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

Summary Reviewer 


The parent of a seven-year-old male enrollee has requested authorization and coverage for speech therapy.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees speech misarticulations. The physician reviewer found that to the literature, speech and language deficits that persist into the primary school years have long-term effects on literacy, school success, socialization, and behavior.  In particular, speech sound disorders not only greatly reduce intelligibility, but have also been associated with later reading disability.  Speech sound disorders refer to any combination of difficulties that impact speech intelligibility, including perception, motor production, and phonological representation of speech sounds and segments. Articulation disorders are those that impact the form of speech sounds and are associated with structural and motor-based problems.  Phonology disorders impact the way speech sounds function within a language.  Treatment approaches have traditionally focused on either articulation or phonology. Articulation approaches are typically selected if the problem is thought to be motor-based, and phonologic approaches tend to target specific sound error patterns.  The literature supports speech therapy intervention for young children with speech sound disorders.  In this patients case, the records document misarticulations negatively impacting his intelligibility, in addition to oral-lingual structural abnormalities and oral-motor deficiencies, all resulting in a speech sound/production disorder.  All told, the requested speech therapy is medically indicated for the treatment of this patient.  Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement for mental health residential treatment center (RTC) services provided from 7/6/15 through 6/28/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees major depressive disorder and anxiety disorder. The physician reviewer found that the records provided for review do not meet the medical necessity criteria for the mental health RTC level of care services provided from 7/6/15 through 6/28/16. Overall, the patient did not require 24-hour a day seven days per week supervision. The patient did not appear to be at imminent risk of harm to self or others. Psychiatric issues prompting his admission including depression and irritability could have been safely and efficiently been treated at a less intensive treatment setting. There also was no evidence of any acute impairment, behavior, or issues with cognition that interfered with activities of daily living. Psychosocial and environmental problems were not likely to threaten the patients safety and would not likely have undermined engagement at a less intensive level of care, such as outpatient care. On 7/10/15, the patients individual therapy note reported the patients mood was normal and his affect was blunted. On 7/28/15, he had a significant reduction in crying spells since admission to the program. On 8/10/15, he continued to report irritability. Such treatment issues are those routinely treated in an outpatient clinic and did not require RTC services to be managed effectively. Further, medication changes made during this time did not require RTC level of care and supervision. Depakote was reduced and Seroquel was increased due to low neutrophils. It was also noted he repeatedly was not using his continuous positive airway pressure (CPAP) routinely including on a progress note dated 11/18/15. However, the medication management could have been adequately addressed on an outpatient basis and the use of CPAP could have been supervised by his caregiver at home. On 12/30/15, it was noted that his home visit did not go well. It was reported he had low frustration tolerance and poor mood regulation. However, these issues did not warrant ongoing residential treatment. Moreover, on 5/29/16 it was noted that the patient had no suicidal or homicidal ideations, had no mania, no psychosis, and no agitation. All told, the mental health RTC services provided from 7/6/15 through 6/28/16 were not medically necessary for treatment of this patients behavioral health issues. Based on the foregoing discussion, 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 22-year-old male enrollee has requested reimbursement for substance use intensive outpatient program services from 10/14/16 through 10/28/16. 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 that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. Based on the documentation provided, the patient had been transitioned into a sober living housing. He participated in groups though he was noted at times to be disruptive and sarcastic. The appeal letter stated that the patient required IOP due to grieving over the loss of his father, abandonment issues from his mother, and to address obsessive thoughts. The documentation does not state if any of these issues were addressed in the group sessions. The majority of the group sessions focused on substance treatment, sobriety, and coping with stressors. There was no documentation that the patient had any suicidal or homicidal ideation. There was no documentation that the patient was medically ill and required frequent supervision. By 10/14/16, the records indicate that the patient could have gone to community 12 step program meetings and achieved the same result. The patient could have been treated in a less restrictive environment as an outpatient with the patient attending community 12 step program meetings and working with his sponsor. Therefore, IOP services provided from 10/14/16 through 10/28/16 were not medically necessary for treatment of this patients medical condition. Based on 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 




