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

Summary Reviewer 


A 52-year-old male enrollee has requested reimbursement for emergency room physician services provided on 6/19/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. The patient presented with an acute injury that was significantly complex that required emergent physician services. There was serious impairment of the lower lip that could affect his oral competence (dysfunction), additional bleeding from the transected labial artery and significant deformity of the lower lip, without emergent treatment. Emergency room personnel did not have the expertise to sufficiently treat this patient and plastic surgery was consulted. Based on the documentation submitted for review, the patient was within an acute phase of injury and thus emergent closure was necessary. Further delaying treatment placed the patient at risk for functional impairment of the mouth, bleeding and significant deformity. Thus, the emergency room physician services provided on 6/19/17 met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a four-month-old male enrollee has requested reimbursement for the nitric oxide therapy provided from 11/4/16 through 11/7/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees respiratory distress syndrome.   The physician reviewer found that the patient was born at 28 weeks gestation on 11/2/16 and had neonatal respiratory distress syndrome causing pulmonary hypertension. The patient was intubated and treated with three doses of surfactant. Despite this treatment, on 11/4/16 the patient was hypoxic with oxygen saturation decreasing into the 60% range. An echocardiogram revealed pulmonary hypertension. As noted by the U.S. Food and Drug Administration (FDA), inhaled nitric oxide is a pulmonary vasculature dilator approved treatment for neonatal pulmonary distress syndrome with pulmonary hypertension. The pulmonary hypertension must be treated immediately to prevent large shunting of deoxygenated blood. Given this indication, the inhaled nitric oxide provided to this patient from 11/4/16 through 11/7/16 was consistent with standard of care and therefore was medically necessary.  Based on the foregoing discussion, the services at issue were 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 59-year-old female enrollee has requested reimbursement for Afirma Gene Expression Classifier assay performed on 10/12/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees thyroid nodule. The physician reviewer found that a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma Gene Expression Classifier assay utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  Therefore, Afirma Gene Expression Classifier assay performed on 10/12/15 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 59-year-old female enrollee has requested reimbursement for Afirma Gene Expression Classifier assay performed on 10/12/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees thyroid nodule. The physician reviewer found the medical evidence supports the services at issue in this clinical setting.  Genetic testing is generally considered standard protocol on all fine needle aspirations performed on thyroid nodules.  There is sufficient literature demonstrating that this testing can be performed to avoid needless surgeries.  In this case, the results helped guide future management.  In sum, Afirma Gene Expression Classifier assay performed on 10/12/15 was likely to have been more efficacious than other modalities for evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for Afirma Gene Expression Classifier assay performed on 10/12/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees thyroid nodule. The physician reviewer found the medical evidence supports the services at issue in this clinical setting.  The cytopathology of the thyroid nodule was consistent with follicular lesion of undetermined significance.  The risk of malignancy is 5 to 15% in these nodules.  The newest 2015 American Thyroid Association guidelines indicate that for nodules with follicular lesion of undetermined significance cytology, investigations such as repeat fine needle aspiration or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with either surveillance or diagnostic surgery.  In this patients case, the services at issue assisted with treatment planning.  Thus, Afirma Gene Expression Classifier assay performed on 10/12/15 was likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 44-year-old male enrollee has requested authorization and coverage MRI of the left shoulder. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that according to the American College of Radiology, the initial appropriate imaging study in the evaluation of atraumatic shoulder pain is radiography. Radiographs can evaluate for the presence of unsuspected fracture or dislocation, osteoarthritis or calcific tendinitis, among other pathology. If radiographs are negative or inconclusive, and rotator cuff pathology is suspected, then shoulder MRI is generally appropriate. MRI can accurately demonstrate rotator cuff tendinosis or full thickness tear as well as labral pathology. MRI can also aid in the diagnosis of extra-articular osseous or soft tissue findings that may contribute to shoulder impingement symptomatology. In this case, the patient had radiographs, which were negative, followed by physical therapy. His pain has persisted. His provider suspects rotator cuff pathology. The medical evidence supports the requested services in this clinical setting. Therefore, MRI of the left shoulder is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 58-year-old male with a diagnosis of ankylosing spondylitis in multiple spine areas.  The patientas provider has recommended Xeljanz XR 11 mg. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has already tried the step therapy with nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, methotrexate and TNF inhibitors. In addition to ankylosing spondylitis, this patient has Crohnas disease, which makes his options limited. There is support for Janus kinase (JAK) inhibitors after failing TNF inhibitors and IL-17 inhibitors. In this patientas case, none of the IL-17 inhibitors will be appropriate since they potentially cause flare-ups and worsen his Crohnas disease. Recent medical evidence indicates that tofacitinib (Xeljanz) can be used in patients with ankylosing spondylitis as an initial therapy or after failing other therapies, especially TNF inhibitors. In addition, tofacitinib is safe for use in patients with Crohnas disease. Therefore, Xeljanz XR 11 mg is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 60-year-old male enrollee has requested reimbursement for platelet-rich plasma injections performed on 3/11/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees plantar fasciitis. The physician reviewer found that the current medical evidence has not established the superior efficacy of the services at issue.  The literature suggests that platelet-rich plasma injections are as effective as corticosteroids.  Per Gogna and colleagues, when compared to low dose radiation, platelet-rich plasma injections were only seen to be as good.  Platelet-rich plasma injections may be appropriate when corticosteroid and electric shock wave treatment therapies are performed and failed.  Thus, platelet-rich plasma injections performed on 3/11/16 were not likely to have been more efficacious than other treatment options. Based upon the information set forth above, the services at issue were 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


