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

Summary Reviewer 2

A 45-year-old male enrollee has requested authorization and coverage for radiofrequency ablation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that King and colleagues noted, aThe literature on sacral lateral branch interventions is sparse. One study demonstrates the face validity of multisite, multi-depth sacral lateral branch blocks for diagnosis of posterior sacroiliac complex pain. Some evidence of moderate quality exists on therapeutic procedures, but it is insufficient to determine the indications and effectiveness of sacral lateral branch thermal radiofrequency neurotomy, and more research is required.a Aydin and colleagues noted, aThe meta-analysis demonstrated that radiofrequency ablation is an effective treatment for sacroiliac joint pain at 3 months and 6 months. This study is limited by the available literature and lack of randomized controlled trials. Further standardization of RFA lesion techniques needs to be established, coupled with prospective randomized controlled trials.a This patient was being treated for chronic low back pain, lumbar spondylosis with radiculopathy, and sacroiliitis. He presented on 9/28/21 reporting almost complete relief of his low back pain from the sacroiliac joint injection on 6/18/21; however, the pain returned about two weeks after the injection, and gradually became severe again. He has current complaints of persistent pain in the left low back. The pain remains severe at 8/10, requiring him to continue to take medications. Examination reveals mild restriction of flexion and extension. There is tenderness to palpation at the lower lumbar levels spinous processes, and left paraspinal and gluteal musculature. There is moderate tenderness to palpation of the left posterior superior iliac spine. There is a positive left FABER test, thigh thrust and compressive tests. Strength testing reveals weakness of the left dorsiflexor at 4/5. Magnetic resonance imaging (MRI) is noted from 8/26/21 to show no change from prior examination on 4/29/19; interval spinal fusion at L5-S1. However, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There has been no literature consensus on which nerves are most appropriate to lesion. In addition, multiple other plausible pain generators (including at the lumbosacral spine) are evident. Therefore, the requested radiofrequency ablation is not likely to be more beneficial for treatment of the patient than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 45-year-old male enrollee has requested authorization and coverage for radiofrequency ablation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that Intra-articular steroid injection is a traditional approach to treating sacroiliac joint pain. For long-term pain relief, however, lesioning the sacral lateral branches may be a better approach. In a randomized, prospective study by Dutta and colleagues comparing the efficacy of intra-articular depo-methylprednisolone injection to that of pulsed radiofrequency ablation for sacroiliac joint pain, the radiofrequency ablation group demonstrated superior pain relief over the steroid injection group at 3-month and 6-month post-procedures. In addition, a recently completed multidisciplinary, multi-society effort to develop appropriate use criteria for sacroiliac interventions concluded that lateral branch radiofrequency neurotomy/radiofrequency ablation is an appropriate treatment for appropriately selected patients. There is sufficient support for the requested services in this clinical setting. Therefore, the requested radiofrequency ablation is likely to be more beneficial for treatment of the patient than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 50-year-old male enrollee has requested reimbursement for mandibular advancement device (E0486) provided on 12/14/18. The Health Insurer has denied this request and reported that the device at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the Health Insurer denied reimbursement for the device at issue claiming that the patient did not fail continuous positive airway pressure (CPAP) treatment as a first-line of treatment prior to use of the mandibular advancement device. The Health Insurer also noted that the patient did not qualify to be diagnosed with obstructive sleep apnea as his apnea-hypopnea index was 4 per hour, and his RDI was 12 per hour. The term RDI has been defined differently when used with portable monitors (home sleep study). Portable monitors are likely to underestimate the severity of events compared to the apnea-hypopnea index by polysomnography. The American Academy of Sleep Medicine recommends that providers consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. This recommendation supports the use of mandibular advancement device if the patient prefers it as a first-line of treatment even without showing intolerance to CPAP. Therefore, the mandibular advancement device provided on 12/14/18 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 48-year-old male enrollee has requested reimbursement for CPT code 84999 performed on 1/31/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees melanoma. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. Thus, CPT code 84999 performed on 1/31/18 was not medically necessary 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 21-year-old male enrollee has requested reimbursement for buprenorphine 74.2 mg implant provided on 9/29/18. The Health Insurer has denied this request and reported that the medication at issue was 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 medical records indicate the patient received two doses of the requested Probuphine as of 8/22/18. The current evidence indicates that standard treatment with this medication is two doses. Additional doses are not indicated per the medical literature. Therefore, buprenorphine 74.2 mg implant provided on 9/29/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 64-year-old male with a medical history including migraine headaches, hypertension, coronary artery disease and benign prostatic hypertrophy, who presented to the emergency department with complaints of a severe headache with chills. He had recently been admitted to the hospital from 10/08/19 through 10/10/19 with a diagnosis of a viral infection with severe headaches.  