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

Summary Reviewer 2

The patient is a 24-year-old female who underwent bilateral thorascopic sympathectomy for severe palmar hyperhidrosis in 2013.  This intervention helped her palmar, but not plantar, symptoms.  The plantar sweating interferes with her social and functional life, and represents a danged as she slips and falls frequently due to her wet feet.  Prior attempts to control her symptoms with conservative measures such as Drysol and Robinul Forte have failed. The patient has requested reimbursement and prospective authorization and coverage for sympathectomy performed by an out-of-network provider from 2/09/17 through 5/10/17. The Health Insurer has denied this request and reported that the services at issue were and are investigational for the treatment of this patient. Plantar hyperhidrosis is relatively uncommon in comparison with palmar hyperhidrosis.  Per the medical evidence, plantar hyperhidrosis responds to sympathectomy.  There are several reports regarding lumbar sympathectomy having a good effect on symptoms.  All told, sympathectomy performed by an out-of-network provider from 2/09/17 through 5/10/17 was and is likely to be of greater benefit than other available treatment options. Based upon the information set forth above, the services at issue were and 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

The patient is a 24-year-old female with symptoms of plantar hyperhidrosis. Her past medical history is significant for bilateral thorascopic sympathectomy for severe palmar hyperhidrosis in 2013. The patient has attempted medical management of her condition with over the counter therapy agents such as Drysol and Robinul Forte.  She reported that this condition limits her ability to function and interferes with her social life. The patient has requested reimbursement and prospective authorization and coverage for sympathectomy performed by an out-of-network provider from 2/09/17 through 5/10/17. The Health Insurer has denied this request and reported that the services at issue were and are investigational for the treatment of this patient. In recent years, lumbar sympathectomy has been proposed for treatment of patients with intractable palmoplantar hyperhidrosis.  To date, the amount of long term, prospective evidence addressing the use of lumbar sympathectomy for the treatment of plantar hyperhidrosis is limited.  Questions about efficacy, side effects and long-term outcomes have yet to be answered.  Since a formal protocol/technique does not yet exist for this novel technique, the level at which surgeons perform their lumbar sympathectomy is controversial and may vary among institutions. For this reason, higher rates of complications are associated with lumbar sympathectomy than alternative treatments for hyperhidrosis.  The evidence addressing the use of lumbar sympathectomy is insufficient, to date, to allow an adequate evaluation of safety and efficacy. Thus, the superior efficacy of sympathectomy performed by an out-of-network provider from 2/09/17 through 5/10/17 has not been established.  Based upon the information set forth above, the services at issue were not and 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 Overturned

Summary Reviewer 


A 59-year-old male enrollee has requested authorization and coverage for Sovaldi for 24 weeks. The Health Insurer has denied this request indicating that the requested medication is medically necessary for treatment of the enrollees medical condition. The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Patients with cirrhosis are reported to be high priority for treatment. The guidelines recommend specialist treatment for patients with decompensated cirrhosis, which is met in this case. The guidelines also recommend 12 weeks of Sovaldi and Daklinza with low-dose ribavirin for decompensated patients with genotype 3 hepatitis C, based on clinical study data (Foster, et al; Nelson, et al). The guidelines recommend that genotype 3 patients who have failed treatment with Sovaldi and ribavirin (regardless of cirrhosis status) should be treated with Sovaldi, Daklinza, and ribavirin for 24 weeks. This is based partially on the results of the ALLY-3 study, which demonstrated poor cure rates of only 71% in Sovaldi-experienced patients after 12 weeks of Sovaldi and Daklinza therapy (Nelson, et al; Leroy, et al). For these reasons, the requested treatment with Sovaldi to be used with Daklinza and ribavirin for 24 weeks is medically necessary for treatment of the patients hepatitis C infection. Therefore, the requested medication is 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 


The patient is a 12-year-old female presenting with class I malocclusion characterized by significant rotations of her anterior teeth. Photographs submitted show the patient to have mild to moderate crowding of her teeth with several teeth rotated causing an aesthetic compromise. The patient shows a class I malocclusion with no excessive overbite or overjet, mild to moderate crowding and rotation of the teeth producing scores below the required score of 26 or greater to be considered a handicapping malocclusion necessitating orthodontic treatment. The patients parent has requested authorization and coverage for orthodontic treatment. The Health Insurer has denied this request as not medically necessary. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested services. The patient shows a class I malocclusion with no excessive overbite or overjet, mild to moderate crowding and rotation of the teeth producing scores below the score of 26 or greater to be considered a handicapping malocclusion necessitating orthodontic treatment. The records submitted do not document a medical condition or significant impairment caused by the malocclusion. Based on the documentation submitted for review, the request for orthodontic treatment is not medically necessary for treatment of the patients medical condition. For the reasons provided, 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 Upheld

Summary Reviewer 


A 52-year-old female enrollee has requested reimbursement for anesthesia services performed on 7/27/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  In this case, there is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, anesthesia services performed on 7/27/15 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 Upheld

