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

Summary Reviewer 


The patient is a 65-year-old male who underwent laboratory testing on 8/11/20.  The patient has requested reimbursement for magnetic resonance elastography performed on 10/07/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of the appeal and determination. The physician reviewer found that this patient has had elevated liver enzymes and imaging showing hepatomegaly with fatty infiltration, consistent with liver diseases including non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, and autoimmune hepatitis. The American Association for the Study of Liver Disease (AASLD) guidelines for non-alcoholic fatty liver disease recommend assessment for liver disease, including fibrosis and cirrhosis. Magnetic resonance elastography is one method for the assessment of liver disease; it has a higher technical success rate than ultrasound elastography, superior accuracy to serum liver function testing for the detection of significant liver fibrosis, and the ability to reliably differentiate between early and late stages of hepatic fibrosis. American Gastroenterological Association (AGA) Institute guidelines for the role of elastography in chronic liver disease state that magnetic resonance elastography has considerably higher diagnostic accuracy in ruling out cirrhosis in patients who do not have cirrhosis than ultrasound elastography, and AGA Institute guidelines for the role of elastography in the evaluation of liver fibrosis recommend using magnetic resonance elastography rather than ultrasound elastography for detection of cirrhosis in patients with a risk for non-alcoholic fatty liver disease and a higher risk of cirrhosis. Given that liver disease (including non-alcoholic fatty liver disease) was suspected in this patient with elevated liver enzymes and hepatic steatosis on imaging, and guidelines recommend assessment for liver disease in such cases with modalities including magnetic resonance elastography, magnetic resonance elastography was medically indicated for the evaluation of this patients elevated liver enzymes and hepatic steatosis. Therefore, magnetic resonance elastography performed on 10/07/20 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 60-year-old male has requested reimbursement for gene testing provided on 11/07/17. 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 prognosis of cutaneous melanoma has classically been determined by the staging system spelled out by Balch. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or class 2 based on the risk of metastasis. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, gene testing provided on 11/07/17 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 2

A 60-year-old male has requested reimbursement for gene testing provided on 11/07/17. 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 there is a lack of support for the services at issue in this clinical setting. The results of this testing were unlikely to have altered treatment recommendations. There is a paucity of evidence from the literature that tailored follow-up according to these test results has an impact on long-term outcomes. Furthermore, prospective randomized studies to determine recurrence risk is lacking for this test. In sum, gene testing provided on 11/07/17 was not likely to have been superior over 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 60-year-old male has requested reimbursement for gene testing provided on 11/07/17. 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 (NCCN) guidelines states while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Thus, gene testing provided on 11/07/17 was not 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 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 61-year-old female enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the requested services in this clinical setting. The patient has obstructive sleep apnea and has no nasal obstruction. Drug induced sleep endoscopy showed no concentric collapse at velum and primarily anterior posterior collapse. The patient has not been able to tolerate the continuous positive airway pressure device. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device given the intolerance to continuous positive airway pressure, anterior posterior collapse, and body mass index within FDA criteria. Therefore, 64568 and 0466T are likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 61-year-old female enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that multiple studies indicate that hypoglossal nerve stimulation is a safe and effective treatment option for moderate-severe obstructive sleep apnea patients who have failed medical therapy. The STAR trial showed that upper airway stimulation provides significant improvement in sleep-related quality of life outcome measures. Safety and stable outcome results for the hypoglossal nerve stimulation/Inspire upper airway stimulation system have been demonstrated over 48 months in the peer-reviewed literature. In sum, 64568 and 0466T are likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 61-year-old female enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this patients case. She has moderate obstructive sleep apnea. The documentation notes that the patient is intolerant to continuous positive airway pressure therapy. The records do not clearly establish that the patient is not a candidate for oral appliance therapy. Mild to moderate obstructive sleep apnea has been shown to be responsive to oral appliance therapy. Thus, 64568 and 0466T are not likely to be more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 12-year-old female enrollee has requested reimbursement for inpatient hospitalization provided from 11/14/16 through 11/17/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees complex regional pain syndrome of her right lower extremity.  The physician reviewer found that based on the presented clinical records submitted for review, the inpatient hospitalization provided from 11/14/16 through 11/17/16 was medically necessary for treatment of the patients medical condition. Complex regional pain syndrome type 1 is a pain syndrome of the extremities characterized by pain, edema, limited range of motion, skin changes, and vasomotor instability. There is typically some inciting event, after which the symptoms occur. Prompt diagnosis and a multidisciplinary approach to treatment have been shown to facilitate recovery (Harris, et al; Wasner, et al). In this case, the patient presented with an acute on chronic exacerbation of her complex regional pain syndrome, refractory to her usual medications, addition of medications, and outpatient pudendal nerve block. Following failure of outpatient management and reports of extreme pain rated at 11/10, she was admitted for ketamine infusion and CT-guided pudendal nerve block. Ketamine is used to treat chronic pain syndromes, particularly those with a neuropathic component. Because neuropathic pain involves N-methyl-D-aspartate receptor upregulation, especially in cases of central sensitization, and ketamine is thought to inhibit this receptor, it has been used in appropriately chosen cases to provide relief. Given that the patient failed outpatient management, acute inpatient management provided at a higher level of care was clinically indicated for this patient. As such, the services at issue have been established as medically necessary for treatment of the patients medical condition. Therefore, 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 47-year-old female enrollee has requested reimbursement and prospective authorization and coverage for continued outpatient day treatment program/recovery facility care provided from 1/24/15 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 status post intracranial hemorrhage. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the services at issue. The patient sustained deficits of physical and cognitive function after a stroke in June 2014. She entered into acute rehabilitation with treatment continuing in the form of a day treatment program through May 2015.  Micklewright and colleagues have shown that entry into a comprehensive day treatment program 0-6 months after acquired brain injury is associated with better outcomes than later entry. The services in dispute are day treatment therapies provided from 1/24/15 and onward, seven months post-stroke and forward. The records submitted for review do not demonstrate the patient has deficits of self-care (ADLs) and functional mobility requiring continued intensive rehabilitation beyond 1/24/15. Based on the medical records submitted and the peer-reviewed literature, the continued outpatient day treatment program/recovery facility care provided from 1/24/15 forward was not and is not medically necessary for treatment of the patients medical condition. For the reasons provided, 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 58-year-old female with gastroesophageal reflux disease (GERD). Computed tomography (CT) scan of the abdomen on 3/14/17 showed mild wall thickening of the distal esophagus and a small hiatal hernia. Esophagogastroduodenoscopy (EGD) on 7/11/17 showed and irregular squamocolumnar junction at 40 cm, 1 cm hiatal hernia, scattered erosions in the gastric body and antrum, and normal appearing duodenal bulb and second portion of the duodenum. Biopsies showed acute and chronic inflammation at the gastroesophageal junction, Barretts esophagus, and minimal chronic gastritis. Esophagram on 9/19/17 showed normal esophageal peristalsis, no ulceration or stricture, and episodes of gastroesophageal reflux. EGD on 9/26/17 showed a normal-appearing esophagus, a Hill Grade 2 lower esophageal valve, and mild gastritis. Bravo pH study on 9/26/17 showed an elevated DeMeester score of 39.7, consistent with increased acid exposure. Per the providers note dated 10/9/17, the patient had a partial response to proton pump inhibitor therapy. The patient has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational. Overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the requested LINX is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

