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

Summary Reviewer 2

A 53-year-old female enrollee has requested reimbursement for gene testing performed on 11/15/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma.The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines note while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low-risk versus high-risk for metastasis, routine (baseline) prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The medical evidence does not support the services at issue in this clinical setting. In sum, gene testing performed on 11/15/16 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 53-year-old female enrollee has requested reimbursement for gene testing performed on 11/15/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma.The physician reviewer found that the melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on DecisionDx-Melanoma test has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, gene testing performed on 11/15/16 was not likely to have been more effective than other modalities for 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 

This patient has idiopathic stature and has demonstrated improvement in growth velocity while on GH therapy. Moreover, he has had no adverse effects of therapy and has open epiphyses. Thus, continuation of GH therapy is medically necessary. According to  the Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or insulin like growth factor finding protein 3 (IGFBP-3); and/or (5) other clinical features suggestive of GH deficiency. This patient met most of these criteria at the time of initiation of GH therapy, and now that he has been receiving GH therapy for over two years with good response and no adverse effects, withdrawal of therapy is not appropriate and may compromise his adult height potential. Accordingly, the requested treatment with Humatrope GH therapy is supported as medically necessary for treatment of this patients idiopathic short stature.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the right hip. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found that considering the patients relatively young age and lack of previous trauma, and further considering the severe long-standing deformity and radiographic findings, the records suggest that the underlying problem is a hip dysplasia.  Most commonly, a hip dysplasia is a congenital or developmental deformity or misalignment of the hip leading to chronic arthritis.  There is a role for MRI in the evaluation of hip problems.  Generally, the evaluation of hip pain will begin with plain x-rays.  For hip dysplasia, plain x-rays will often be sufficient, as the displacement will often be readily apparent.  CT scans are often employed as well to confirm the plain x-ray findings.  There are various entities, however, that can only be imaged by magnetic resonance scanning.  Conditions such as labral tears, ligamentous injuries, and subtle osteochondral lesions are only demonstrable with MRI.  Early stage subtle avascular necrosis can also be optimally imaged with MRI.  However, in this patients case, he has very severe osteoarthritis of the hip.  He has no subtle abnormalities.  MRI would be expected to confirm the obvious arthritic change.  All told, the requested MRI of the right hip is not medically indicated for the evaluation of this patient.  Therefore, 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 reimbursement for inpatient hospital services provided from 3/01/18 through 3/02/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who reported chest tightness and dyspnea. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient presented with unforeseen symptoms possibly due to coronary ischemia associated with an abnormal electrocardiogram and normal initial troponin value. In this circumstance, a period of overnight observation without hospital admission is reasonable and appropriate to confirm no evidence of myocardial infarction with serial troponins prior to discharge. Since the patient was clinically stable after initial evaluation, with an anticipated length of stay of less than 48 hours or less than two midnights, hospital admission was not medically necessary. Based on the records, an observational level of stay would have been safe and effective. Thus, inpatient hospital services provided from 3/01/18 through 3/02/18 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 51-year-old female who underwent a colonoscopy on 5/10/19 for the indication of colorectal cancer screening. Per the records, this revealed two polyps (which were removed) and internal hemorrhoids. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. According to the American Society of Anesthesiologists guidelines for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures, such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care is more likely necessary in patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, American Society of Anesthesiologists (ASA) class III or higher, or morbid obesity. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, during endoscopic procedures (unlike surgery), consciousness during the procedure is