The parent of a 17-year-old female enrollee has requested reimbursement for the residential mental health treatment services provided from 1/21/15 through 12/31/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that the documentation provided for review does not support the medical necessity of the residential mental health treatment services provided from 1/21/15 through 12/31/15 for treatment of this patients medical condition. The patient did not appear to be at imminent risk of harm to self or others. The patients psychiatric issues prompting admission including depression and impulsivity could have been safely and efficiently treated at a less intensive setting. There also did not appear to be any acute impairment, behavior, or issues with cognition that interfered with activities of daily living. Psychosocial and environmental problems were not likely to threaten the patients safety and she was not at risk of undermining treatment at a less intensive level of care, such as outpatient care. All told, the patient did not require 24-hour supervision for the period of time at issue. Accordingly, the services at issue were not medically necessary. Based on the foregoing discussion, 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 66-year-old male enrollee has requested authorization and coverage for Repatha Sureclick. The Health Insurer has denied this request and reported that the requested medication is 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 requested medication. This patient presents with some coronary risk, including hyperlipidemia, but no documented clinical cardiovascular disease.  Coronary calcification does not equal coronary stenosis. Repatha (evolocumab) is a proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic cardiovascular disease who require additional lowering of LDL cholesterol. This patient does not fit either of those criteria. There is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. These diagnoses require not only elevated LDL levels that significantly exceed 180 mg/dl but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a strong family history of coronary disease (younger than 50 years in second-degree relative or aged younger than 55 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria.   There is a lack of documentation to confirm the presence of obstructive coronary or vascular disease.  Repatha has not been adequately studied in the setting of primary prevention in patients with increased coronary risk but no evidence of clinical obstructive cardiovascular disease, such as this patient. Current guidelines that are endorsed by several national organizations also do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Therefore, Repatha SureClick is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 67-year-old male enrollee has requested reimbursement for inpatient stay provided from 1/02/19 through 1/03/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the majority of patients who present with renal colic can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The records did not indicate significant complications or major issues with pain control. The procedure performed is considered a minimally invasive outpatient procedure. The patients perioperative clinical status does not suggest the need for acute inpatient care. Observation status for this patients clinical presentation and postoperative course would have been medically appropriate. Admission status may be changed anytime during observation if the patient requires continuing services and monitoring, and if the patients condition is severe enough to require inpatient treatment. The current medical evidence does not support inpatient services in this clinical setting. Therefore, inpatient services provided from 1/02/19 through 1/03/19 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 61-year-old male with benign prostatic hyperplasia (BPH) and American Urological Association (AUA) symptom score of 20. The patient underwent UroLift on 10/18/16 to relieve obstructive symptoms. The patient has requested reimbursement for the UroLift procedure provided on 10/18/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational.  Currently, there is a lack of peer-reviewed medical literature or clinical guidelines that support the utility of UroLift with standard available treatment options. As noted by Chung and Woo, UroLift appears to be a well tolerated and effective minimally invasive treatment for lower urinary tract symptoms due to BPH in men who wish to preserve sexual function or who are not suitable for invasive surgery. Further studies will confirm the currently mixed results regarding intraprostatic botulinum toxin or ethanol injections. Thus, additional investigation is appropriate to confirm these initial results. For these reasons, the UroLift procedure provided on 10/18/16 was 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 service at issue was 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 61-year-old male with a history of lower urinary tract symptoms. The patients symptom score is 20. The patient underwent cystoscopy which revealed bladder outlet obstruction. There is also significant post-void residual urine. The patient underwent a prostate biopsy in the past which revealed a low grade low volume low risk prostate cancer. His prostate specific antigen (PSA) is 1.15. He has failed medical therapy including of alfuzosin, Cialis, tamsulosin. The patient elected to proceed with UroLift procedure attempt to relieve his bilateral obstruction and associated symptoms. The provider recommended prostatic urethral lift (PUL) procedure with UroLift. The patient has requested reimbursement for the UroLift procedure provided on 10/18/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational. UroLift procedure has been demonstrated to be an effective treatment for well selected patient 50 years of age or older with benign prostatic hyperplasia (BPH). There is good quality evidence to establish the efficiency of PUL in treating symptomatic patients with BPH without adversely affecting the quality of life. Based on the current literature, PUL can be considered as an option for those symptomatic BPH patients with small or medium size prostates 80 ml or less, without median lobe enlargement, who failed on medical therapy or are intolerant, and would like to preserve their sexual function. However, there is a paucity of studies indicating safety of this procedure for a patient with previously diagnosed prostate cancer. Although this patients symptoms are most likely related to bladder outlet obstruction, given the limited data showing long-term improvement in this clinical setting, the UroLift procedure provided on 10/18/16 was 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 service at issue was 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 61-year-old male with a diagnosis of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. Associated symptoms include nocturia, slow stream, and incomplete emptying. Prior failed therapy includes uroxatral. The patient has requested reimbursement for the UroLift procedure provided on 10/18/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational. The prostatic urethral lift (PUL) system is a novel, minimally invasive approach to treating BPH that lifts or holds the enlarged prostate tissue out of the way of the urethra. Recent clinical trials including prospective sham controlled randomized studies have shown that the UroLift System treatment is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function. Compared with standard available options, PUL is minimally invasive procedure without a requirement of general anesthesia with a potentially shorter operative time. A recent prospective, randomized, multinational study compared the outcome of PUL to transurethral resection of the prostate (TURP) and concluded that participants who underwent the PUL procedure responded significantly better than those who underwent TURP as therapy for BPH with regard to important aspects of quality of life (Snksen, et al). All told, the UroLift procedure provided on 10/18/16 was 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 service at issue was 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 Upheld

