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

Summary Reviewer 


A 24-year-old female enrollee has requested authorization and coverage for lymph node transfer procedure. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees lymphedema of the left lower extremity. The physician reviewer found that there is sufficient support in the medical literature for the requested procedure in this clinical setting. The patient has well documented evidence of continued lymphedema of the left lower extremity following a left inguinal node biopsy for treatment of angiomyomatous hamartoma. She is documented to have initiated control of her condition with commonly used modalities, including compression garments, pump, physical therapy and elevation. She has had two previous episodes of cellulitis with sepsis. Her examination documentation support that she has a condition of significant lymphedema that has not resolved but has progressed despite standard of care modalities.  Although her most recent documentation supports that she has improved lymphedema, she still has been documented to have complete obstruction of her deep lymphatics with shunting. Lymphedema treatment can be a difficult problem. The medical literature suggests that all attempts at standard of care management should be exhausted prior to any complex treatment.  Current standard of care management has failed in this patient.  Once lymphedema has begun, it can be difficult to treat and control nonoperatively. Thus, one must look to other forms of treatment when nonoperative measures have failed.  Over the years, there have been surgical techniques that have been developed for treatment. These options include lymph node transfer, some form of lympho-vascular anastomosis/bypass and lymphatic liposuction. There is support in the medical literature for the requested procedure. Given her significant history of cellulitis and sepsis, the procedure of lymph node transfer would benefit this patient.  There is enough evidence in the documentation provided as well as in the medical literature to support surgical intervention. In summary, standard available therapy has failed to resolve this patients lymphedema. She has already had severe infection associated with her lymphedema.  Therefore, lymph node transfer is medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 54-year-old female enrollee has requested reimbursement for acute hospital stay from 12/30/17 through 2/11/18. 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. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. At the time of admission, the records did not document that she required frequent treatment with intravenous analgesic medication. The documentation did not indicate an emergent need for surgical intervention. The current medical evidence does not support the services at issue in this clinical setting. Therefore, acute hospital stay provided from 12/30/17 through 2/11/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 36-year-old male enrollee has requested reimbursement for monitored anesthesia provided during a colonoscopy on 4/30/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  There is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, monitored anesthesia was not medically necessary for the treatment of this patient.  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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 36-year-old male enrollee has requested reimbursement for acute inpatient psychiatric treatment provided from 2/12/16 through 2/23/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a threat to himself or others.  Although grandiose, he demonstrated no overt psychosis.  He did not attest to visual hallucinations or auditory hallucinations.  No delusions were apparent, and he was medically stable.  He was goal-directed.  The patient was cooperative with his medication regimen and tolerated it well.  He was deemed to be no elopement risk.  During the dates of service in dispute, he no longer required inpatient treatment and could have been treated at a lower level of care.  All told, acute inpatient psychiatric treatment provided from 2/12/16 through 2/23/16 was not medically indicated for the treatment of this patient.  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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 45-year-old male who has requested reimbursement for procedure code 81599 performed on 7/06/20. Pathology from a shave biopsy of the left lateral temple on 6/11/20 showed a malignant melanoma, Breslow depth at least 3.8 mm, with ulceration present. On 7/06/20, DecisionDx-Melanoma testing was performed. The Health Insurer has denied reimbursement for the services at issue. Per the Health Insurer, procedure code 81599 performed on 7/06/20 was not medically necessary for the evaluation of this patient.  The physician reviewer found that prognostic gene expression profiling (GEP) testing to differentiate melanomas at low versus high risk for metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive result, GEP testing should not guide clinical decision making in this group. It remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. It remains unclear whether this GEP profile is reliably predictive of outcomes across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Use of this testing is not recommended by the National Comprehensive Cancer Network guidelines. Therefore, procedure code 81599 performed on 7/06/20 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 68-year-old female enrollee has requested reimbursement for human epididymis protein 4 (HE4) testing performed on 9/20/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that human epididymis