Summary Reviewer 

A 35-year-old female enrollee has requested reimbursement for inpatient behavioral health services provided on 4/30/19 through 5/02/19. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining necessary level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no current suicidal or homicidal ideation, plan, intention or severe distress. With regards to functional status, the records support a score of 1 due to no problems with group attendance. Per the records, the patient found the groups to be supportive. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2. In terms of level of stress of the recovery environment, the records support a score of 1 due to a low stress environment. With regards to level of support for the recovery environment, the records support a score of 1 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 2 given her previous treatment. The records noted prior psychiatric hospitalizations, and the patient reportedly had been minimally engaged with outpatient psychiatry following discharge from her prior hospitalization. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment along with insight into her treatment needs. Thus, the patient has a composite score of 10. This correlates with treatment in a community-based outpatient clinic setting. Therefore, inpatient behavioral health services provided on 4/30/19 through 5/02/19 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 16-year-old male enrollee has requested reimbursement for mental health program services provided from 4/20/15 through 6/25/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found according to medical literature for adolescents receiving treatment in residential care for the types of behavioral health problems demonstrated by this patient, continued stay is medically necessary if the patient identifies with the severity of the drug problem and manifests insight into his personal relationship with mood-altering chemicals yet does not demonstrate behaviors indicating that he is developing problem solving skills necessary to cope with the problem and would probably relapse if moved to a lesser level of care. The material from the weekly case notes indicates that during the time period in dispute from 4/20/15 through 6/25/15, the patient was working slowly but steadily toward a better understanding and acceptance of his substance abuse and the role it played in his life.  However, the first documentation that he was actually successful in using his coping skills was the weekly case note dated 5/7/15. At that point, he would have been safe to have been transitioned to a lower level of care to continue his treatment. For these reasons, continued mental health program services were medically necessary from 4/20/15 through 5/7/15 but not thereafter. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. Specifically, dates of 4/20/15 through 5/7/15 were medically necessary. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 51-year-old female enrollee has requested reimbursement for hyaluronan knee injections performed on 12/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees osteoarthritis.  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the hyaluronan knee injections performed on 12/6/17 were medically necessary for treatment of this patients medical condition. Based on the foregoing, 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 20-year-old female enrollee has requested reimbursement for the wilderness therapy program received from 5/22/15 through 8/3/15.  The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is lack of support in the literature for the medical necessity of the services at issue in this clinical setting. In an article by Widmer and colleagues, the authors noted that while some studies report benefits of wilderness therapy, caution should be exercised in the interpretation of these results. In order to establish its efficacy, a multi-centered, highly-powered, randomized controlled trial would need to be performed. Currently, there are not enough studies to indicate that wilderness therapy is effective in the treatment of depression and anxiety over standard therapies. In addition, from the records provided, there was a lack of oversight by a child and adolescent psychiatrist, and there were no nursing staff to properly administer medications and monitor the patients. Accordingly, based on the medical literature, wilderness therapy received from 5/22/15 through 8/3/15 did not meet the standard of care for the treatment of depression, anxiety, and substance use. As such, the wilderness therapy program received from 5/22/15 through 8/3/15 was not medically necessary for treatment of this patients medical condition. Therefore, based on the information noted above, 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 


A 38-year-old female enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation from 1/06/16 forward.  The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  Although some preliminary positivism regarding the application of transcranial magnetic stimulation therapy for the bipolar population can be found in the medical literature or in reports from clinical practices in the community, there is an absence of well-controlled and adequately powered exploratory and confirmatory studies regarding this intervention for the treatment of bipolarity at this time.  Further, it does not appear that the patient has failed other treatments commonly relied upon to treat bipolar disorder.  Additionally, it does not appear that the patient had an informational consultative appointment with an electroconvulsive therapy specialist to learn more about the treatment, as the intervention remains a trusted, rapid and effective treatment for both mania and bipolar depression.  Finally, there was a dearth of information regarding the status of supportive relationships and community functioning, or outcomes of non-pharmacological interventions.  Although the patient reportedly had tried multiple courses of past psychotherapies, there was no reported outcome of cognitive behavioral therapy and it does not appear that she had trialed other evidence-based therapies for bipolar illness, such as family therapy or interpersonal/social rhythm therapy.  All told, transcranial magnetic stimulation from 1/06/16 forward was not and is not medically indicated for the treatment of this patient.  Therefore, the services at issue were not and 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 Upheld

Summary Reviewer 


A 47-year-old female enrollee has requested authorization and coverage for a positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollees pulmonary blastoma. The physician reviewer found that the use of PET/CT for surveillance in non small cell lung cancer is not supported by the National Comprehensive Cancer Network (NCCN) guidelines absent any clinical evidence of tumor recurrence or imaging finding on conventional studies suspicious for tumor. In this case, the patients most recent PET/CT in April 2016 was negative and a follow-up CT of the chest showed no sign of tumor recurrence. Together with negative serum tumor markers, the requested PET/CT is not medically necessary per NCCN guidelines which state that PET/CT is not routinely indicated for surveillance after definitive therapy. Thus, absent biochemical or conventional imaging findings suggestive of tumor recurrence, the requested PET/CT scan is not medically necessary for evaluation of this patients pulmonary blastoma. Based on the foregoing discussion, the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 60-year-old female enrollee has requested reimbursement for a breast tomosynthesis that was performed on 10/29/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for purposes of the enrollees breast cancer screening.  The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  All told, breast tomosynthesis performed on 10/29/15 was 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 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 60-year-old female enrollee has requested reimbursement for a breast tomosynthesis that was performed on 10/29/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for purposes of the enrollees breast cancer screening.  The physician reviewer found there is limited 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. While the technology is promising, its clinical efficacy has not yet been substantiated in peer-reviewed literature. At this time, there is insufficient data from randomized, controlled studies demonstrating that the addition of breast tomosynthesis to standard mammography results in improved outcomes in this patient population. Therefore, the superior effectiveness of breast tomosynthesis performed on 10/29/15 has not been established. 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 Overturned

Summary Reviewer 3


A 60-year-old female enrollee has requested reimbursement for a breast tomosynthesis that was performed on 10/29/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for purposes of the enrollees breast cancer screening.  The physician reviewer found breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, she has breasts that have been described as being heterogeneously dense.  Even though the patients mammogram has not changed since the last study, it is specifically these 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.  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.