acceptable and is the goal during most procedures. Monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic variant. All told, monitored anesthesia care provided on 5/10/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 57-year-old female enrollee has requested authorization and coverage for duloxetine 60 mg, #60 per 30 days. The Health Insurer has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollees fibromyalgia.   The physician reviewer found that a review of the literature reveals that there is a lack of evidence that doses greater than 60 mg per day of duloxetine confer additional benefit for fibromyalgia patients, even in patients who do not respond to a 60 mg dose. In addition, higher duloxetine doses are associated with a higher rate of adverse reactions. Further, the documentation does not reveal that the patients history, symptoms, and examination findings are consistent with a diagnosis of fibromyalgia. Moreover, the documentation does not reveal that the patient has had significant objective functional improvement or a significant objective improvement in pain on duloxetine. For these reasons the documentation does not support the medical necessity of duloxetine 60 mg, #60 per 30 days for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication quantity 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 38-year-old female enrollee has requested authorization and coverage for autologous chondrocyte transplant. The Health Insurer has denied this request and reported that the requested services are not medically necessary for treatment of the enrollees knee pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient has had persistent and progressively worsening right knee pain and swelling. Significant functional difficulty is documented in activities of daily living and recreational/work activities. Clinical examination findings are consistent with imaging evidence of full thickness grade IV chondral defects of the medial femoral condyle and trochlea and genu varum. She is status post arthroscopic chondroplasty, loose body removal and cartilage biopsy on 9/13/17. There is no specific evidence in current peer-reviewed literature limiting the use of autologous cultured chondrocytes to a single lesion, although the risk factor for failure increases with lesion size and complexity. Given the young age of this patient, significant functional difficulty, and size of the lesions, the use of autologous chondrocyte transplant for the medial femoral condyle lesion and trochlear lesion is reasonable to allow potential delay of total knee replacement which would likely be the next definitive treatment. Therefore, the requested autologous chondrocyte transplant is medically necessary for the treatment of this patient. Therefore, 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 33-year-old female enrollee has requested reimbursement for fecal lactoferrin testing performed on 12/06/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition. The physician reviewer found that in MosliAaas comparative meta-analysis of 19 studies, the diagnostic accuracy of C-reactive protein, fecal calprotectin, or stool lactoferrin was examined against endoscopy as a gold standard in
patients with symptoms/signs consistent with active inflammatory bowel disease. Fecal calprotectin was found to be more sensitive than C-reactive protein for this patientAaas indication. Similar results were reported by Menees and colleagues. In this meta-analysis which evaluated the performance of fecal calprotectin in distinguishing between inflammatory bowel disease and irritable bowel syndrome, patients with a fecal calprotectin level of less than 40 microg/g had a 1 percent chance or less of having inflammatory bowel disease. Fecal calprotectin has in recent years become increasingly attractive to some clinicians for assessment of inflammatory bowel disease activity in lieu of direct imaging of the gut.
Whereas conditions like irritable bowel syndrome and CrohnAaas disease could have been suspected as contributory to the patientAaas symptoms, no specific mention was made by the patientAaas provider that inflammatory bowel disease was under consideration. In this case, lactoferrin testing was not supported in the face of many other concomitantly-ordered inflammatory markers that proved negative, such as C-reactive protein, sedimentation rate, leukocyte count, or fecal calprotectin. With so many other negative inflammatory markers, the likelihood of a missed inflammatory bowel disease diagnosis was remote. Therefore, fecal lactoferrin testing performed on 12/06/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 33-year-old female enrollee has requested reimbursement for fecal lactoferrin testing performed on 12/06/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition. The physician reviewer found that the patient had gastrointestinal symptoms, such as mucus in her stool, which could be consistent with irritable bowel syndrome, or with inflammatory bowel disease (CrohnAaas disease or ulcerative colitis). The American College of Gastroenterology guidelines for the management of CrohnAaas disease support the use of fecal calprotectin testing, stating that when there are symptoms concerning for active CrohnAaas disease, AaAFecal calprotectin and fecal lactoferrin measurements may have an adjunctive role in monitoring disease activityAaA and AaAstudies have shown that both fecal lactoferrin and fecal calprotectin are sensitive markers of disease activity and correlate with a number of the endoscopic activity indicesAaA Lactoferrin testing is a highly sensitive, low-risk test to assess for inflammatory bowel disease. Therefore, fecal lactoferrin testing performed on 12/06/19 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 33-year-old female enrollee has requested reimbursement for fecal lactoferrin testing performed on 12/06/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition. The physician reviewer found that the documentation does not reveal that the provider seeks to differentiate between inflammatory bowel disease (CrohnAaas disease and ulcerative colitis) and irritable bowel syndrome. The medical
records does not identify features to support one diagnosis over the other. A gastroenterologist uses the clinical history along with laboratory studies including surrogate studies to obtain clues to ongoing inflammation related to the suspecting an underlying disorder of inflammatory bowel disease. In addition, radiographic studies and endoscopic evaluation are tools that can be used but carry their own potential risks. The patient underwent fecal lactoferrin to assess the level of inflammation.
