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

Summary Reviewer 2


The parent of a 14-year-old male enrollee has requested authorization and coverage for surgery for scoliosis. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that surgery for scoliosis has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Samdani and colleagues reviewed 32 patients who underwent a fusionless treatment of thoracic vertebral body tethering (VBT) with a minimum one-year follow-up. The authors concluded that that anterior VBT was a safe and potentially effective treatment option for skeletally immature patients with idiopathic scoliosis. However, the authors stated that longer term follow-up of this cohort will reveal the true benefits of this promising technique. In this case, the patient has been diagnosed with idiopathic scoliosis with a 44 degree thoracic curve and 24 degree lumbar curve. There is a lack of documentation of significant pain or current functional or activity limitation. In addition, there is a lack of evidence demonstrating an adequate trial of bracing as recommended by the treating provider has been tried. Finally, there is a lack of large volume, long-term peer-reviewed outcome studies to support the safety and effectiveness of vertebral body tethering at this time. In sum, the requested surgery for scoliosis 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 3


The parent of a 14-year-old male enrollee has requested authorization and coverage for surgery for scoliosis. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that standard interventions for adolescents and adults, including spinal deformity correction and fusion, may not be appropriate for young patients with considerable growth remaining. Preliminary outcomes for fusionless spine surgery are promising, but further investigation, including long-term follow-up, is necessary. In addition, the requested technique is not the standard of care in this clinical setting. Vertebral body stapling, a fusionless treatment option, has been shown to be effective in controlling curve progression in the high-risk group of children younger than 10 years with idiopathic scoliosis between 30 and 39 degrees in whom bracing may be ineffective (Theologis, et al). Therefore, surgery for scoliosis 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 

The patient is a 33-year-old female with a history of asthma, allergic rhinitis, aspirin allergy, and recurrent nasal polyps despite treatment with multiple nasal sprays. The patient has requested authorization and coverage for Dupixent. The physician reviewer found that Dupixent is a U.S. Food and Drug Administration (FDA) approved medication for adults with chronic rhinosinusitis with nasal polyposis, and the only approved therapy shown to shrink nasal polyp size and also improve the signs and symptoms of the associated chronic rhinosinusitis. This patient has persistent nasal polyposis after nasal surgeries two years ago, and she has had recurrent rhinosinusitis despite treatment with intranasal corticosteroids such as Flonase, Nasonex and XHance. The likely culprit of the recurrence of polyps is related to her aspirin allergy, as a condition called Samteras triad. It is a chronic condition called aspirin-exacerbated respiratory disease (AERD). The nasal polyps tent to recur despite standard treatment, such as the ones the patient has tried. The current medical evidence supports the requested medication in this clinical setting. Therefore, Dupixent is medically necessary.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 63-year-old female enrollee has requested reimbursement for computed tomography (CT) of the head or brain and computed tomography angiography (CTA) of the head and neck performed on 4/29/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation supports the services at issue in this clinical setting.  This patient had episodes of acute neurologic dysfunction.  Her differential diagnosis included stroke or dissection, and imaging was carried out to assess these possibilities.  Imaging such as CT and MRI allow for distinction between hemorrhagic and ischemic strokes, providing greater certainty whether to administer thrombolysis.  Imaging in this circumstance of acute transient neurologic dysfunction appropriately included brain and neurovascular imaging.  CT of the head or brain and CTA of the head and neck were appropriate testing in this clinical setting, as it appears that MRI-MRA were not completed due to claustrophobia.  In sum, CT of the head or brain and CTA of the head and neck performed on 4/29/15 were medically indicated 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 45-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 2/6/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the patient is a 45-year-old female who underwent routine screening mammogram with computer-aided detection and digital breast tomosynthesis on 2/6/15.  The mammogram revealed dense breasts, but was negative and unchanged compared with prior exams. The patient is requesting reimbursement for the breast tomosynthesis performed on 2/6/15. The Health Insurer has denied this request as investigational.There is a lack of peer-reviewed literature that supports the use of three-dimensional (3D) breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in the peer-reviewed literature. Thus, the breast tomosynthesis performed on 2/6/15 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 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 2


