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

Summary Reviewer 1
A 57-year-old male requested authorization and coverage for implantation of device (the Coflex device) between the bones of the spine. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees chronic lower back pain. The physician reviewer found that the medical evidence fails to support that the Coflex device, when used under these circumstances, results in any improved outcome when compared to laminectomy alone.  Moreover, there are studies that indicate that the Coflex device has to be removed in some cases, either due to infection or displacement due to a fractured spinous process. For these reasons, implantation of the Coflex device between the bones of the spine is not likely to be more effective than the standard available options for the treatment of this patients medical condition. 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 57-year-old male requested authorization and coverage for implantation of device (the Coflex device) between the bones of the spine. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees chronic lower back pain. The physician reviewer found that the current evidence based medical peer reviewed literature and long term studies support the use of Coflex interlaminar stabilization with decompression as a safe and efficacious alternative to decompression and/or lumbar fusion for the treatment of lumbar spinal stenosis. However, this patient presents with progressively worsening and debilitating low back pain. He has symptoms of neurogenic claudication with associated significant functional limitations. The signs and symptoms reported are consistent with imaging evidence of moderate to severe spinal stenosis at L4/5 with grade 1 anterolisthesis at L4/5. The U.S. Food and Drug Administration contraindications for Coflex include severe facet hypertrophy that requires extensive bone removal which would create instability. Given the presence of severe facet disease, proceeding with the Coflex device is not supported in this patients case. Therefore, implantation of the Coflex device between the bones of the spine is not likely to be more beneficial than other standard methods for the treatment of this patient. 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 3