The patient is a 58-year-old female with a history of gastroesophageal reflux disease (GERD). Evaluation has included esophagogastroduodenoscopy (EGD) in 2017 with a small hiatal hernia, irregular Z-line and histologically mild acute and chronic esophagitis, and minimal to mild Helicobacter pylori-negative gastritis. In 2017, pH testing performed off acid blocker therapy identified a composite DeMeester score of 39.7 and zero correlation of acid reflux events with heartburn. The patient has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational. The LINX device received U.S. Food and Drug Administration (FDA) premarketing for patients with GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. This patient has GERD based on pH recording and radiographic criteria. However, she does not have evidence of advanced esophagitis nor was there correlation noted between acid reflux events and heartburn. Given that only 64% of patients achieved either normalization of or at least 50% reduction in esophageal acid exposure with LINX (1), this patients lack of correlation of symptoms with acid exposure does not support an indication for the requested procedure. Thus, the requested LINX procedure is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

The patient is a 58-year-old female under evaluation and treatment for GERD. The patient is considered to have both typical and atypical symptoms with only a partial response to proton pump inhibitor (PPI) therapy. Upper endoscopy showed no Barretts and a 1 cm hiatal hernia without esophagitis. Barium esophagram suggested normal peristalsis. The patient underwent a pH study of the esophagus which was positive for pathologic reflux with acidification of the esophagus 13% of the time. There was a poor correlation between acid reflux events and the timing of symptoms. The patient has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational. The U.S. Food Drug Administration (FDA) approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. This patient has a poor association between symptoms and episodes of pathologic reflux. In addition, the patient has atypical symptoms and only a partial response to PPI therapy. These findings indicate that the patient will not experience improvement with a surgical approach to her reflux disease beyond what she has experienced with PPI therapy. For these reasons, the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 47-year-old male enrollee has requested reimbursement for the magnetic resonance imaging (MRI) of the pelvis provided on 5/19/17. The Health Insurer has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees prostate cancer. The physician reviewer found that repeat imaging in this clinical setting to evaluate the patient for a change in the size of the tumor focus as well as the capsule and surrounding structures is state of the art medicine. Even though the patients PSA has remained stable the patient has a history of proven malignancy even in the face of a low PSA level. Currently, prostate MRI using a 3 Tesla magnet and restriction spectrum imaging (RSI) or diffusion weighted imaging is the most sensitive way to image the prostate and the surrounding anatomy. Based on the findings on this follow-up MRI, if there had been a change in the size of the tumor or if another focus of restricted diffusion was visualized, then the patient would likely have been referred for surgery. Given this support, an MRI of the prostate was indicated and MRI has been proven to be the most reliable means for further evaluation in this clinical setting. Accordingly, the MRI of the pelvis provided on 5/19/17 was medically necessary. For the reasons discussed, the service at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 53-year-old female enrollee has requested reimbursement for the bilateral three dimensional digital breast tomosynthesis provided on 10/16/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography alone. Overall, three dimensional digital breast tomosynthesis allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue. Moreover, the addition of breast tomosynthesis has been found to increase cancer detection. Thus, the digital breast tomosynthesis on 10/16/15 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 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 53-year-old female enrollee has requested reimbursement for the bilateral three dimensional digital breast tomosynthesis provided on 10/16/15. The Health Insurer has denied this request indicating that the services at issue are 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. This patients breasts were described as heterogeneously dense. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 10/16/15 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 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.