A 45-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 2/6/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the patient is a 45-year-old female with a family history of breast cancer. The patient had a screening mammogram including tomosynthesis performed on 2/6/15 revealing extremely dense tissue but no evidence of malignancy. The patient is requesting reimbursement for the breast tomosynthesis performed on 2/6/15. The Health Insurer has denied this request as investigational. The American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category in light of the advantages it brings to radiologists in the interpretation of mammograms particularly in cases of extremely dense tissue, such as in this case. The tomographic qualities of tomosynthesis often allow radiologists to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. Thus, the use of tomosynthesis was likely of more benefit to the patient than if she had her study using two-dimensional technique only. 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 3


A 45-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 2/6/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the patient is a 45-year-old female who was apparently asymptomatic with respect to her breasts. She has a family history of breast cancer (sister at age 40). On 2/6/15, she underwent a routine screening mammogram as well as a three-dimensional tomosynthesis examination.  Those studies were compared to prior mammograms dated 8/14/09, 8/6/10 and 9/23/11.  On the current examination, no abnormalities were detected, and there had been no interval changes. There were no masses, suspicious calcifications, or areas of asymmetry. Her breasts were described as extremely dense. The patient is requesting reimbursement for the breast tomosynthesis performed on 2/6/15. The Health Insurer has denied this request as investigational. Tomosynthesis is a technique that was developed 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 the dense breast tissue. In this case, the patient has extremely dense breasts. While one could make the argument that her mammogram has not changed since the last study, it is specifically those 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. Given the above, the breast tomosynthesis performed on 2/6/15 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 58-year-old female enrollee has requested reimbursement for blepharoplasty of the upper eyelid performed on 12/07/18. 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 the submitted documentation fails to demonstrate the medical necessity of the services at issue. The blepharoplasty was not medically necessary based on the lack of appropriate visual field studies and the lack of photographic evidence. In this setting, a suprathreshold static visual field test would have been appropriate rather than the full threshold test that was done in this case. In addition, the results provided were grayscale representations of the field, not the actual visual field test result. Thus, it is not possible to determine the degree from fixation where the absolute scotoma begins. There were no photographs to support the need for functional surgery. Therefore, upper eyelid blepharoplasty performed on 12/07/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 64-year-old male enrollee has requested reimbursement for assay of vitamin D performed on 8/08/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollee, who has a history of hyperlipidemia. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The clinical manifestations of vitamin D deficiency depend upon the severity and duration of the deficiency. The majority of patients with moderate to mild vitamin D deficiency are asymptomatic. In the setting of severe vitamin D deficiency, there can be hypocalcemia which leads to bone disorders. Patient groups who are at risk for vitamin D insufficiency include those who have dark skin or are obese, those taking medications that accelerate the metabolism of vitamin D, hospitalized or institutionalized people or those who have limited effective sun exposure. Other people at high risk include those with osteoporosis or malabsorption, including inflammatory bowel disease and celiac disease.  Screening of the general population is not recommended. In this case, the patient did not have chronic medical conditions that would cause vitamin D deficiency. Thus, assay of vitamin D performed on 8/08/18 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 62-year-old female who is status post mastectomy with lymph node dissection in June 2020. The patient has requested reimbursement for hospital admission provided from 9/29/20 through 10/01/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Schwartz stated, As surgical procedures become less morbid with decreased operative times, less postoperative pain, and quicker recovery, the benefits of hospital admission become less significant and same-day discharge is possible without compromising outcomes, patient safety, or satisfaction. Oxley and colleagues performed a study of same day discharge after immediate post-mastectomy alloplastic breast reconstruction. The authors noted, Any patients with high-risk anesthetic histories, ASA III or above or significant sleep apnea are admitted for a planned overnight stay at the hospital. All other patients (ASA II or lower) are treated as same day discharge procedures, either at the hospital or day care clinicSame day discharge following IPMABR (immediate post-mastectomy alloplastic breast reconstruction) is safe and greatly reduces resource use. In this case, the patient developed an acute unilateral breast hematoma following previous subpectoral placement of a tissue expander. An arterial bleeder was identified, and the hematoma was evacuated in the operating room. She was admitted for two days of inpatient hospital stay. There is no history of intercurrent disease or of increased anesthesia or postoperative risk factors. No special postoperative monitoring was required, and her recovery was uneventful. Drainage was reduced markedly by the morning following the procedure. Based on the medical records received for review, there is no indication that inpatient hospital care was required as contrasted to observation care. Therefore, hospital admission provided from 9/29/20 through 10/01/20 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 56-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Optune electrical stimulation device from 4/20/15 forward. The Health Insurer has denied this request indicating that the device at issue was not and is not medically necessary for treatment of the enrollees recurrent glioblastoma multiforme. The physician reviewer found The central nervous system tumors are classified by the World Health Organization (WHO) based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV.  Anaplastic astrocytomas and glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. This patient has exhausted all these options.  In 2011, the U.S. Food and Drug Administration approved the NovoTTF-100A device, now known as the Optune electrical stimulation device, to deliver alternating electrical fields to treat recurrent glioblastoma multiforme.  The approval was based on a randomized clinical study where 237 patients were treated with either NovoTTF versus best standard of care chemotherapy, including bevacizumab.  There was no difference in overall survival between the two arms.  The Optune electrical stimulation device is medically indicated for this patient who has exhausted standard treatment options.  There is sufficient medical evidence to demonstrate the safety of this device.  All told, Optune electrical stimulation device from 4/20/15 forward was and is medically indicated for the treatment of this patient.  Therefore, the device at issue was and is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 38-year-old male enrollee has requested authorization and coverage for a cardioverter defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee, who has cardiac sarcoidosis. The physician reviewer found that Cardioverter defibrillator implantation is a Class IIa recommendation in patients with cardiac sarcoid, independent of ventricular function, if there is an indication for permanent pacemaker implantation. In this patients case, given the symptomatic bradycardia due to intermittent second degree heart block, a permanent pacemaker is indicated. Therefore, an implantable cardioverter defibrillator is indicated. This is due to the increased risk for sudden cardiac death with this type of cardiomyopathy. Therefore, the requested cardioverter defibrillator is likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested device is 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 2