A 57-year-old male requested authorization and coverage for implantation of device (the Coflex device) between the bones of the spine. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees chronic lower back pain. The physician reviewer found that the medical literature does not demonstrate the superior benefits of the requested device in this clinical setting. While there is some evidence to indicate that the Coflex interlaminar stabilization implant has been effective, the literature appears to support its use in patients with low grade spinal stenosis. In this patients case, his symptoms are more consistent with high grade or severe spinal stenosis. Further studies are needed in order to demonstrate the superior efficacy of the requested device for patients in this clinical setting. Accordingly, implantation of the Coflex device between the bones of the spine is not likely to be more beneficial than the standard available options for the treatment of this patient. 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 10-year-old female enrollee has requested authorization and coverage for rizatriptan, nine tablets per day. The Health Insurer has denied this request and reported that the requested medication quantity is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient has been diagnosed with chronic migraine, which is unresponsive to ibuprofen when she is having a severe episode. Rizatriptan 10 mg effectively relieves the pain. Her provider noted that the patient is having more than four severe headaches per month, and she has recommended nine tablets per month, using the medication no more than twice per week. This is in keeping with the dose recommendations by the manufacturer of rizatriptan. Sometimes a second dose of rizatriptan is required if the headache does not respond to the first 10 mg tablet. The medical evidence supports the requested medication quantity in this clinical setting. Barbanti and colleagues and Evers noted the efficacy and safety of rizatriptan in the treatment of pediatric migraine. Therefore, rizatriptan, nine tablets per month are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 
The patient is a 52-year-old female who has a history of chronic groin pain. In 2013, she had a repair of a right inguinal hernia. The patient has requested reimbursement for CT of the pelvis (72193) performed on 5/05/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination.  The physician reviewer found that the Health Insureras denial noted that the patientas ahip paina should have been managed conservatively for six weeks, and that plain x-rays had not been obtained. The Health Insurer used the requirements for musculoskeletal hip pain, rather than groin pain. When considering the possibility of an inguinal hernia, the referring practitioner has multiple modalities at his disposal. The first is a physical examination. Inguinal hernias, however, can be difficult to detect, especially in heavy individuals. After a physical examination, and generally before any contemplated surgery, another confirmatory imaging test is often performed. One possibility is ultrasound, although sonography is largely operator dependent. As noted by Piga, aWe found that ultrasound had the highest sensitivity and specificity. However, it must be taken into consideration that performance is highly dependent on the operatoras level of expertise.a An ultrasound study will also not necessarily detect a sliding or intermittent hernia. Another possibility, and often the preferred imaging test, is a CT scan of the area. The advantage of a CT scan is that it is not at all operator dependent, and that it will not only detect a hernia, but it will also establish the nature of the hernia. In addition, a CT scan will differentiate between an inguinal hernia, a femoral hernia, and an obturator hernia. Garvey noted, aThis prospective non-contrast CT study of patients with undiagnosed chronic groin pain detected the majority of occult hernias requiring surgical intervention. These results suggest that CT can be a useful adjunct to the evaluation of patients presenting with chronic undiagnosed groin pain, but that experienced clinical judgment remains a critical element in the diagnostic pathway.a There are several articles in the literature touting herniography in the evaluation of inguinal hernias. While this test is a possibility, it requires an injection of contrast material into the abdominal cavity. This may be an accurate test, but it is rarely performed as a routine procedure. If the patient truly had hip pain, the Health Insurer would have been correct in its reasoning. However, based on the provideras note, there is no indication that the patientas pain was related to her hip joint. Therefore, CT of the pelvis (72193) performed on 5/05/21 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 42-year-old male enrollee has requested authorization and coverage for lumbar total disc arthroplasty (artificial disc). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found per the current medical evidence, the superior efficacy of the requested services has not been established.  The clinical documentation submitted for review indicated the patient had undergone diagnostic studies including an MRI, a CT scan of the lumbar spine, and electrodiagnostic studies.  The patient was treated with physical therapy, acupuncture, selective nerve root blocks, and medications.  However, the peer-reviewed literature indicates the use of artificial disc replacement requires further studies.  All told, the requested lumbar total disc arthroplasty (artificial disc) is not likely to be more effective than other treatment options.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 42-year-old male enrollee has requested authorization and coverage for lumbar total disc arthroplasty (artificial disc). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found the medical literature has not demonstrated the superior effectiveness of the requested services.  The use of total disc arthroplasty has not been shown to be more beneficial than other more accepted surgical treatments such as fusion in the lumbar region.  The long-term durability of these devices is unknown when subjected to the stresses of the lumbar spine.  Therefore, the requested lumbar total disc arthroplasty (artificial disc) is not likely to be of greater benefit than other treatment options.  For these reasons, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 42-year-old male enrollee has requested authorization and coverage for lumbar total disc arthroplasty (artificial disc). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found the current medical evidence does not support the requested services in this clinical setting.  The long-term safety and efficacy of total disc arthroplasty has not been established.  There is the possibility of long-term complications of implantation of metal and metal methyl methacrylate devices in the spine.  Additionally, the studies to date do not adequately delineate the problem of component wear.  Van Den Eerenbeemt and colleagues noted that high-quality randomized controlled trials with relevant control groups and long-term follow-up are needed to evaluate the safety and efficacy of total disc replacement.  In sum, the requested lumbar total disc arthroplasty (artificial disc) is not likely to be superior over other available options.  Accordingly, 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of an 11-year-old male enrollee has requested authorization and coverage for child mental health outpatient services with Robert Colegrove, EdD. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has a history of inattentive behavior, anxiety, avoidance behaviors, and difficulty with impulse control. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Per the records, psychological testing was requested to aid with determining the patients diagnosis and clarifying a written diagnosis of attention deficit/hyperactivity disorder. Psychological and neuropsychological tests are not mandatory for the diagnosis of attention deficit/hyperactivity disorder. The current standard of care for the diagnosis of attention deficit/hyperactivity disorder is through full clinical evaluation. In this case, the documentation suggests a diagnosis of attention deficit/hyperactivity disorder.  Based on the current evidence, attention deficit/hyperactivity disorder is a clinical diagnosis, and testing is not needed to establish this diagnosis. Thus, the requested child mental health outpatient services with Robert Colegrove, EdD are not medically necessary for the treatment of this patient. Therefore, the requested services are 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 


