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

Summary Reviewer 

A 60-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) scan of the shoulder. The Health Insurer has denied this request indicating that the requested services are not medically necessary for the evaluation of the enrollees shoulder pain. The physician reviewer found that the submitted documentation does not support the medical necessity of the requested services in this clinical setting. The American College of Radiology (ACR) has established appropriateness criteria to evaluate various clinical presentations. The ACR recommends obtaining plain x-rays as a first line evaluation of shoulder pain. The next study recommended is MRI. However, in this patients case, MRI is not medically indicated at this time. It is unclear how recent the trauma occurred and it would be expected that an MRI might show changes of wear and tear. Similarly, in a study by Schwartzberg and colleagues, they found a high rate of superior glenoid labral tear diagnoses based on MRI in a cohort of middle-aged, asymptomatic people. The study indicated that rotator cuff tears or labral tears are common, especially in the elderly, and that it is important to remember that their presence does not always impute pain or clinically significant loss of function.  This study reaffirms that magnetic resonance findings are not necessarily an explanation for the patients symptoms. In this patients case, he has not undergone a trial of intensive conservative management.  Three months of conservative treatment with persistence of symptoms is not unreasonable. All told, MRI of the shoulder is not medically necessary for the evaluation of this patient. Therefore, for the reasons stated above, the requested services are 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 55-year-old female enrollee has requested authorization and coverage for Xeljanz XR (tofacitinib extended release) 11 mg tablets, #30 per 30 days. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriatic arthritis. The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. The U.S. Food and Drug Administration (FDA) package insert for Xeljanz notes that the use of Xeljanz/Xeljanz XR is not recommended in combination with biologic disease-modifying antirheumatic drugs or potent immunosuppressants. In this case, the patient has a history of peripheral or non-axial psoriatic arthritis and systemic lupus. Tumor necrosis factor inhibitors would be contraindicated in her case. Per the medical evidence, the use of Xeljanz is not recommended in this case, as it will be used with CellCept. There are a lack of studies in the literature demonstrating the efficacy and safety of the requested medication when used in conjunction with other immunosuppressive agents, to include CellCept. Although a tumor necrosis factor inhibitor would not be recommended, there are other agents which have not been utilized in this case. As such, for Xeljanz XR (tofacitinib extended release) 11 mg tablets, #30 per 30 days is not medically necessary for the treatment of this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 43-year-old female enrollee 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 the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has symptomatic left great saphenous vein reflux. The vein measures 5.2 mm, and there is reflux of 2 seconds. The clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum recommend a cutoff value of 1 second for abnormally reversed flow (reflux) in the femoral and popliteal veins and of 500 ms for the great saphenous vein, the small saphenous vein, the tibial, deep femoral, and the perforating veins. The current medical evidence supports the requested services in this clinical setting. Therefore, endovenous ablation is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 58-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/10/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings to radiologists interpreting mammograms especially in patients with heterogeneously dense tissue such as the patient in this case. Tomosynthesis allows radiologists to separate dense glandular elements form underlying mass and architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional imaging protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Based upon the information set forth above, the services at issue were 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


A 58-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/10/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the breast tomosynthesis performed on 2/10/16 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two dimensional (2D) and three dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the documentation submitted for review and medical literature, the use of breast tomosynthesis 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 services at issue were 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


A 58-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/10/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Given the support in the medical literature, the breast tomosynthesis performed on 2/10/16 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 services at issue were 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 30-year-old male enrollee 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 the enrollees medical condition. The physician reviewer found that Arya and colleagues stated, True gynecomastia refers to enlarged glandular tissue rather than deposition of fat tissue. Enlargement of breast due to deposition of fat in the breast area is known as pseudogynecomastia. Bellini and colleagues stated, In pseudogynecomastia, there is an increased development of the fatty component in the male breast region. In true gynecomastia, however, there is an increase in volume of the male breast gland with a dense fibrous and vascular stroma, which makes suction more difficult. The gynecomastia liposuction treatment is usually associated to a resection under direct vision of the glandular tissue through a periareolar or transareolar incision. Innocenti and colleagues stated, in regard to excision of gynecomastia, that If necessary, liposuction of the peripheral fatty tissue was usually performed. Liposuction for chest contouring of fatty tissue can be performed in addition to direct excision of glandular gynecomastia for an improved cosmetic result on the entire chest. Liposuction around the glandular tissue is not a separate technique but is rather a more efficient method of fat excision. Fatty tissue removal around the glandular tissue for contouring is an included part of excision of gynecomastia. It is not a separate procedure. Extensive liposuction to the anterior chest for removal of pseudogynecomastia and general chest contouring is not medically necessary and is a cosmetic procedure. Suction assisted lipectomy trunk (CPT 15877) is not medically necessary as a separately billed procedure. In this case, the Health Insurer declined coverage for 19303 because the code is for a mastectomy in a woman. However, the Health Insurer did approve 19300 on appeal because that applied to a mastectomy for gynecomastia in a male. CPT 19303 is not medically necessary because it applies to a mastectomy in a woman. Therefore, suction assisted lipectomy, trunk (CPT 15877) and mastectomy, simple complete (CPT 19303) are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 34-year-old male enrollee has requested authorization and coverage for computed tomography (CT) of the abdomen and CT of the chest (74178 and 71270). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that there is agreement by the National Comprehensive Cancer Network, which noted, A PET-CT scan should be performed to confirm complete remission (CR). Patients in CR should receive clinical follow-up with a history and physical examination and laboratory studies (e.g., complete blood cell count, comprehensive metabolic panel, lactate dehydrogenase level) every three to six months for five years and then yearly or as clinically indicated. Imaging studies (CT scan) should be performed no more often than every six months for two years after the completion of treatment, and then only as clinically indicated. Considering these many studies and advising bodies, the requested services are not medically indicated. Therefore, CT of the abdomen and CT of the chest (74178 and 71270) are not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 73-year-old male enrollee has requested reimbursement for targeted genomic sequence analysis (81445). 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 this patient has metastatic non-small cell lung cancer. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care for patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. This patient has progression of disease after prior therapy including with immunotherapy. The medical evidence supports the services at issue in this clinical setting. Therefore, targeted genomic sequence analysis (81445) performed on 4/17/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 68-year-old female enrollee has requested authorization and coverage for iStent placement (times two).  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation supports a portion of the services at issue.  The use of iStent implantation in this case is likely more beneficial than any other standard therapy.  However, there is a lack of evidence in the medical literature that simultaneous placement of two iStents is appropriate.  The patient had visually significant cataract causing driving difficulty, and poorly controlled glaucoma on maximal medical therapy.  There is good evidence in the medical literature in controlled clinical trials indicating that treatment with the iStent is safe and effective for the patients disease.  The use of two iStents placed simultaneously is currently being studied.  However, there is no evidence currently that it is more effective than a single implant.  The standard therapy of cataract surgery alone with continued topical medication is not as effective for treating the patients glaucoma.  All told, one iStent placement is likely to be of greater benefit than other treatment options.  Based upon the information set forth above, a portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 68-year-old female enrollee has requested authorization and coverage for iStent placement (times two).  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the submitted records support the superior efficacy of the services at issue.  This patient has glaucoma in conjunction with cataract, which is the approved indication for the iStent.   The patient is on maximal medical therapy for her glaucoma, and has shown advanced optic nerve cupping and visual field loss in both eyes.  The use of the iStent for patients in this clinical setting has become the standard of care.  Alternative treatment options, such as trabeculectomy or implantation of a tube shunt, are highly invasive and include the risk of serious vision-threatening complications.  The data show that insertion of two stents provides better intraocular pressure control than one stent.  Therefore, the iStent placement (times two) is likely to be of greater benefit than other 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 68-year-old female enrollee has requested authorization and coverage for iStent placement (times two).  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence supports the requested iStent placement (times two) in this clinical setting.  The peer-reviewed has demonstrated the superior efficacy of the requested services in this patients case.  Studies reviewed indicate that this procedure is a safe and effective modality for achieving better glaucoma control after cataract surgery.  Thus, iStent placement (times two) is likely to be more effective than other treatment alternatives.  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 Upheld