A 60-year-old male enrollee has requested reimbursement for platelet-rich plasma injections performed on 3/11/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees plantar fasciitis. The physician reviewer found that the medical evidence has not established the superior efficacy of services at issue.  Most of the studies on the use of platelet-rich plasma therapy for plantar fasciitis advise of some efficacy.  However, the reviewers often note that further investigation is necessary to fully understand this treatment and its full potential.  There is a lack of large, double blind, placebo-controlled studies for this treatment modality.  Currently, the minimally invasive endoscopic plantar fasciotomy demonstrates a 90% cure rate.  Physical therapy including ultrasound, stretching of plantar fascia, off-loading of pressure to the plantar fascia with casting, local steroid injections to the origin of the plantar fascia, and orthotics all demonstrate a high cure rate for plantar fasciitis.  Based upon the information set forth above, the services at issue were 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


A 60-year-old male enrollee has requested reimbursement for platelet-rich plasma injections performed on 3/11/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees plantar fasciitis. The physician reviewer found that the use of platelet-rich plasma injections for tendon and ligament injuries show no statistically significant benefit.  For muscle injury, evidence is also insufficient, conflicting, or poor, as it is for the treatment of osteoarthritis and other joint pathologies.  For plantar fasciitis, the evidence is insufficient and conflicting, and demonstrates an incomplete assessment of net benefit versus harm.  Therefore, additional studies and research are warranted.  In a study by De Vos and colleagues, a randomized controlled trial was done on patients with chronic Achilles tendinopathy.  The patients were equally divided to receive either platelet-rich plasma injections or saline injections.  The study showed no statistically significant differences in pain or activity levels between the two groups.  Sanchez and colleagues did a retrospective, case controlled study of 12 athletes who underwent surgical repair of a complete Achilles tendon tear to see if platelet-rich plasma promotes healing and functional recovery.  The authors concluded that platelet-rich plasma may enhance healing and functional recovery, but further studies are needed to verify outcomes.  Based upon the information set forth above, the services at issue were 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 Upheld

Summary Reviewer 

A 26-year-old male enrollee has requested reimbursement for substance use partial hospitalization services provided from 9/14/18 through 10/04/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to an overall good functional level with appropriate activities of daily living. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and controlled depression and anxiety symptoms. With regards to level of stress of the recovery environment, the records support a score of 3 due to no mention of a stressful recovery environment. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 3 due to success in the partial hospitalization program with a good level of cooperation and maintenance of sobriety. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into his need for treatment. Thus, the patient has a composite score of 15. This score is consistent with a community-based outpatient clinic setting. Therefore, substance use partial hospitalization services from 9/14/18 through 10/04/18 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 40-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/9/16. 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 was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, 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 9/9/16 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 40-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/9/16. 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. In this particular patient, the presence of breast implants and the family history of breast cancer are not automatic indications for tomosynthesis. However, the patients breasts are extremely dense, and patients with dense breasts can benefit most from tomosynthesis. The ability to separate overlapping breast tissues and better demonstrate an occult tumor is one of the primary benefits of tomosynthesis. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 9/9/16 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 3


A 40-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/9/16. 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 there is a lack of peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in peer-reviewed literature. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 9/9/16 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a deceased male enrollee has requested reimbursement for substance abuse intensive outpatient program services provided from 1/1/13 through 2/11/13. 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 the substance abuse intensive outpatient program services provided from 1/1/13 through 1/17/13 was medically necessary for treatment of the patients medical condition, but not thereafter. In this case, the patient was not suicidal or homicidal. He was not aggressive or violent towards others. He was medically and psychiatrically stable. By 1/18/13 he demonstrated improved energy, stamina, understanding, and communication skills. He was motivated as evidenced by his active participation in the program. His family was supportive and participated in his treatment plan. In addition, the services provided through 1/17/13 were indicated to develop and solidify the aforementioned skills towards use in the outpatient setting. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.