The parent of a five-year-old female enrollee has requested authorization and coverage for genetic testing. The Health Insurer has denied this request indicating that the requested testing is not medically necessary for evaluation of the enrollees developmental delay. The physician reviewer found that based on the medical literature and the presented clinical records submitted for review, the request for genetic testing is medically necessary for evaluation of the patients medical condition. The clinical utility of CMA is well established in the peer-reviewed literature and is considered a first-line genetic test for patients with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics (AAP), the American College of Medical Genetics (ACMG), the American College of Neurology (AAN) and the Child Neurology Society (CNS) (Schaefer, et al; Moeschler, et al; Shevell, et al; Shen, et al). CMA technology has been shown to provide clinically actionable information. The study by Coulter and colleagues demonstrated that CMA results influenced medical care by in the majority of patients by precipitating medical referrals, diagnostic imaging, and specific laboratory testing supporting the use of CMA as a clinically useful diagnostic test. Current data suggest that many clinically significant genetic changes can impact neurodevelopment without associated anatomic departures. For the reasons provided, the request for genetic testing has been established as medically necessary for evaluation of the patients medical condition. Therefore, the requested testing is medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 33-year-old female enrollee has requested reimbursement for 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that in this case, the patient had severe dysphagia with an inability to tolerate solid food intake and a hiatal hernia, with upper gastrointestinal series showing reflux. Hernia repair surgery was being contemplated before the endoscopy with pH study. This is consistent with current medical literature, which recommends a pH study to evaluate esophageal motility before undergoing such a surgery. Additionally, dysphagia in the setting of dilated and angulated esophagus can be suggestive of achalasia, and warrants evaluation with impedance and with esophagogastroduodenoscopy. Furthermore, esophagogastroduodenoscopy is recommended for the evaluation of dysphagia. Therefore, 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 33-year-old female enrollee has requested reimbursement for 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient has a history of obesity status post gastric bypass and cholecystectomy, who presented with dysphagia. The patient was taken for an urgent cholecystectomy and has had solid food dysphagia since. She describes predominantly solid food dysphagia but does not endorse particular difficulty with liquids. She was taken for an upper endoscopy, which revealed a 3 cm hiatal hernia and angulation in proximity of the surgical intervention, suggestive of possible obstructive process.  The provider seeks surgical revision, given the patientas symptoms of abdominal pain, nausea and vomiting. The requested testing has not been proven to be safe and effective based on well-designed randomized controlled trials and has not been shown to necessarily alter health outcomes. Therefore, 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 33-year-old female enrollee has requested reimbursement for 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the services at issue in this setting. If the patient had achalasia, this would be important to know. As part of revision surgery, the patient would likely undergo a myotomy of the lower esophageal sphincter, perhaps via a POEM procedure. In addition, it was important to quantify and characterize acid reflux prior to baseline in order to determine if an anti-reflux procedure such as transoral incisionless fundoplication would be needed along with revision surgery. Therefore, 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21 was likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 39-year-old male who is status post repair of left cleft lip and palate as a child. He does have a maxillofacial skeletal deformity and was evaluated by an oral surgeon and was found to have severe maxillary hypoplasia, mandibular hyperplasia, and missing tooth number 10 with an alveolar cleft in this area. His provider recommended orthognathic surgery with a Lefort 1 osteotomy, mandibular osteotomy and repair of his alveolar cleft. The patient has requested authorization and coverage for bone graft procedure; nasal, maxillary, or malar areas (includes obtaining graft) (CPT code 21210). The Health Insurer has denied this request indicating that the requested procedure is not medically necessary. Applying the parameters of care outlined by the American Association of Oral and Maxillofacial Surgeons (AAOMS), the proposed surgery is supported as medically necessary for the treatment of this patients medical condition. The provider reports that the patient has a maxillofacial skeletal deformity that cannot be corrected with orthodontics. The proposed procedure will result in improved musculoskeletal and dento-osseous relationships and improvement in mastication. The patient also has an alveolar cleft in the area of missing tooth number 10. Alveolar grafting of this site is indicated and is separate from the Lefort 1 procedure. The goals of this procedure are to provide adequate bone stock for his adjacent teeth and future dental replacement if needed, to establish a nasal skeletal base, and more ideal architecture in the area. All told, the requested bone graft procedure; nasal, maxillary, or malar areas (includes obtaining graft) (CPT code 21210) is medically necessary.  Based on the foregoing discussion, 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 Overturned

Summary Reviewer 

The patient is a 54-year-old female who presented to her provider on 8/31/20. The records noted chronic migraines and headaches. The patient has a history of sagittal venous thrombosis. The patient requested authorization and coverage for Botox and Xeomin injections (64612, 64646, 64647 and 64644). 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 Cervical dystonia (CD) is a movement disorder clinically characterized by involuntary contractions of cervical muscles, which cause abnormal head movements and postures, often associated with head tremor and chronic pain. Classifications of CD include torticollis (turning or rotation of the head towards one side); laterocollis (tilting of the head towards one side); anterocollis (head and neck flexion), and retrocollis (head and neck extension) or a combination of these movements. Per the 2016 American Academy of Neurology (AAN) practice guidelines, botulinum toxin is accepted as first-line treatment for CD. OnabotulinumtoxinA (OnaBoNT-A/Botox) and incobotulinumtoxinA (incoBoNT-A/Xeomin) are two preparations of botulinum toxin approved by the U.S. Food and Drug Administration. In this case, the patient has cervical dystonia with spasmodic torticollis.  Per the AAN practice guidelines, botulinum toxin (Botox and Xeomin) are accepted as first-line treatment for cervical dystonia. Therefore, Botox and Xeomin injections (64612, 64646, 64647 and 64644) are medically necessary for the treatment of this patient.