Summary Reviewer 1

A 23-year-old female enrollee has requested reimbursement for genotype testing performed on 11/10/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health conditions. The physician reviewer found that there is a lack of support for the services at issue in this patients case. Pharmacogenetics deals with the differences in effect of drugs due to individuals genetic variations. This testing may be beneficial for treatment-resistant patients in order to help predict response to certain medications. In this case, the records do not demonstrate that the patient was treatment-resistant. In this setting, the services at issue were not consistent with standards of good medical practice. Therefore, genotype testing performed on 11/10/17 was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 23-year-old female enrollee has requested reimbursement for genotype testing performed on 11/10/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health conditions. The physician reviewer found that in this patients case, the records do no document adequate trials of medications from different classes for adequate time periods with appropriate strategies, including augmentation, if appropriate.  The patient had a clinical picture complicated by substance use. In general, genetic testing results show if a patient is a normal responder of certain classes of medications, may be more or less likely to respond to certain medications, is at low risk of certain adverse events, at higher risk of others, or may have decreased activity of a certain enzymatic line. The fact that one of these results may show up on genetic testing does not necessarily indicate that one medication will, definitively, be more or less effective than another. There are other factors that influence medication efficacy, such as drug-drug interactions, variance in hepatic metabolism of each individual, and individual variances, such as substance abuse.  Studies have shown that clinically useful predictors in genetic testing are scarce for antidepressant therapy, with results being inconsistent and only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability in the treatment of depression. There is a lack of large randomized trials supporting its use. The existing studies have also indicated that there was no significant correlation between either genotypes or medication serum concentration and response treatment. The current evidence does not support the use of genotyping when choosing an antidepressant, and even less is understood about its use in the treatment of anxiety disorders. Genetic testing lacks evidence based research to show its effective use in guiding the clinician towards choosing a medication regimen. In sum, genotype testing performed on 11/10/17 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 23-year-old female enrollee has requested reimbursement for genotype testing performed on 11/10/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health conditions. The physician reviewer found that the documentation indicates that the patient has a history of mood and anxiety problems.  She also reported a significant history of substance use. The submitted records do not indicate past medication trials which the patient has attempted for her psychiatric conditions. It appears that the patient has attempted non-medication treatment, such as psychotherapy, but details of this were not provided. It is not clear that the patient has had cognitive behavioral therapy for her major depressive disorder or generalized anxiety disorder diagnoses.  It is not clear that the patient has tried other forms of psychotherapy that have been shown to be effective for her diagnoses. Cognitive behavioral therapy is a first-line treatment for the patients conditions. Thus, genotype testing performed on 11/10/17 was not likely to have been more efficacious than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 60-year-old male enrollee has requested reimbursement for inpatient care provided on 11/07/18. 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 supports the medical necessity of the services at issue. By 11/07/18, the patient had been admitted for two days, but was not yet on a full liquid diet, and still had episodes of hypertension requiring intravenous hydralazine. He had just started having bowel movements and had the nasogastric tube removed the day before. In such cases, discharge on 11/06/18 or 11/07/18 would have been premature. The patient warranted confirmation that small bowel obstruction had been resolved, bowel function had returned to normal, and that he was able to tolerate sufficient oral intake to maintain nutrition before discharge, or there would be a high probability of readmission. Therefore, inpatient care provided on 11/07/18 was medically necessary for the treatment of this patient.