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

Summary Reviewer 3

A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 3/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees keratoconus. The physician reviewer found that there is strong evidence in the literature that collagen crosslinking can halt the progression of keratoconus. It is U.S. Food and Drug Administration (FDA) approved for this indication. Given the patients age, he is at significant risk for progression. Given his history of progressive blurriness, particularly in the right eye which had not yet undergone crosslinking, it highly suggests progression in the right eye. Therefore, corneal collagen crosslinking performed on 3/13/17 was likely to have been more effective than other available 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 Overturned

Summary Reviewer 
 
A 45-year-old female enrollee has requested reimbursement for repair of blepharoptosis provided on 2/4/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees left eyelid ptosis.   The physician reviewer found that the report by the American Academy of Ophthalmology (AAO) has outlined the indicators that ptosis repair can lead to functional improvement. The AAO state that, repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities. The AAO guidelines indicate that preoperative indicators of improvement include margin reflex distance 1 (MRD1) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment. This patient meets many of these criteria as her superior visual field is reduced from about 50 degrees to about 37 degrees, which is a reduction about 26%. Moreover, the patients MRD1 is 2 mm. In addition to these criteria, the patients dry eyes will likely improve with a conservative blepharoptosis repair (Vold, et al). All told, the repair of blepharoptosis provided on 2/4/16 was medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 56-year-old female enrollee has requested authorization and coverage for Repatha SureClick (evolocumab subcutaneous solution auto-injector 140 mg/mL). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hyperlipidemia. The physician reviewer found that in this case, there is no documented heart disease and mildly elevated LDL level. The patient has been intolerant of two statin medications and Zetia. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor sufficiently studied only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol. This patient does not fit any of those criteria. PCSK9 inhibitors have not been sufficiently studied in other patient populations, such as this patient with no documented cardiovascular disease and relatively mildly elevated lipid levels after lifestyle changes.   Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Thus, Repatha SureClick (evolocumab subcutaneous solution auto-injector 140 mg/mL) 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 58-year-old male enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees severe and persistent asthma. The physician reviewer found the current medical evidence supports the requested services in this clinical setting.  Initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed.  Cox and colleagues examined 112 subjects with moderate to severe asthma, and the authors noted that bronchial thermoplasty resulted in improved asthma control.  Pavord and colleagues examined the safety of thermoplasty and found short-term worsening in symptoms, but evidence of improved long-term control of asthma.  Castro and colleagues compared thermoplasty with a sham procedure and followed the patients for 12 months as well.  The authors found that the thermoplasty group had fewer exacerbations and improved quality of life when compared to the sham group.  In this patients case, he is on a very aggressive regimen of bronchodilators along with antihistamines and Xolair.  There is little left in the standard armamentarium to control his refractory symptoms.  All told, the requested bronchial thermoplasty is medically indicated 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 29-year-old female enrollee has requested reimbursement for chiropractic care provided from 1/30/19 through 6/28/19 and physical therapy provided from 5/06/19 through 6/06/19. 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 in this case, the patient underwent physical therapy and chiropractic care after her motor vehicle accident in November 2018. She had persistent symptoms despite the physical therapy and chiropractic services that were rendered. She did not have any impairment that would have precluded her from performing an independent exercise and palliative modality program after a short series of visits to physical therapy following the motor vehicle accident. There was no indication of objective benefit of ongoing chiropractic therapy. While the patient may have had ongoing symptoms, her symptoms would not have been expected to marginally improve with the interventions in question over an independent program. In fact, despite the interventions that were rendered, no significant objective benefit that can be reasonably attributed to the services in question is documented. Therefore, chiropractic care provided from 1/30/19 through 6/28/19 and physical therapy provided from 5/06/19 through 6/06/19 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 59-year-old female who presented in September 2019 for a routine examination. The patient has requested reimbursement for vitamin D screening test (CPT 82306) performed on 11/16/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the patient. The physician reviewer found that the U.S. Preventative Services Task Force recommends against universal screening for vitamin D deficiency. The American Association of Clinical Endocrinologists and American College of Endocrinology recommend screening only in patients who present with known risk factors that include: malnutrition, sedentary lifestyle, limited sun exposure, obesity, dark skin, age greater than or equal to 65, conditions causing gastrointestinal malabsorption, including short bowel syndrome, pancreatitis, iniammatory bowel disease, amyloidosis, celiac sprue, and bariatric surgery, liver disease or failure, renal insuiciency or nephrotic syndrome, cystic fibrosis, and medications that alter vitamin D metabolism, including anticonvulsants and glucocorticoids. Vitamin D insufficiency appears to be common among patients who are taking medications that accelerate the metabolism of vitamin D, hospitalized on a general medical service, institutionalized, and in patients who have limited sun exposure, osteoporosis, or malabsorption. Most patients with vitamin D deficiency are asymptomatic. Prolonged, severe vitamin D deficiency causes secondary hyperparathyroidism, which leads to phosphaturia, demineralization of bones, and when prolonged, osteomalacia. Symptoms may include bone pain and tenderness, muscle weakness, fracture, and difficulty walking. In this case, the patient was diagnosed with vitamin D insufficiency in February 2016. Thus, the laboratory test was not for screening but monitoring of a known deficiency condition, and was therefore appropriate. In sum, vitamin D screening test (CPT 82306) performed on 11/16/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement for residential treatment services from 8/04/15 through 12/10/15.  The Health Insurer has denied this request indicating that the not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Based upon the records, this patient was able to engage in therapy.  The patient was able to confront various issues with his family and had the ability to express emotion with less depression.  The patient did not appear to be a safety risk according to the records and was not showing any impairment of reality, including command hallucinations, agitation or aggression or withdrawal.  The medical evidence does not support continued treatment at the residential treatment facility in this clinical setting.  Per the records, the patient could have been safely and effectively treated in a less restrictive setting.  In sum, residential treatment services from 8/04/15 through 12/10/15 were not medically indicated 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 Overturned