Summary Reviewer 1

A 45-year-old female enrollee has requested reimbursement for the Decision Dx melanoma test performed on 4/4/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is insufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. According to the results of analysis of patients melanoma performed with Decision Dx melanoma, the tumor was classified as Class 1 with a low risk of near-term (within five years) metastatic disease. Although Decision Dx melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. Therefore, Decision Dx melanoma test performed on 4/4/16 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 testing 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 Upheld

Summary Reviewer 2

A 45-year-old female enrollee has requested reimbursement for the Decision Dx melanoma test performed on 4/4/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the Decision Dx melanoma test performed on 4/4/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patients tissue underwent Decision Dx testing where the genes are examined for certain markers and then the lesion can be further stratified to tell if there is high risk for metastasis. The treatment of this patient would not change based on the results of the. The test is not considered standard of care. There is a lack of peer-reviewed literature to support its use in the care of patients with thin melanomas to effect health outcomes. In sum, there is a lack of published data to support its use in this clinical setting. Therefore, the testing at issue 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 testing 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 Upheld

Summary Reviewer 3

A 45-year-old female enrollee has requested reimbursement for the Decision Dx melanoma test performed on 4/4/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the patient was diagnosed with a nevoid melanoma measuring 0.42 mm Breslow depth on the right cheek. She underwent Decision Dx Melanoma gene testing to assess the risk of metastatic disease. The use of Decision Dx Melanoma gene testing is not recommended outside of clinical trials according to the National Comprehensive Cancer Network guidelines. In addition, the testing at issue is not the standard of care in melanoma treatment or work-up. For the reasons provided, the Decision Dx melanoma test performed on 4/4/16 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 testing 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 59-year-old female enrollee has requested authorization and coverage for Fentora buccal tablets 800 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees pain. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain associated with spine degenerative disc disease and/or post-laminectomy syndrome is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  There are a variety of anticonvulsants and antidepressants considered adjunctive to this therapy.  High-dose opioids are associated with a high risk of dependence and tolerance.  Baron and McDonald reported that high-dose and short-acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Ballantyne and Mao reported that prolonged use of high-dose, short-acting opiates might induce tolerance and abnormal pain sensitivity.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, Fentora buccal tablets 800 mg are not medically indicated for the treatment of this patient.  Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.