularity. Furthermore, the data presented supports clinical investigations that recommend not to use suction drainage as by this procedure a considerable amount of the regeneratory potential of postoperative joint effusions might be extracted.a Lubowitz concluded, aArthroscopic abrasion arthroplasty results in a positive outcome in 66% of patients, and may still merit consideration as a salvage procedure.a This patient presented with a history of right medial meniscus tear and a significant loose body in the lateral gutter, resulting in mechanical locking. She had arthritic changes in the knee for which an arthroplasty might be indicated. However, her primary concern was mechanical locking. Surgery was performed on 8/16/19 to include right knee arthroscopy with partial medial meniscectomy, removal of a large intra-articular body, and abrasion chondroplasty for to the undersurface of the patella for grade III and IV chondral wear. Current evidence-based medical literature supports the inclusion of abrasion chondroplasty (CPT code 29879) during concurrent medial meniscectomy and loose body removal for mechanical locking and to potentially delay total knee replacement given her relatively young age and documented grade III to IV chondral wear. Therefore, arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19 was likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the role of arthroscopic debridement in the painful degenerative knee is controversial. Studies have shown that arthroscopic surgery for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. However, there are some exceptions to this rule. Patients with symptomatic meniscal tears and degenerative changes in the knee can benefit from arthroscopic meniscectomy, particularly if they are having mechanical symptoms such as locking. Similarly, a large loose body causing mechanical symptoms should be removed, even in the presence of osteoarthritis. Loose body removal has been proven to be more effective than conservative treatment for knee osteoarthritis. Therefore, the partial medial meniscectomy and loose body removal were medically necessary. The third procedure is abrasion chondroplasty, which has been denied. The role of arthroscopic debridement in the painful degenerative knee is controversial. Abrasion chondroplasty consists of shaving of fibrillated loose articular cartilage with a mechanical shaver. Studies have shown that such arthroscopic debridement for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. As such, arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19 was not likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the American Academy of Orthopaedic Surgeons (AAOS) published clinical practice guidelines on osteoarthritis of the knee. The guidelines noted, aWe cannot recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.a Kirkley and colleagues published their results on a prospective randomized trial of patients with moderate to severe knee osteoarthritis that were treated with knee arthroscopy. The authors concluded, aArthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy.a These results were further supported by Mosely and colleagues who showed that athe outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.a In this case, the patient was being treated for knee osteoarthritis. There is no evidence of an appropriate course of non-operative treatment. There were no submitted radiology reports for knee x-rays or a knee magnetic resonance imaging (MRI). While removal of the loose body was necessary to improve mechanical symptoms to the knee, the abrasion chondroplasty for the treatment for knee osteoarthritis and degenerative joint disease is not supported by the current AAOS guidelines. Thus, arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19 was not likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 19-year-old male enrollee has requested reimbursement for wilderness treatment program services provided from 10/23/18 through 1/16/19. 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 the American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. With regard to risk of harm, the records support a score of 4. The patient had serious risk of harm due to a recent pattern of excessive substance use resulting in loss of self-control and harmful behaviors with no demonstrated ability to abstain from use. In terms of functional status, the records support a score of 3. The records documented a need for a leave of absence from school due to substance abuse, as well as recent gains in sobriety achieved in a structured setting. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to interaction between substance use and psychiatric disorders, as well as recent head injuries. 
In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to exposure to alcohol and drug use on his college campus. With regard to level of support of the recovery environment, the records support a score of 3. The patient was reluctant to seek support or help for his mental health issues and substance abuse while enrolled in college. In terms of treatment and recovery history, the records support a score of 1. There was no prior experience with treatment or recovery. With regard to engagement and recovery status, the records support a score of 3. The patients records documented limited ability to accept responsibility for recovery. Thus, the patient had a composite score of 20. In sum, medically monitored residence-based services were indicated in this setting. Therefore, wilderness treatment program services provided from 10/23/18 through 1/16/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 52-year-old male enrollee has requested authorization and coverage for olaparib (Lynparza) tablet 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that Lynparza has been approved for use in patients with BRCA positive breast cancer or ovarian cancer. There is early experience with Lynparza in prostate cancer, mostly demonstrating some efficacy only in patients with DNA repair mutations, such as BRCA or ATM (Sonnenburg and Morgans). This patient was found to have the FANCA mutation, which is a related type of mutation. However, thus far, there is a lack of data demonstrating that patients with this mutation will obtain a meaningful response to Lynparza. Clarke and colleagues suggested that regardless of mutation status, there is somewhat better progression free survival with a combination of Lynparza and abiraterone than with abiraterone alone, though there was considerable toxicity in the combination arm. Given these findings, the requested Lynparza tablet 100 mg is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment 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 52-year-old male enrollee has requested authorization and coverage for olaparib (Lynparza) tablet 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that the standard of care for prostate cancer includes use of docetaxel or cabazitaxel which have been demonstrated in phase III randomized trials to prolong survival. This patient did not progress on docetaxel and has not been treated with cabazitaxel. Further, additional agents referenced in the National Comprehensive Cancer Network (NCCN) guidelines have greater support for this patients condition than the proposed treatment. Mateo and colleagues reported that Lynparza may provide additional benefit in patients with a BRCA or ATM mutation. However, this patients records document the presence of a FANCA mutation, which has not been shown to increase the effectiveness of Lynparza. For these reasons, the requested Lynparza tablet 100 mg is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment 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 52-year-old male enrollee has requested authorization and coverage for olaparib (Lynparza) tablet 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that this patient has exhausted several prior lines of therapy. The PARP inhibitor Lynparza was studied in 49 patients with castration resistant prostate cancer (Mateo, et al). In this phase II study, all patients were previously treated with at least two prior regimens for castration resistant disease and all had received prior docetaxel chemotherapy. Among the patients with a DNA repair gene abnormality, 88% demonstrated a response. Given this support, the requested Lynparza tablet 100 mg is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 29-year-old male enrollee has requested reimbursement for custom foot orthoses/inserts (L3030-NU, LT, RT) that were ordered on 1/10/15. The Health Insurer has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that this patient presented status post a trip and fall injury on 1/4/15 with acute low back, mid-back and right hip pain and disability. Clinical exam findings were consistent with the reported diagnoses of lumbar radiculitis, lumbar/lumbosacral subluxation, thoracic sprain/strain, and pelvic, hip, and pubic subluxation. There was no evidence of a foot condition/deformity or leg length discrepancy. There was no radiographic or imaging evidence of spinal segmental instability. The patient reported a 10-30% reduction in symptoms and functional improvement over the initial week of care. There is no compelling documentation presented to support the medical necessity of custom made bilateral foot orthoses for this patient. Therefore, in the absence of evidence based medical guideline or peer-reviewed support, the custom foot orthoses/inserts (L3030-NU, LT, RT) were not medically necessary for treatment of the patients medical condition. Based on the above, the equipment 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 Overturned

