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

Summary Reviewer 

A 64-year-old female enrollee has requested reimbursement for knee injections provided on 6/15/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees knee pain. The physician reviewer found that this patient presented on 6/15/18 with recurrent right knee pain and limitations in functional mobility and activities of daily living. Clinical examination findings were consistent with reported radiographic evidence of right knee degenerative joint disease. Reasonable conservative treatment, including medications, activity modification, weight loss, and physical therapy have failed to provide adequate symptom relief. She was status post previous injections on 12/19/16 and 9/22/17 which had provided sustained pain relief and functional improvement for longer than six months. Evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Thus, knee injections provided on 6/15/18 were medically necessary for the treatment of this patient. Therefore, the services at issue were 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 20-year-old male enrollee has requested reimbursement for residential treatment, partial hospitalization program services and intensive outpatient program services provided from 3/6/15 through 5/3/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the services at issue were not medically indicated for this patient during the dates in dispute. According to the documentation submitted for review, the patient presented to residential treatment on 3/6/15 with mild. He was not a danger to himself or others. There were no emotional, behavioral, or cognitive barriers requiring residential treatment. He was psychiatrically stable. Although his liver function tests were elevated, he was medically stable. He participated in the program and was motivated. He did not require 24-hour monitoring at residential level of care. As of 3/25/15, partial hospitalization program services were not clinically indicated. The patient no longer had PAWS and he was not at risk to himself or others. He was counseled regarding the need to monitor his liver function tests and liver health. His overall mood was euthymic. As of 3/25/15 he could have been stepped down to a lower level of care. Further, the intensive outpatient program services were not indicated for this patient. As of 4/17/15, he had a sponsor, and he was actively attending meetings/groups, and was employed. He was highly motivated. His mother was participating in family sessions. There were no emotional, behavioral, or cognitive barriers to treatment at a lower level of care. Therefore, the residential treatment, partial hospitalization program services and intensive outpatient program services provided from 3/6/15 through 5/3/15 were not medically necessary. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The parent of a 16-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) testing performed on 4/26/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for the enrollees dysmorphic facies and postural and kinetic tremor. The physician reviewer found the array-based CGH, also known as CMA, has become standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or multiple congenital anomalies. Until recently, it was a diagnostic test that was employed when the first-line investigation of karyotype returned normal. Subsequently, CGH has emerged as a first-line investigation. The yield of this test is estimated to be 8-17% and varies with the degree of cognitive impairment, the presence of dysmorphic features, and the presence of congenital anomalies. More recently, data have shown that actionable findings from chromosomal microarray justify its use (Coulter, et al). Based on the support in the peer-reviewed literature, the CGH testing performed on 4/26/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2
The parent of a 16-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) testing performed on 4/26/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for the enrollees dysmorphic facies and postural and kinetic tremor. The physician reviewer found that CGH, also referred to as CMA, is a well-established first-line genetic test for individuals with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics (AAP), the American College of Medical Genetics (ACMG), the American College of Neurology (AAN) and the Child Neurology Society (CNS) (Schaefer et al; Moeschler et al; Shevell, et al; Shen et al). CMA technology has been shown to provide clinically actionable information. In this case, the patient presented with kinetic tremor. The clinical utility of CMA in the evaluation of seizure concerns is also well established. Olson and colleagues evaluated 805 patients with epilepsy/seizures using CMA technology. The authors found that in at least 40 cases (5%), the epilepsy phenotype was explained by a [copy number variant] CNV, including 29 patients with epilepsy-associated syndromes and 11 with likely disease-associated