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

Summary Reviewer 


A 58-year-old male enrollee has requested reimbursement for an aflibercept injection, J0178 performed on 2/23/15. The Health Insurer has denied this request indicating that the service at issue was not medically necessary for treatment of the enrollees cystoid macular edema. The physician reviewer found the submitted documentation fails to establish the medical necessity of the service at issue. Eylea has shown promising results in treatment of macular edema in cases of diabetic retinopathy and central retinal vein occlusion. However, the medical literature has not yet demonstrated that Eylea has any application in post-cataract surgery cystoid macular edema. As such, the aflibercept injection, J0178 performed on 2/23/15 was not clinically indicated in this patients case. For the reasons provided, the service at issue was 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 16-year-old transgender male. The patientas parent has requested authorization and coverage for a mastectomy. 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 the current medical evidence supports the requested services in this clinical setting. The World Professional Association for Transgender Health states, aChest surgery in female-to-male patient could be carried out [in minors]a preferably after ample time living in the desired gender role and after one year of testosterone treatment.a While length of time living stably in gender role and length of time on testosterone are not absolute requirements, they are met by this patient. This patient has lived in male role for three years and has been on testosterone for one year, having started testosterone in June 2019. Chest surgery in transmasculine minors has been demonstrated to be a safe and effective treatment for gender dysphoria. Olson-Kennedy and colleagues stated, aChest dysphoria was high among presurgical transmasculine youth, and surgical interventions positively affected both minors and young adults.a Therefore, the requested mastectomy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 58-year-old female who has a history of opiate use disorder, alcohol, benzodiazepine, amphetamine and cannabis use disorders and past psychiatric history of bipolar disorder  and depression. She presented to an inpatient rehabilitation facility on 8/7/17. She had been using opiates since age 43 for back pain. The patient has requested reimbursement for residential treatment for 8/21/17 through 9/12/17. The Health Insurer denied this request and reported that the services at issue were not medically necessary. This denial is the subject of this appeal and determination. The submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. A notation on 8/20/17 indicated that the patients mood and affect were improved. By 8/21/17, the clinical notes show the patient was independently engaging in everyday activities. The patient indicated an ability to function and receive services as an outpatient. Progress note on 8/22/17 reported that the patient attended a yoga class which is a testament to her physical health. She also attended a family barbeque, watched movies and attended beach meetings. The record reported that the patient was engaging with peers and counselors. There were no signs or symptoms of an acute withdrawal or psychiatric symptoms, such as suicidal or homicidal ideations or psychosis. By 8/21/17, the patients symptoms did not necessitate inpatient residential treatment. Such services rendered to the patient for the reimbursement period specified could have been achieved at a lower level of care. Therefore, residential treatment services provided from 8/21/17 through 9/12/17 were not medically necessary. Therefore, for the reasons stated 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 43-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/2/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found the tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. 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 9/2/16 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 service 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 digital breast tomosynthesis performed on 9/2/16. The Health Insurer has denied this request indicating that the service 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 9/2/16 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 service 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 digital breast tomosynthesis performed on 9/2/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved since the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. As the 2D images were most likely reconstructed from the primary tomosynthesis acquisition, a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to a prior mammogram from eight years earlier, and especially when there is considerable fatty change. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 9/2/16 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 service 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/30/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that there is evidence based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis, to the usual two dimensional protocol was likely to be more effective than had her examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service at issue was likely to have been 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 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/30/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that the medical literature supports breast tomosynthesis 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. Thus, the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed on 8/30/16 was likely to have been superior to other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to have been 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 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/30/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that 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 scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, she has breasts containing multiple masses, many of which are changing in size.  The ability of better characterizing the margins of masses and establishing whether there might be suggestion of malignancy is a valuable advantage of tomosynthesis over other methods of testing.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Had there been no interval change, a tomosynthesis would not be indicated but considering the changes, tomosynthesis, for this patient, is helpful. Therefore, digital breast tomosynthesis performed on 8/30/16 was likely to have been of greater benefit than other modalities for evaluating this patient. Based upon the information set forth above, the service at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 34-year-old female enrollee has requested reimbursement for partial hospitalization program level of care provided on 1/08/16, 11/11/16, 1/12/16, 1/15/16, 1/18/16, 1/19/16, 1/20/16, 1/21/16, 1/22/16, 1/25/16, 1/26/16, 1/27/16, 1/28/16, 1/29/16, 2/01/16, 2/02/16, 2/03/16, 2/04/16, 2/05/16, 2/08/16, 2/10/16, 2/11/16, 2/12/16, 2/15/16, 2/16/16, 2/17/16, 2/18/16, 2/19/16 and inpatient outpatient treatment provided on 2/24/16, 2/26/16, 2/29/16, 3/01/16, 3/02/16, 3/03/16, 3/04/16, 3/07/16, 3/08/16, 3/09/16, 3/10/16, 3/11/16, 3/17/16, 3/18/16, 3/21/16, 3/24/16, 3/25/16, 3/28/16, 3/29/16, 3/30/16 and 3/31/16. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that patients require safe and stable living environments in order to develop their recovery skills. The submitted records support the services at issue in this patients case. The six ASAM dimensions for partial hospitalization program level of care were met. There was a minimal risk of severe withdrawal, although she had to have detoxification prior to the disputed timeframe. She had no medical conditions/complications. Her emotional/behavioral/cognitive conditions/complications included a moderately severe mixed manic-depressive state. The patient was somewhat motivated to change, although she required structure of a day program at least to engage and get her on track. She had a high likelihood of relapse without close monitoring and support, given her relapse during the program. The records documented a minimally supportive environment. Given the severity of the patients illness, partial hospitalization program level of care and stepdown to intensive outpatient program treatment were in accordance with generally accepted standards of medical practice. Therefore, partial hospitalization program level of care provided on 1/08/16, 11/11/16, 1/12/16, 1/15/16, 1/18/16, 1/19/16, 1/20/16, 1/21/16, 1/22/16, 1/25/16, 1/26/16, 1/27/16, 1/28/16, 1/29/16, 2/01/16, 2/02/16, 2/03/16, 2/04/16, 2/05/16, 2/08/16, 2/10/16, 2/11/16, 2/12/16, 2/15/16, 2/16/16, 2/17/16, 2/18/16 and 2/19/16 and intensive outpatient treatment provided on 2/24/16, 2/26/16, 2/29/16, 3/01/16, 3/02/16, 3/03/16, 3/04/16, 3/07/16, 3/08/16, 3/09/16, 3/10/16, 3/11/16, 3/17/16, 3/18/16, 3/21/16, 3/24/16, 3/25/16, 3/28/16, 3/29/16, 3/30/16 and 3/31/16 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 28-year-old male enrollee has requested reimbursement for Prometheus Anser ADA diagnostic test performed on 12/30/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease.
 The physician reviewer found that monitoring patients on adalimumab with measurement of adalimumab levels and antibodies to adalimumab continues to be an area of interest in the inflammatory bowel disease community. In general, adalimumab levels correlate inversely with disease activity. However, there is a lack controlled data which has identified the optimal drug level and so, the issue remains speculative. This patients level was in the normal range despite the fact that he was having an active flare/progression of disease, highlighting the limitation of the test. Using the Anser ADA, one can set up a hypothetical table categorizing drug levels as high or low and antibody levels as high or low. In theory, one could use this table to determine whether to dose increase or switch to a biologic agent with a different mechanism of action. Unfortunately, this hypothetical benefit is not supported by high quality medical evidence. In sum, Prometheus Anser ADA diagnostic test performed on 12/30/15 was not likely to be more effective than standard options of therapy, like empiric dose titration. Therefore, for the reasons stated above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 28-year-old male enrollee has requested reimbursement for Prometheus Anser ADA diagnostic test performed on 12/30/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease.
 The physician reviewer found that the Anser ADA test assesses serum adalimumab (ADA) and anti-ADA antibodies. Some evidence exists that low serum levels of infliximab or adalimumab and/or the presence of antibodies to infliximab or adalimumab may play a role in primary or secondary response failures. However, it has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. While there have been testimonials, there are few well-controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established. Moreover, it has not been established how patient management would change based on test results.  In sum, the Prometheus Anser ADA diagnostic test performed on 12/30/15 was not likely to have been more effective than other treatment modalities for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for the evaluation of this 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 28-year-old male enrollee has requested reimbursement for Prometheus Anser ADA diagnostic test performed on 12/30/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease.
 The physician reviewer found that there is a lack of support as to the superior efficacy of the services at issue in this clinical setting.  In this patients case, Anser ADA was ordered to direct the management of the patients Crohns disease. The use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with Humira (adalimumab) may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature (Karmiris, et al; Imaeda, et al; Lichtenstein, et al). These small studies demonstrated, at best, correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Karmiris and colleagues found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. The available data does not allow final conclusions about the relevance of anti-adalimumab antibodies to the clinical efficacy of adalimumab. A study by Yanai and Hanauer concluded that prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response. As such, clinical literature does not support the superior efficacy of Prometheus Anser ADA diagnostic test performed on 12/30/15 over standard therapy in the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 57-year-old male enrollee has requested reimbursement for magnetic resonance imaging (MRI) (code 73721) performed on 12/22/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees knee pain. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. MRI is the most optimal means to evaluate an internal derangement. Plain x-rays are of only limited value because the menisci and ligaments are not visible on plain x-rays. One can assess the degree of degenerative disease and whether there are any acute bony structural abnormalities, but this information is only of limited interest in this patient. The initial x-rays did not demonstrate a fracture, and whether or not he has degenerative change has no bearing. Some patients with no degenerative disease have grossly abnormal menisci, and conversely, there are patients who have gross degenerative joint disease but relatively intact menisci. In a typical patient without trauma, conservative management may be appropriate prior to considering an MRI. However, this patient had an acute traumatic event. Subsequently, the patients symptoms worsened to the point where he had difficulty bearing weight. In this patients case, there was an indication for subsequent cross-sectional imaging following trauma and a negative initial plain x-ray. In sum, considering the worsening symptoms, and the likelihood of associated ligamentous injuries, the MRI was the best means for further evaluation. Thus, MRI (code 73721) performed on 12/22/17 was medically necessary for the evaluation of this patient. Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.