Summary Reviewer 

The patient is a 40-year-old female with low back pain and right L5 and S1 radiculopathy. She is status post decompression and fusion at L5-S1 with pedicle screw fixation. The physician reviewer found that the requested laminectomy, facetectomy and foraminotomy are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 15-year-old female diagnosed with major depressive disorder, recurrent, severe, alcohol use disorder, severe, and self-harm. The patient was admitted to intensive outpatient program (IOP) treatment on 1/19/17. The clinical record documents discord between the patient and her family. During the course of treatment, the patient has described herself as a mediator between her parents. An entry on 2/8/17 reveals that she was allowed to go on a trip with her father from 2/9/17 until 2/13/19, while in IOP. On 4/10/17, the patient reported less suicidal ideation but continued mood symptoms thus Prozac was increased from 20 mg daily for 30 mg daily with a plan to reassess in five weeks. Also on 4/10/17, she indicated in group that she does not express her anger in adaptive ways and she acknowledged that she wanted to learn more adaptive strategies. Her parent has requested reimbursement and prospective authorization and coverage for mental health IOP services from 4/10/17 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary. The additional information provided has been reviewed. On 5/24/17, an entry indicates that clients and parents attended a multifamily group. However, there is no indication the session focused on the specific issues and needs of this patient. Progress notes from other group encounters are similarly not specific to this patients needs and do not tailor care to the diagnoses and circumstances of the patient. Individual outpatient therapy and focused parent-child intervention in a less restrictive environment is likely to be more effective. More specific and focused treatment could be provided in a less restrictive setting. Accordingly, the IOP services provided from 4/10/17 forward were not and are not medically necessary for treatment of this patients behavioral health issues.  Based on the foregoing discussion, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 62-year-old female enrollee has requested reimbursement for ChemoFX assay performed on 5/08/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found ChemoFx is an attempt to determine the likelihood of a specific chemotherapeutic agent being effective in a patient, by testing the growth of an individuals cancer in an environment of various agents in vitro.  The hope is that drugs to which the cancer cells will respond to in vitro will then be clinically useful in that patient.  Such personalized selection would then spare the patient the toxicity of drugs that would not be useful.  There have been many such assays developed over the years.  As yet, none has convincingly demonstrated that selecting the specific chemotherapeutic regimen under the guidance of this assay has given the patient a significantly better survival, when compared to selecting a regimen based on known clinical studies and standards.  At this time, the evidence is insufficient to use the information from these assays to supplement standard of care chemotherapy decisions.  All told, ChemoFx assay performed on 5/08/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  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 2

A 62-year-old female enrollee has requested reimbursement for ChemoFX assay performed on 5/08/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found Chemosensitivity testing, such as ChemoFx, is not considered a standard of care and is not recommended by current guidelines.  In vitro assays of chemosensitivity or resistance, such as the ChemoFx assay, have been developed as a method to select the optimal chemotherapy regimen or identify those agents least likely to be effective.  However, the utility of these assays have not been prospectively validated.  Therefore, ChemoFx assay performed on 5/08/15 was not likely to have been more efficacious than other methods of evaluating this patient.  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.