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

Summary Reviewer 


A 57-year-old female enrollee has requested reimbursement for partial hospitalization from 8/4/16 through 8/17/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is sufficient support in the medical literature for the services at issue in this clinical setting.  In general, community intervention settings offer optimization of treatment gains. However, transient placement in more restrictive settings is often clinically appropriate, as in this patients case. In this particular case, the treatment team recommended continued treatment at the partial hospital level of care. The treatment team noted that the patient did not command the skills needed to maintain weight and function with full autonomy in the outpatient setting. The treating team justified their determination within context of the partial hospital level of care guidelines developed by the American Psychiatric Association. Factors that warrant partial placement based on the assessment included patient status and environmental support, psychiatric comorbidity, preoccupation with intrusive repetitive thoughts, and the need for structure to help with weight management and dietary habits. On 8/4/16, the patient was demonstrating rigidity regarding her meal plan.  She took small bites and took five minutes to finish the final bites of a sandwich.  She was passive-aggressive in her attempts to bypass programmatic procedures and became irritated when called out. On 8/6/16, her anxiety spiked upon learning that her daughter had attempted suicide. On 8/8/16, she became panicked after the sensation of having food stuck in her esophagus, and was unable to eat afterwards.  On 8/9/16, the patient reported more intense urges to exercise and restrict her diet.  Additionally, the patients serotonergic medication was changed and benzodiazepine was reduced, while gabapentin, trazodone and atenolol were added. Considering these factors, the patient had not consolidated the treatment gains necessary to follow a meal plan and maintain a healthy weight in a less restrictive setting. She was at risk for undue morbidity and admission to a higher level of care in the absence of partial hospitalization.  The setting was safe, appropriate and consistent with good medical practice. The patient received services that were reasonably expected to improve her condition and prevent a more serious episode of illness. As such, the services at issue from 8/4/16 through 8/17/16 were consistent with community standards and afforded opportunity for aggressive medication changes and arrangement of comprehensive aftercare in her community.  Therefore, for the reasons stated above, the services at issue were 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 patient is a 41-year-old male with chronic migraine. On 10/16/17, Botox injections were provided. He reported 15 headaches per month lasting more than four hours associated with migraine symptoms at the start of treatment. The patient has requested reimbursement for Botox injections provided on 10/16/17 and 1/08/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.  The use of Botox is indicated for the treatment of chronic headaches in individuals who have at least 14 headache days per month. This patient reports that he experiences 15 headache days per month. Furthermore, Botox has been approved by the U.S. Food and Drug Administration for the treatment of migraines. Therefore, Botox injections provided on 10/16/17 and 1/08/18 were likely to be more effective than other treatment options. Based upon the information set forth above, the services at issue were 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 patient is a 41-year-old male with a history of migraines. Headaches vary in location from frontal to lateral. The quality of the headache is described as throbbing with moderate to high severity. The patient has tried several prophylactic therapies which have failed to control his headaches. He has requested reimbursement for Botox injections provided on 10/16/17 and 1/08/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.  Botox is a tool in the management of chronic migraine which has shown effectiveness. Repeated onabotulinumtoxinA treatments have been shown to be safe and well-tolerated. Botox has been approved by the U.S. Food and Drug Administration (FDA) for use in prophylactic management in chronic migraine. This patient fits the criteria for chronic migraine. He has failed a number of accepted preventable therapies, including medications within the anti-hypertensive, antiepileptic, and antidepressant classes. In sum, Botox injections provided on 10/16/17 and 1/08/18 were likely to have been superior over other treatment modalities. Based upon the information set forth above, the services at issue were 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 patient is a 41-year-old male with a diagnosis of chronic migraine. He has been on multiple antidepressant medications. The patient has also been treated with amlodipine and topiramate. A headache diary confirms the presence of chronic daily headache. The patient has requested reimbursement for Botox injections provided on 10/16/17 and 1/08/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.  The medical evidence supports the services at issue in this clinical setting. This patients records support the diagnosis of chronic migraine. He has already been on several preventive agents. Botox injections was appropriate in this patients case. Thus, Botox injections provided on 10/16/17 and 1/08/18 were likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the services at issue were 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 