An elevated fecal lactoferrin is not specific for inflammatory bowel disease. Any inflammatory process within the gastrointestinal tract will result in the activation of the innate immune response and release of calprotectin. Fecal calprotectin concentration has been shown in studies to be elevated in many conditions, including rheumatologic conditions. Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to cause significant increases in fecal lactoferrin levels. Proton pump inhibitors (PPIs) have been associated with significantly elevated fecal lactoferrin levels, regardless of reason for PPI. There is a lack of support for the services at issue in this clinical setting. Therefore, fecal lactoferrin testing performed on 12/06/19 was
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 43-year-old female who was admitted for treatment of alcohol use disorder on 7/22/19. The patient has a history of severe alcohol use disorder and had been drinking in a binge type fashion. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The American Society of Addiction Medicine (ASAM) criteria reviews the six dimensions of assessment to determine the appropriate level of care. In terms of dimension 1, acute intoxication and withdrawal potential, the patient was in mild alcohol withdrawal, with the possibility of Xanax withdrawal as an additional concern. She endorsed multiple symptoms of withdrawal, including agitation, insomnia, nausea, and restlessness. She was unable to cope with withdrawal discomfort. The CIWA was 9 on admission. Overall severity is rated as moderate. With regard to dimension 2, biomedical conditions, the patient was recently diagnosed with bronchitis/atypical pneumonia and was on oral antibiotics. She was having difficulty coping with her symptoms such that it was distracting from her recovery. Overall rating is moderate. In terms of dimension 3, emotional/behavioral/cognitive conditions and complications, she had a history of depression, anxiety, and undiagnosed eating disorder. She had sought treatment from her primary care provider and was prescribed Xanax, which complicated her anxiety and alcohol use disorder. She reported intense urges to use alcohol and was engaging in binge episodes for several days at a time. Thus, the overall severity is moderate. With regard to dimension 4, readiness to change, she voiced a desire to stop drinking but felt unable to refrain from drinking due to overwhelming urges to drink. She required structured therapy and 24-hour program milieu in order to stop. Therefore, the severity is moderate. In terms of dimension 5, relapse, continued use or continued problem potential, this patient was experiencing severe psychiatric distress that was contributing to cravings and urges to use alcohol. Thus, the severity is severe. With regard to dimension 6, recovery environment, the patients husband had an alcohol use disorder and had a recent relapse. Therefore, the severity is moderate. Based on the submitted documentation, the patient met criteria for subacute residential services. Thus, substance abuse sub-acute residential treatment center services provided from 7/29/19 through 8/18/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The parent of a four-year-old male enrollee has requested reimbursement for chromosomal microarray testing provided on 11/12/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the clinical utility of chromosomal microarray (CMA) is well-established, and is now considered first-line genetic testing for individuals with developmental delays and autism spectrum disorders. It is important to note that CMA technology has been shown to provide clinically actionable information. Research continues to support the use of CMA testing in the evaluation of developmental delays and autism spectrum disorders. Recent evidence-based international guidelines promote the use of CMA as a first-tier investigation for global developmental delay if no etiological indicators from history and examination are found. The higher sensitivity that it has for identifying submicroscopic deletions and duplications (than standard karyotyping methods) and better definition of the breakpoints and size of imbalances all make CMA a suitable first-line test. Therefore, chromosomal microarray testing provided on 11/12/18 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of a four-year-old male enrollee has requested reimbursement for chromosomal microarray testing provided on 11/12/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that Chromosomal microarray (CMA) is recommended by the American College of Medical Genetics (ACMG) as a first-tier test for patients with autism spectrum disorders. CMA has become the standard of care for diagnosis in patients with autism spectrum disorders. Increasing numbers of patients with autism spectrum disorders have been found to have underlying copy number variations. As such, it is possible that some copy number variations have also been associated with specific neuropsychological treatments or medications that have been shown to be more efficacious in patients with autism spectrum disorders due to that underlying cause. Additionally, copy number variations on CMA may inform about possible other complications and medical risks, some of which can be screened for and treated. Therefore, chromosomal microarray testing provided on 11/12/18 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The parent of a four-year-old male enrollee has requested reimbursement for chromosomal microarray testing provided on 11/12/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. According to the American College of Medical Genetics and Genomics, chromosome microarray testing is first-line testing in autism disorders. Battaglia and colleagues noted that chromosome microarray testing is a first tier test for individuals with autism or intellectual disability. There is sufficient literature at this time to consider chromosome microarray testing a first-line diagnostic assay in this case. Thus, chromosomal microarray testing provided on 11/12/18 was likely to have been more beneficial than other methods of evaluating this patient.