protein 4 (HE4) is a blood tumor marker that is often used in the management of ovarian carcinoma. There has been interest in applying HE4 in the management of endometrial cancer, particularly the endometrioid variant, as seen in this patients case. In 2019, Li and colleagues demonstrated that HE4 is superior to CA-125 in the detection of endometrial cancer. In 2015, Li and colleagues demonstrated that the level of HE4 correlates with prognosis. Plotti and colleagues reviewed 49 articles relevant to this issue, and the authors reported that HE4 was promising in endometrioid endometrial cancer. Therefore, HE4 testing performed on 9/20/18 was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 68-year-old female enrollee has requested reimbursement for human epididymis protein 4 (HE4) testing performed on 9/20/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. In patients with endometrial cancer, human epididymis protein 4 (HE4) has been described as a potential marker for deep myometrial invasion and for advanced-stage disease. However, the sensitivity and specificity is not well-documented, and normal values are still being delineated. Routine testing is not considered a standard of care for surveillance and is unlikely to change outcomes in determining recurrence of disease. In sum, HE4 testing performed on 9/20/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 68-year-old female enrollee has requested reimbursement for human epididymis protein 4 (HE4) testing performed on 9/20/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that for patients with localized endometrial cancer, if the patient has elevated CA-125 at the time of initial diagnosis, then current National Comprehensive Cancer Network guidelines recommend serial testing of serum CA-125 for recurrence monitoring.  Multiple other serum proteins expressed by endometrial cancer are currently being investigated as possible markers for recurrent disease, including human epididymis protein 4 (HE4). Secreted HE4 has been extensively studied as a serum biomarker for proposed uses for either screening, detection of recurrence or monitoring of therapeutic response for ovarian cancer. Secreted HE4 is also associated with endometrial cancer, and continues to be studied as a potential biomarker for differentiating between malignant and benign pelvic masses, screening for malignancy, prognosis, recurrence detection, and therapeutic response. However, it is not currently accepted as a standard of care for patients with endometrial cancer. The study by Abbink and colleagues compared HE4 to the standard of care marker CA-125. Although the authors indicated the possibility of superior performance of HE4 compared to CA-125 for detection of recurrence in patients with endometrial cancer, they also noted that a future prospective study on a larger cohort of patients with endometrial cancer is needed to affirm the preoperative value of serum HE4 and the use of HE4 in routine follow-up. At this time, the superior efficacy of the services at issue has not been established. Thus, HE4 testing performed on 9/20/18 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 54-year-old female enrollee has requested authorization and coverage for panniculectomy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation establishes the medical necessity of the requested surgery. In this case, the patient presents with evidence of a symptomatic lower abdominal pannus in the setting of a need for repair of a ventral and incisional hernias. Her symptoms include skin breakdown over the lower aspect of the abdomen in the region of the groins and vertical scarring. In addition, the surgical plan of panniculectomy is to allow for greater exposure of the hernias for repair and to assist in the healing of the abdominal wall reconstruction, presumably by placing the incision in an area not directly overlying the hernias. Photographs support that the lower abdomen is a source of her functional issues. According to Manahan and colleagues The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms. This is the case for this patient and thus, panniculectomy is medically necessary for treatment of the patients medical condition. Given the above reasons, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The parent of a 12-year-old male enrollee has requested authorization and coverage for functional electrical stimulation RT300 therapy system.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees incomplete paraplegia. The physician reviewer found there is sufficient support for the requested device in this clinical setting.  This patient has a complicated medical condition that affects his activities of daily living as well as physical and psychosocial development as he matures into adulthood.  Since this patients condition is thought to not to be autoimmune mediated, standard immunotherapy and anti-inflammatory therapies would not be beneficial.  In this patients case, treatment is relegated to regaining as much function as possible.  Standard therapy in this case would be both active and passive physical therapy which the patient has already been receiving.  The medical evidence supports functional electrical stimulation in this patients case.  All told, the requested functional electrical stimulation RT300 therapy system is likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested device 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of a 12-year-old male enrollee has requested authorization and coverage for functional electrical stimulation RT300 therapy system.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees incomplete paraplegia. The physician reviewer found transversemyelitis is a neurological disorder caused by inflammation across both sides of one level of the spinal cord.  