Summary Reviewer 

The patient is a 54-year-old male who has been diagnosed with alcohol use disorder, elevated liver function testing, atrial fibrillation, hypertension and rheumatoid arthritis. The patient has requested reimbursement for substance abuse residential treatment from 8/01/19 through 8/04/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that per American Society of Addiction Medicine criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. With regards to dimension 1, acute intoxication/withdrawal potential, the patient was drinking heavily and reported feeling withdrawal symptoms. In terms of dimension 2, biomedical conditions and complications, the patient was on blood thinners, making potential falls while intoxicated fatal. With regards to dimension 3, emotional, behavioral or cognitive conditions, the patient had anxiety symptoms. In terms of dimension 4, readiness to change, the patient was willing to change but was ambivalent. With regards to dimension 5, relapse, continued use or continued problem potential, the patient had a long history of use without long periods of sobriety. In terms of dimension 6, recovery environment, the patients environment was supportive but lacked structure. Given the severity of the patients illness, residential treatment was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patients illness. Therefore, substance abuse residential treatment from 8/01/19 through 8/04/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 47-year-old female enrollee has requested authorization and coverage for a sleep study.  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 there is sufficient support for the requested services in this patients case.  Diagnostic sleep studies are indicated for patients with an increased risk of obstructive sleep apnea. In this patients case, she has a very high risk of obstructive sleep apnea because of obesity, witnessed apnea and elevated Epworth Sleepiness Scale score.  The records document awakening gasping and snoring.  Since she has a high risk of sleep apnea, the requested sleep study is appropriate.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested sleep study is medically indicated for the treatment of this patient.  Therefore, the requested services are medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 78-year-old female enrollee has requested reimbursement for emergency health services (99285) provided on 2/28/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. The patient presented on 2/28/17 with abdominal pain that commenced suddenly that morning and was associated with vomiting and increasing abdominal distention. She had a history of an abdominal aortic aneurysm, putting her at risk for dissection. Patients with aortic aneurysms are cautioned to seek immediate medical attention for the sudden onset of abdominal pain. This patients symptoms of worsening abdominal pain with vomiting meets the prudent layperson criteria for an emergency medical condition. Moreover, CPT code 99285 corresponds to an emergency department visit of high severity where there is an immediate threat to life or physiologic function. The code includes a complete history, physical examination, and decision-making of high complexity. In this case, the medical records support CPT code 99285 level of care. This patient is an elderly female with a history of an abdominal aortic aneurysm as well as a prior abdominal surgery. The history of abdominal aortic aneurysm in a patient with abdominal pain requires thorough and detailed history, examination and imaging. This ruled out an aortic dissection, but revealed a small bowel obstruction. This is a life-threatening emergency, necessitating fluid resuscitation and gastric decompression as well as surgical consultation. Therefore, the care and treatment of this patient meets all three components of a CPT code 99285. Thus, the emergency health services (99285) provided on 2/28/17 met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 66-year-old male enrollee has requested authorization and coverage for Praluent. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has been diagnosed with hyperlipidemia and cardiovascular disease. The physician reviewer found that the documentation provided does not support the requested medication in this clinical setting. Based on the records, the patient has been diagnosed with hyperlipidemia and documented coronary disease. In this setting, medical therapy is indicated to achieve a goal reduction in LDL cholesterol to less than 70 mg/dl according to current guidelines.  Since this was documented to be achieved with Vytorin 10/80 alone, the medical necessity for the addition of a proprotein convertase subtilisin/kexin type-9 (PCSK9) inhibitor, such as Praluent, is not supported by the documentation.  PCSK9 inhibitors are approved for patients with familial hyperlipidemia or documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol. The medical literature suggests that additional LDL lowering on top of that achieved with Vytorin is not medically necessary since the LDL cholesterol was already less than 70 mg/dl without the addition of a PCSK9 inhibitor. Accordingly, Praluent is not medically necessary for the treatment of this patients medical condition. Therefore, based on the above, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 43-year-old female enrollee has requested reimbursement for the screening digital breast tomosynthesis performed on 6/17/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed on 6/17/16 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was 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 43-year-old female enrollee has requested reimbursement for the screening digital breast tomosynthesis performed on 6/17/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 6/17/16 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 diagnostic procedure at issue was 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 43-year-old female enrollee has requested reimbursement for the screening digital breast tomosynthesis performed on 6/17/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that there is a lack of peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in peer-reviewed literature. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 6/17/16 was not 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 diagnostic procedure at issue was 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.