A 38-year-old male enrollee has requested authorization and coverage for a cardioverter defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee, who has cardiac sarcoidosis. The physician reviewer found that this patient has a history of cardiac sarcoidosis and symptomatic 2:1 atrioventricular block in need of pacemaker placement. In this circumstance of cardiac sarcoidosis and ejection fraction greater than 35% with an indication for pacemaker placement, it is reasonable to implant a defibrillator if meaningful survival of greater than one year is expected. Some patients with cardiac sarcoidosis with normal ejection fraction and no heart failure symptoms have high arrhythmic event rates, especially when late gadolinium enhancement is identified on cardiac MRI or abnormal findings are seen on cardiac PET imaging, such as this patient. The medical evidence supports the requested device in this case. Therefore, the requested cardioverter defibrillator is likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested device is 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

A 38-year-old male enrollee has requested authorization and coverage for a cardioverter defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee, who has cardiac sarcoidosis. The physician reviewer found that there is support for the requested device in this patients case. Implantable cardioverter defibrillators are indicated for patients with cardiac sarcoidosis who have an indication for permanent pacemaker placement. In this case, the patient has an indication for pacemaker placement, as he has symptomatic second degree atrioventricular block.  Therefore, the requested cardioverter defibrillator is likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested device is 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 Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested authorization and coverage for anterior dual fusion. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support in the medical literature for spinal fusion for the management of chronic regional low back pain. A multicenter randomized study by Brox and colleagues compared the effectiveness of lumbar instrumented fusion with cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. The authors found there was no advantage over instrumentation and fusion versus the conservative treatment method. The patient has well-documented multi-level cervical and lumbar degenerative disc disease. He has upper extremity neurological symptoms considered to reference cervical spine myelopathies. However his studies do not demonstrate instability on flexion extension views. MRI revealed a stable grade 1 spondylolisthesis at L3-4. This would not be addressed with an L4-S1 fusion which would likely aggravate that condition by increasing stresses at that level after fusion. In addition, the diagnosis of neural foraminal stenosis at the lumbar spine is weakly supported with anatomical studies and even if present can be addressed with the posterior approach laminotomy foraminotomy without fusion. In addition, upper extremities symptoms suggest an undiagnosed neurological disorder as a comorbidity. Therefore, the anterior dual fusion 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.