The inflammation can damage or destroy myelin.  Symptoms of transverse myelitis include a loss of spinal cord function.  What usually begins as a sudden onset of lower back pain, muscle weakness, or abnormal sensations in the toes and feet can rapidly progress to more severe symptoms, including paralysis, urinary retention, and loss of bowel control.  Although some patients recover from transverse myelitis with minor or no residual problems, others have permanent impairments that affect their ability to perform tasks of daily living.  Functional electrical stimulation applies small electrical pulses to paralyzed muscles to restore or improve their function.  Functional electrical stimulation is used in neurologically impaired individuals, including those with spinal cord injury and stroke, to stimulate muscles during activity.  Per the medical evidence, functional electrical stimulation can minimize contractures and can decrease spasticity.  The current medical evidence supports the requested device in this clinical setting.  In sum, the requested functional electrical stimulation RT300 therapy system is likely to be superior over other treatment alternatives.  Based upon the information set forth above, the requested device 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


The parent of a 12-year-old male enrollee has requested authorization and coverage for functional electrical stimulation RT300 therapy system.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees incomplete paraplegia. The physician reviewer found the requested device is likely to be more effective than other options for treating this patient.  There have been a number of studies reporting the benefits and utility of functional electrical stimulation cycling in patients with spinal cord injury.  The study by Johnson and colleagues demonstrated that cycling with functional electrical stimulation led to gains in oxygen uptake when compared to passive cycling alone.  Per the submitted documentation, the patient has demonstrated good response to initial trials with the requested device.  Based on the literature, his clinical history, and his response to a trial evaluation, the requested functional electrical stimulation RT300 therapy system is likely to be more effective than other treatment modalities.  Based upon the information set forth above, the requested device 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 55-year-old female enrollee has requested authorization and coverage for Sirturo. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees mycobacterium avium-intracellulare complex (MAC). The physician reviewer found the submitted documentation fails to demonstrate that the patients medical condition meets medical necessity criteria for the requested medication, Sirturo. Sirturo is U.S. Food and Drug Administration (FDA) approved for treatment of drug resistant tuberculosis (TB) resistant to INH and Rifampin; the patients records do not show that she has drug resistant TB. Furthermore, Sirturo has potential adverse cardiac effects (Sirturo Prescribing Information). Moreover, medical studies evaluating the use of Sirturo for treatment of MAC are limited. A study by Philley and colleagues involving patients with atypical mycobacteria who were treated with Sirturo included only 10 patients, and was not blinded, randomized or controlled. Finally, the record indicates that the patients MAC appears stable on CT scan. All told, the requested medication is not medically necessary for treatment of the patients medical condition. Based on the submitted documentation and per accepted clinical guidelines, the requested medication is 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 12-year-old male enrollee has requested authorization and coverage for Remicade 400 mg for two weeks and then once monthly for one year. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees juvenile dermatomyositis (JDMS). The physician reviewer found remicade is likely to be more effective for this patient than other available treatment options. This patient has JDMS and has been treated with numerous treatments, which have been either ineffective or partially effective. The patient was doing better while on IVIG, but developed headaches after the infusions, which is a common side effect. After stopping IVIG, the patient has become weaker with his creatine kinase (CK) levels increasing. The medical literature supports infliximab for the treatment of refractory myositis demonstrating beneficial effect with improved motor strength, decrease in fatigue, and a decrease in CK. Thus, infliximab is clinically indicated for this patient with JDMS and 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of a 12-year-old male enrollee has requested authorization and coverage for Remicade 400 mg for two weeks and then once monthly for one year. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees juvenile dermatomyositis (JDMS). The physician reviewer found in this case, the patients current treatment consists of two oral disease modifying agents, CellCept and methotrexate for a diagnosis of juvenile dermatomyositis. The documentation submitted for review fails to provide supporting evidence of active disease at this time. There is a lack of evidence demonstrating active vasculitis or active inflammatory muscle disease. On the basis of this lack of documentation, escalation of therapy with an additional agent is not warranted and Remicade is not clinically indicated. As such, the request for Remicade is not likely to be more beneficial than other modalities. 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.