The patient is a 30-year-old male with a history of gynecomastia. Therefore, the patient has requested authorization and coverage for suction assisted lipectomy, trunk (CPT 15877) and mastectomy, simple complete (CPT 19303). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the case was previously reviewed, and additional documentation was submitted for reconsideration. Additional medical information received for review included an email from the provider indicating that a surgical facility charges for liposuction for time and supplies, and there would still be a charge even if he charged no professional fee.  On 5/09/20, the provider noted, aThe bilateral breasts demonstrate Simon Grade IIa gynecomastia. There are tender subareolar masses bilaterally measuring approximately 2 cm x 3 cm x 3 cm.a He also reported that the patient adesires surgical excision of gynecomastia in addition to potential suction lipectomy.a The American Society of Plastic Surgeons reports the following gynecomastia scale adapted from the McKinney and Simon, Hoffman and Kohn scales: grade I a small breast enlargement with localized button of tissue that is concentrated around the areola; grade II - moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest; grade III -moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present; grade IV - marked breast enlargement with skin redundancy and feminization of the breast. In this case, photographs demonstrate chest enlargement that significantly exceeds the 2 cm x 3 cm x 3 cm size of the glandular tissue, so that the chest enlargement constitutes mixed gynecomastia, with a mixture of both true glandular gynecomastia and fatty tissue constituting pseudogynecomastia. There is no change in determination that liposuction is an optional surgical technique that can be used during gynecomastia surgery and is not a separate surgical procedure for the patient for treatment of gynecomastia. Liposuction of the chest area well beyond the limited area of the gynecomastia excision can be performed for improved cosmetic appearance, particularly when the gynecomastia is mixed and there is some degree of pseudogynecomastia present. Liposuction for that purpose would be cosmetic and not medically necessary. Thus, suction assisted lipectomy trunk (CPT 15877) is not medically necessary as a separately billed procedure. CPT 19303 is not medically necessary because it applies to a mastectomy in a woman. In sum, suction assisted lipectomy, trunk (CPT 15877) and mastectomy, simple complete (CPT 19303) are not medically necessary for the treatment of this patient. The Health Insurer has approved the appropriate CPT code in this case (CPT code 19300).
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 42-year-old male enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back and left lower extremity pain.   The physician reviewer found according to the providers notes, the patient previously underwent lumbar medial branch blocks and lumbar RFA in the past. The records indicate that the patient underwent lumbar medial branch blocks successfully and then underwent lumbar RFA. The prior RFA provided over one year of pain relief. Given this patients treatment history, repeated lumbar medial branch blocks are not needed prior to repeat RFA. Therefore, the requested RFA 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


A 42-year-old male enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back and left lower extremity pain.   The physician reviewer found that evidence based clinical practice guidelines for performing radiofrequency neurolysis are consistent with the treatment plan following this patients care (Manchikanti, et al). It is important to note that radiofrequency neurolysis is not permanent as the nerves re-grow. Typically, the lesions produce up to one year of pain relief (Choi, et al). Given that this patients provider followed the treatment paradigm for managing this patients care and properly administered medial branch blocks with the previous radiofrequency ablation, the requested repeat radiofrequency ablation is likely to provide this patient with a superior health outcome as compared to standard available treatment options. 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 3

A 42-year-old male enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back and left lower extremity pain.   The physician reviewer found that in the documentation available for review, the provider does not document a pain diary for a medial branch block performed prior to the previous radiofrequency ablation. The current peer-reviewed medical literature is clear about how a diagnostic medial branch block is supposed to be done prior to radiofrequency ablation with use of a pain to verify when the local anesthetic wore off (Derby, et al). In the absence of this information, the requested repeat radiofrequency ablation cannot be supported as 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 Overturned

Summary Reviewer 1

The parent of a 13-year-old male enrollee has requested authorization and coverage for Privigen. 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 this patient has a history of PANS and current documented autoimmune encephalitis. He has been under the care of numerous specialists, with multiple hospitalizations, psychiatric admissions, and almost two months at a long-term care facility. Despite treatments with steroid burst, psychotherapy, and numerous psychoactive medications, he continued to have severe symptoms, including oppressive suicidal ideation. Only after beginning treatment with appropriately dosed IVIG have the neuropsychiatric symptoms started to recede. Therefore, Privigen is likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of a 13-year-old male enrollee has requested authorization and coverage for Privigen. 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 IVIG has potential risks associated with its use. Katz and colleagues noted, Most adverse effects are mild and transient including headaches, flushing, fever, chills, fatigue, nausea, diarrhea, blood pressure changes and tachycardia. IgA deficiency-related anaphylactic reactions are largely preventable. Late adverse events are rare and include acute renal failure and thromboembolic events. There remains significant debate regarding the diagnosis and treatment of PANDAS and PANS. In sum, Privigen is not likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The parent of a 13-year-old male enrollee has requested authorization and coverage for Privigen. 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 while PANDAS is not a diagnosis that has held up to careful scrutiny, autoimmune encephalitis with a vast range of neuropsychiatric symptomatology has. Additionally, the diagnosis of methylene tetrahydrofolate reductase (MTHFR) deficiency may manifest as isolated neuropsychiatric disease.  Given that this patient has been closely followed for MTHFR and will continued to be monitored for homocysteinemia and treated appropriately with B9, B12 and betaine if this becomes problematic, his clinical response to Privigen (IVIG) has been sufficient to justify its continued use for his recurrent neuropsychiatric symptomatology that is presumably due to his autoimmune encephalitis. There is support for the requested medication in this clinical setting. Thus, Privigen is likely to be more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 50-year-old male enrollee has requested reimbursement for MRI of the pelvis without and without dye performed on 7/24/18. 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 clinical model for the approach to diagnosing prostate cancer is quickly moving towards the use of MRI targeted biopsy. The medical evidence indicates the superiority of this modality compared to traditional biopsy, resulting in a decrease in the number of false negative results, improved tumor characterization and localization, as well as better treatment planning. According to the American College of Radiology appropriateness criteria in the setting of clinically suspected prostate cancer in a patient without history of prior biopsy, MRI with subsequent targeted biopsy is considered usually appropriate. In this case, the patient had clinically suspected prostate cancer given his elevated PSA and strong family history. Therefore, MRI prior to prostate biopsy was indicated. Therefore, MRI of the pelvis with and without dye performed on 7/24/18 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 37-year-old female enrollee has requested authorization and coverage for an implanted electrical stimulator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees pain. The physician reviewer found that there is a lack of support for the requested device in this patients case. The records do not document a nonsteroidal anti-inflammatory drug trial. There is no surgical consultation that addresses the extruded disc in her neck. While there is literature supporting the use of cervical spinal cord stimulator for cervical radiculopathy, there are several available alternatives before embarking on spinal cord stimulation. Therefore, the implanted electrical stimulator is not likely to be more effective than other treatment options. Based upon the information set forth above, the requested device 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 37-year-old female enrollee has requested authorization and coverage for an implanted electrical stimulator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees pain. The physician reviewer found that there is support for the requested device in this patients case. This patient has ongoing cervical radiculopathy despite cervical spine surgery, and she has failed postoperative measures, including medication management and activity modification. The requested device is standard of care for the treatment of the patients medical condition. In sum, the requested implanted electrical stimulator is likely to be more effective for treatment of the patients condition than other available 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 Upheld

Summary Reviewer 3

A 37-year-old female enrollee has requested authorization and coverage for an implanted electrical stimulator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees pain. The physician reviewer found that the medical records fail to demonstrate the superior efficacy of the requested device. It is unclear if other standard treatment options for neck and shoulder pain have been done. General statements of undergoing all conservative treatment measures available without specific names, duration with quantities, and results, is insufficient. The medical records indicate that other treatment options have not been exhausted. There are other standard treatment options that are not invasive or permanent, that have not been documented to have been tried and failed. Finally, no mention of the completion of behavior therapy has been documented despite research to support its use. Thus, the requested implanted electrical stimulator is not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested device 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 1

A 46-year-old female enrollee has requested authorization and coverage for ketamine infusion and one day inpatient stay. The Health Insurer has denied this request indicating that the requested services are considered experimental/investigational for treatment of the enrollees peripheral neuropathy status post chemotherapy treatment. The physician reviewer found the requested services are not likely to be more effective for this patient than other available treatment options. There is insufficient evidence in the peer-reviewed literature to support the use of ketamine for the treatment of neuropathic pain conditions. Moreover, the safety of long-term use of ketamine has also not been established. Therefore, ketamine infusion is not likely to be more beneficial for treatment of the patients neuropathic pain than other available standard treatments. 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.