CNVs involving epilepsy genes or hotspots. Copy number abnormalities were found to play an important role in patients with epilepsy. The authors concluded that because the diagnostic yield of CMA for epilepsy patients is similar to the yield in autism spectrum disorders and in prenatal diagnosis, for which published guidelines recommend testing with CMA, we recommend the implementation of CMA in the evaluation of unexplained epilepsy. For these reasons, CGH testing performed on 4/26/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The parent of a 16-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) testing performed on 4/26/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for the enrollees dysmorphic facies and postural and kinetic tremor. The physician reviewer found thatCGH, also known as chromosomal microarray (CMA), is recommended by the American College of Medical Genetics (ACMG) as a first-tier test for patients with autism spectrum disorders or developmental delay and intellectual disability. The yield of CMA in patients with these disorders is estimated to be around 10%. However, there is no indication that this patient has these conditions. The clinic notes report that he has anxiety and depression with hallucinations, tremor, and differences in sensation. The notes also mention mild dysmorphic features, however these were not specified. In this clinical setting, the yield of CMA is likely to be low for this patient. As such, the CGH testing performed on 4/26/16, 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 91-year-old male enrollee has requested reimbursement for services provided from 3/13/18 through 3/16/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees acute on chronic diastolic heart failure. The physician reviewer found that the records provided for review document that this patient presented with dyspnea on exertion. He was mildly bradycardic, his blood pressure was normal, his respiratory rate was 20, and he was not hypoxic on room air. His anemia and renal function had worsened, with a creatinine almost double his baseline. On 3/15/18, the patient was transfused PRBCs when his hemoglobin dropped below 7. His symptoms appeared to improve with a transfusion of PRBCs and additional diuretics. His renal function returned to baseline with careful diuretic administration. This patient met the criteria for admission and treatment in the telemetry unit given the presence of worsening CHF on imaging, increase of creatinine to twice the level of baseline, and hemoglobin less than 7. All told, the services provided from 3/13/18 through 3/16/18 were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were 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 five-year-old male enrollee has requested authorization and coverage for Gammagard 20 gm infused every four weeks for one year, 40 units per dose for a total of 520 units. 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 PANS represents sudden onset of psychiatric symptoms, typically consistent with obsessive-compulsive disorder, following infection with a number of agents, including group A streptococcus and mycoplasma. This represents a broader variation of PANDAS. An article by Calaprice and colleagues noted that the majority of practitioners utilized both short-term and long-term courses of antibiotics, intravenous immunoglobulin, particularly for patients with immunoglobulin G (IgG) deficiencies, plasmapheresis, psychotropic medications, and psychotherapy. Complementary and alternative medicines, including gluten-free diet and homeopathic medications, were also utilized. The authors noted that intravenous immunoglobulin therapy was reported to have been beneficial in reducing PANS symptoms for many patients, but was most beneficial, and most enduringly beneficial, for the subset with IgG deficiencies. This patient has a history of recurrent sinopulmonary infections, with reproducible laboratory evidence of common variable immune deficiency. He also meets criteria for PANDAS/PANS. Based on the current standard of care for patients with this constellation of disorders, monthly intravenous immunoglobulin therapy as prescribed is medically appropriate. Therefore, Gammagard 20 gm infused every four weeks for one year, 40 units per dose for a total of 520 units is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 32-year-old female enrollee has requested authorization and coverage for Gamunex-C. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the standard treatment of small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain, which can include several different classes of
medications. In small fiber neuropathy, current neuropathic pain treatment options are generally insufficient to relieve the pain substantially. Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. Intravenous immunoglobulin (IVIG) is a first-line treatment for immune-mediated neuropathies, such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy.
Erythromelalgia is a rare disorder that is characterized by erythematous, warm, painful extremities, which is often precipitated by cold conditions. The pathophysiology of erythromelalgia is incompletely understood. In a case study by Moody and colleagues, a patient with seronegative polyarthritis presented with a six-year history of erythromelalgia with recurrent bouts of painful erythema and triggered by minor trauma. Several medical therapies provided limited and inconsistent relief of her symptoms over many years. Treatment with intravenous immunoglobulin significantly decreased the frequency and severity of her symptoms. In this case, the patient has debilitating small fiber polyneuropathy with laboratory evidence of autoimmunity as well as clinical symptoms consistent with erythromelalgia. She has tried and failed conventional medical therapy. Based on the current medical evidence, patients with autoimmune small fiber neuropathy and erythromelalgia may improve clinically with intravenous immunoglobulin. Therefore, Gamunex-C is likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 32-year-old female enrollee has requested authorization and coverage for Gamunex-C. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the requested medication in this clinical setting. Schofield and Chemali noted, Immunoglobulin therapy has been used increasingly with significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are most often small fiber (autonomic and/or sensory) polyneuropathies. De Greef and colleagues noted that, Small fiber neuropathy is the most common cause of neuropathic pain in peripheral neuropathies. Patients experience excruciating pain, and currently available anti-neuropathic and other pain drugs do not relieve the pain substantially. Several open-label studies have suggested an immunological basis in small fiber neuropathy and have reported efficacy of treatment with intravenous immunoglobulin. Gamunex-C is an appropriate treatment in this patients case. All told, Gamunex-C is likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 32-year-old female enrollee has requested authorization and coverage for Gamunex-C. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is support for the requested medication in this patients case. The patient has been diagnosed with autoimmune small fiber neuropathy. As noted by Schofield and Chemali, Intravenous immunoglobulin therapy is U.S. Food and Drug Administration (FDA) approved for the immune-mediated peripheral nerve disorders Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. Immunoglobulin therapy has been used increasingly with significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are most often small fiber (autonomic and/or sensory) polyneuropathies. Intravenous immunoglobulin is used to treat a variety of autoimmune disorders, with a very good success rate. Thus, Gamunex-C is likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain.   The physician reviewer found the minimally invasive SI joint fusion has not been demonstrated to result in superior health outcomes for the treatment of back pain when compared to standard available treatment options. Further, this patients medical records do not show any evidence of SI joint instability, fracture, or tumor, thus the criteria for SI joint fusion are not met. This patient has chronic back pain after previous lumbar fusion surgery. The pain is likely degenerative in cause. For these reasons, the requested SI joint fusion 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 services are 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 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain.  The physician reviewer found according to the coverage criteria by the International Society for the Advancement of Spine Surgery (ISASS), specific criteria must be met for all patients treated with minimally invasive SI joint fusion. The criteria require documentation of significant SI joint pain, SI joint pain confirmed with at least three physical examination maneuvers that stress the SI joint, confirmation of the SI joint as a pain generator with 75% or greater acute decrease in pain upon fluoroscopically guided diagnostic intra-articular SI joint block using local anesthetic, failure to respond to at least six months of non-surgical treatment consisting of non-steroidal anti-inflammatory drugs and/or opioids and one or more of the following: rest, physical therapy, SI joint steroid injection, and failure to respond means continued pain that interferes with activities of daily living and/or results in functional disability, as well as a record that additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been ruled out. Although this patient meets most of these criteria, there is insufficient evidence of a recent visual acuity score (VAS) score, three physical exam maneuvers demonstrating SI joint pain and confirmation by recent injection that resulted in greater than 75% pain relief. Therefore, the requested SI joint fusion 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 services are 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 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain.   The physician reviewer found this patient meets the criteria for a minimally invasive SI fusion. In the peer-reviewed medical literature, Polly and colleagues reported on a randomized controlled trial of 148 patients treated with minimally invasive SI joint fusion using triangular titanium implants or nonsurgical treatment with follow-up at one year. The authors concluded that this level one study showed that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. In another recent study, Whang and colleagues found that six month follow-up from this level one study showed that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruptions. Based upon a review of the recent literature, the requested minimally invasive form of SI joint fusion 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 services are 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 Overturned

Summary Reviewer 

A 42-year-old male enrollee has requested authorization and coverage for the prescription medication Skyrizi 150 mg syringe. 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 according to the American Academy of Dermatology and the National Psoriasis Foundation, two leading authorities on psoriasis treatment, Skyrizi is a safe, effective and well-tolerated treatment of chronic plaque psoriasis. It is an immunoglobulin G (IgG) monoclonal antibody that neutralizes IL-17 and as such does not seem to have a significant effect on the pathogenesis of coronavirus infections. It is recommended as monotherapy for treatment of psoriasis. Methotrexate is an antimetabolite which can also work in treating psoriasis, but the efficacy and onset of action are not as good as compare with biologics.  Cyclosporine is only a short-term treatment for a chronic disease and would not be appropriate. Acitretin has inferior efficacy and risk profile to some of the biologic treatments. There is sufficient support for the requested medication in this clinical setting. Therefore, the prescription medication Skyrizi 150 mg syringe is medically necessary for the treatment of this patient.