The physician reviewer found that at the time of admission, the patient was hemodynamically stable and afebrile with normal oxygen saturations on room air. The physical examination did not show any neurological deficits or altered mental status. His blood pressure had normalized with treatment in the emergency department. The laboratory studies did not show any active infection, significant electrolyte disturbance or end organ damage. Imaging was negative for acute disease or injury. There was no need for urgent procedures or surgical intervention. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patientas 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. Therefore, acute inpatient services at the step-down level of care from 10/11/19 through 10/13/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 23-year-old male enrollee has requested reimbursement and prospective authorization and coverage for substance abuse partial hospitalization program (PHP) services provided from 5/28/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees opiate dependence and depression.The physician reviewer found that the American Psychiatric Association (APA) treatment guidelines recommend that PHP treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance uselack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. As documented in this patients case notes, he has poor coping skills, is impulsive, has low self-esteem, and demonstrates a pattern of being unable to abstain from drugs and alcohol as evidenced by multiple treatment episodes. Consistent with the American Society of Addiction Medicine (ASAM) criteria, he requires safe and stable living environments in order to develop recovery skills, and the services at the PHP level of care are thus appropriate. All told, the PHP services provided from 5/28/15 forward were and are medically necessary for treatment of this patients medical condition.Therefore, the Health Insurer's denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 51-year-old female enrollee has requested reimbursement for MRI performed on 8/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The first appropriate imaging for the evaluation of low back pain with radicular symptoms is lumbar radiograph. According to the American College of Radiology, if the pain persists after four to six weeks of conservative management, and the patient is a surgical or intervention candidate, then MRI of the lumbar spine is the usually appropriate next examination. This patient had low back pain with associated left radiculopathy symptoms for nine months. She failed conservative management, including massage and chiropractic therapy. Therefore, MRI of the lumbar spine was an appropriate examination. Thus, MRI performed on 8/08/18 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 16-year-old female enrollee has requested reimbursement for residential treatment center services from 5/28/16 through 6/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records available for review noted that the patient was receptive to interventions and actively participated in treatment and programming. The resident complied with her meal plan overall. Per the discharge summary, the patient endorsed the self-harming instances in an attempt to prolong her stay in the treatment center. A comparison of medications from 5/18/16 to discharge indicated that these medications could have been administered at an outpatient setting and did not necessitate residential treatment. All told, there is no indication from the reviewed records to reflect that this patient could not have been transitioned to a lower level of care during the period in dispute. Therefore, for the reasons stated above, the services at issue were not medically necessary for treatment of this patient. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 63-year-old female enrollee has requested authorization and coverage for acute rehabilitation admission. 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 the submitted documentation supports the requested services in this clinical setting. This patient has been diagnosed with a stroke secondary to a subarachnoid hemorrhage affecting the left frontoparietal and temporal region, resulting in aphasia and right-sided paresis. The patient is right-sided dominant and is therefore limited from performing activities of daily living. She is likely to benefit from speech therapy as well as occupational and physical therapy services that would be provided in a rehabilitation facility. It has become the standard of care to refer patients who experience a stroke to a rehabilitation facility. Therefore, the requested acute rehabilitation admission is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 48-year-old male who reports left leg pain. The patient has requested authorization and coverage for endovenous ablation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the documentation supports the medical necessity of the requested services. The records note pain in the left lower extremity that is impacting the patients quality of life and activities. There is documentation of significant reflux in the vein to be treated and an absence of deep vein thrombosis. There is documentation of adequate arterial perfusion to the lower extremities bilaterally. Additionally, the notes document that the symptoms have been recalcitrant to conservative efforts. Therefore, the requested endovenous ablation is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 35-year-old male enrollee has requested authorization and coverage for bariatric surgery and one day inpatient admission. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees morbid obesity. The physician reviewer found that this patient meets all nationally accepted criteria for bariatric surgery including the American Society for Metabolic and Bariatric Surgery. This patient is an adult that is morbidly obese with a BMI of 52 kg/m2. The patient has failed dietary efforts including more than six months of supervised weight loss. The patient completed a comprehensive multidisciplinary evaluation that did not reveal any obvious dietary, psychological or medical barriers to surgery. The patient has no correctable causes of obesity and has demonstrated ongoing reliable participation in preparatory program. The provider as included an attestation regarding compliance to a long-term program with diet, multidisciplinary program, lifestyle changes and follow-up. Given these findings, the requested bariatric surgery and one day inpatient admission are supported as medically necessary for treatment of this patients medical condition. Based on the foregoing, 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 Upheld

Summary Reviewer 1

A 48-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 10/15/20. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient had a rising CA-19-9 and Guardant360 cell-free DNA testing was ordered. According to the National Comprehensive Cancer Network (NCCN) guidelines on pancreatic cancer, aTesting on tumor tissue is preferred; however, cell-free DNA testing can be considered if tumor tissue testing is not feasible.a This case is clinically complex since biomarkers are indicating cancer recurrence, yet there is no obvious tumor mass to be found on imaging despite a rigorous search. The NCCN guidelines goes on to say, aData are not available to show that earlier treatment of recurrences, following detection by increased tumor marker levels or CT scan, leads to better patient outcomes.a The Guardant360 test is a liquid biopsy that analyzes patient plasma for mutations in a panel of 70 genes. In this case, the Guardant360 test was not done to analyze mutational analysis of an existing recurrence or an existing mass. Instead, it was performed to look for recurrence. This is not an appropriate use of the test. Therefore, Guardant360 testing performed on 10/15/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 48-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 10/15/20. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that liquid biopsies are tests conducted on blood samples that examine biomarkers shed by tumors, such as cancer cells or pieces of tumor DNA. It is used at the time of diagnosis or with tumor recurrence, as cells shed from tumor can be detected in lieu of additional biopsy. At the time that this patient had Guardant360 testing, computed tomography (CT) scan was read as showing no evidence of metastatic disease. Continued surveillance with liquid biopsy performed at the time of documented recurrence would be more likely to yield accurate results. Therefore, Guardant360 testing performed on 10/15/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 48-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 10/15/20. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that Guardant Assay is a multigene assay done on the DNA found in blood, presumably shed by cancer cells. In many cancer situations, such as in non-small cell lung carcinoma, it is important to ascertain a variety of mutations, as each may have treatment implications. Generally, it is preferable to assay these genomic changes from a tissue biopsy. However, if this is not feasible or safe, serum based assays are acceptable. This patient had already had a panel assay (Caris) from a tissue sample. In this case, it appears as if Guardant360 was being used to determine if there was cancer recurrence. The medical evidence does not support the services at issue in this setting. If the assay is being used to select a specific treatment, the chances of this being beneficial is very low. Therefore, Guardant360 testing performed on 10/15/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 21-year-old male, who is under evaluation and management for gastroesophageal reflux disease (GERD). The patient has been treated with lansoprazole and pantoprazole. A recent upper endoscopy was normal, except for an irregular Z-line. The patient underwent a 96-hour esophageal power of hydrogen study and had a low prevalence of acidic reflux on each of the days. There are no episodes of long reflux. An esophagram confirmed the absence of a hiatal hernia. The patient has requested authorization and coverage for the esophageal sphincter augmentation device (CPT code 43284). The Health Insurer has denied this request as investigational. According to the documentation submitted for review, there is a lack of evidence demonstrating the patient has a very low percentage acid exposure time (AET) of the esophagus, with very brief reflux episodes. In addition, in a young male patient, especially with refractory GERD symptoms, biopsies of the proximal and distal esophagus should be done to rule out eosinophilic esophagitis. The records do not indicate that these biopsies have been completed. Therefore, based on the clinical record, the request for esophageal sphincter augmentation device (CPT code 43284) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld.