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

Summary Reviewer 2
A 52-year-old male requested authorization and coverage for hypoglossal stimulator.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea. The physician reviewer found that obstructive sleep apnea (OSA) is an increasingly prevalent clinical problem with significant effects on both personal and public health. CPAP has demonstrated excellent efficacy and low morbidity with long term adherence rates approach 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation in animal and human subjects, the three  and four  year results of a large multicenter, prospective trial were published in January 2016 and February 2017. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This trial has demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with OSA who have failed CPAP. This patient meets the criteria. He has failed CPAP, which is the gold standard treatment for OSA. All told, implantation with a hypoglossal stimulator is likely to be more beneficial than the standard options available for treatment of this patients medical condition.Therefore, for the reasons stated above, the requested services are 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 3

A 52-year-old male requested authorization and coverage for hypoglossal stimulator.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea. The physician reviewer found that there are multiple references supporting the efficacy of hypoglossal stimulator in this clinical setting. However, further studies comparing this intervention with conventional therapies are needed to definitively evaluate outcomes (Certal et al). In this patients case, there is a lack of records that indicates other procedures have been tried and failed. The provider does suggest that the patient would meet clinical criteria for consideration of hypoglossal nerve stimulator therapy for improvement of the symptoms of snoring and apnea. However, the records do not indicate that this patient has undergone other methods of management.  Specifically, other surgical procedures have not been attempted such as improvement of the nasal airway with turbinate reduction and possible nasal septal reconstruction.  These methods have not been shown to improve sleep apnea, but can improve tolerance to nasal CPAP therapy. Additionally, the patient may be a candidate for other traditional oropharyngeal surgery such as uvulopalatopharyngoplasty with tonsillectomy which may improve this patients symptoms. In summary, hypoglossal stimulator is not likely to be more effective than conventional therapies for treatment of this patients medical condition.Therefore, for the reasons stated 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 Upheld

Summary Reviewer 

A 21-year-old male enrollee has requested reimbursement for substance use partial hospitalization provided on 10/12/17 and from 11/17/17 through 12/08/17 and substance use intensive outpatient program services provided from 12/09/17 through 1/11/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for 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. With regards to risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors or history of suicide attempts. In terms of functional status, the records support a score of 2 to 3 due to school problems and daily substance use that impacted motivation. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability. In terms of level of stress of the recovery environment, the records support a score of 3. With regards to level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. In terms of treatment and recovery history, the records support a score of 3 due to lack of past recent intensive treatment. 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 to 16. This score correlates with treatment in a community-based outpatient clinic setting. This patient could have received effective treatment on an outpatient basis, due to his lack of self-harm behaviors, cooperative behaviors, and lack of active suicidal or homicidal ideation. He was motivated for treatment with mention of insight into his illness as well as documentation of his knowledge of skills to maintain sobriety. The submitted documentation does not indicate that he was having severe mood swings or other severe psychiatric symptoms. Thus, substance use partial hospitalization provided on 10/12/17 and from 11/17/17 through 12/08/17 and substance use intensive outpatient program services provided from 12/09/17 through 1/11/18 were not medically necessary for the treatment of this patient. Therefore, 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 Overturned

Summary Reviewer 


A 56-year-old female enrollee has requested authorization and coverage for Vemlidy.  The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees hepatitis B. The physician reviewer found that the guidlines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. For this reason, Vemlidy is medically necessary for the treatment of this patient. Therefore, the requested medication 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 52-year-old female enrollee has requested authorization and coverage for matrix-assisted autologous chondrocyte implantation (MACI) procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. In this case, the requested MACI procedure is not recommended or supported by high-quality literature for this patients condition. This procedure is not indicated for lesions involving the patellar cartilage or for bipolar patellofemoral lesions. Additionally, this procedure is not indicated in the presence of patellofemoral malalignment.  There is lack of data to support the efficacy of MACI in these clinical situations, which have all been documented as being present based on the submitted operative report. Thus, the requested MACI procedure is not likely to be superior over other treatment options. 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 Overturned

Summary Reviewer 2

A 52-year-old female enrollee has requested authorization and coverage for matrix-assisted autologous chondrocyte implantation (MACI) procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain. The physician reviewer found that the records document a history of progressively worsening bilateral knee pain. Functional difficulty is reported in activities of daily living and recreational pursuits. She is status post bilateral knee arthroscopy, chondroplasty, synovectomy, and plica resection, and chondral biopsy on the right knee on 7/18/18. The surgeon reports right knee operative findings including a full thickness grade III/IV chondral defect on the lateral facet of the patella measuring 2.5 x 2.5 cm, and a full thickness grade III defect on the trochlea measuring 1.5 x 1.5 cm. The left knee had similar findings with grade IV chondral defect in the lateral facet of the patella measuring 2 x 2 cm, and a grade III defect on the anterolateral trochlea measuring 5 x 5 mm. All defects had been debrided back to stable margins with Outerbridge grade I/II at the lesion borders. Detailed evidence of recent nonoperative treatment protocol trial and failure has been submitted. There is U.S. Food and Drug Administration (FDA) approval for the use of MACI in this clinical scenario. There is current peer-reviewed evidence indicating that MACI is safe and effective for treatment of full thickness cartilage defects in the knee, with no effect of the location of the defects or number of defects on study outcomes. Therefore, the requested MACI procedure is likely to be superior over other treatment options. Based upon the information set forth above, the requested services are 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 52-year-old female enrollee has requested authorization and coverage for matrix-assisted autologous chondrocyte implantation (MACI) procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain. The physician reviewer found that the records note chronic bilateral patellofemoral knee pain with chondral defects and kissing lesions that have been well-documented at the time of arthroscopy. There is sufficient support for the requested MACI procedure in this setting. Kreuz and colleagues evaluated the long-term clinical and radiological outcome of MACI for articular cartilage defects in the knee joint, and 21 patients with full-thickness grade IV cartilage defects were included. The clinical and radiological outcomes 12 years after transplantation revealed persisting good results of the mid-term follow-up. Based on a review of the recent medical literature, the MACI procedure is a good option for full thickness chondral defects. Thus, the requested MACI procedure is likely to be more effective than other available treatment options. Based upon the information set forth above, the requested services are 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 Overturned

Summary Reviewer 

The patient is a 56-year-old transgender female who has been diagnosed with gender dysphoria. The patient has requested authorization and coverage for facial feminization surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, aimproved mental health-related quality of life.a The World Professional Association for Transgender Health position statement states, aNon-genital surgical proceduresanotably facial feminization surgeryaare often of greater practical significance in the patientas daily life than reconstruction of the genitalsaThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.a There is sufficient support for the requested services in this patientas case. Therefore, the requested facial feminization surgery is 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 CPT code 31299 performed on 12/22/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. The patient has a history of nasal obstruction, septal deviation and turbinate hypertrophy. The patient had used nasal sprays in the past, with minimal improvement. Cryotherapy has been found to benefit patients with chronic nasal drainage. Gerka Stuyt and colleagues performed a prospective single-arm trial of 24 adult patients at seven locations within a large health maintenance organization. The authors noted, aCryoablation of the posterior nasal nerve shows improvement in nasal symptoms over a one-year period and is consistent with other published data.a Ow and colleagues noted, aCryotherapy with the ClariFix device significantly and clinically improves rhinitis symptoms and quality of life that are durable through 24 months after treatment.a Therefore, CPT code 31299 performed on 12/22/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 40-year-old female enrollee has requested reimbursement for CPT code 31299 performed on 12/22/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the medical evidence does not support the superior efficacy of the services at issue. Kompelli and colleagues performed a systematic review of cryotherapy for the treatment of chronic rhinitis. The authors could not make evidence-based recommendations for the use of cryotherapy due to the weak pool of evidence. Sinno and colleagues performed a systematic review of inferior turbinate reduction techniques and found limited objective data and no evidence of long-term efficacy of cryotherapy. The authors concluded that submucosal resection and radiofrequency ablation were the best techniques for providing long-term resolution of symptoms, preservation of turbinate function, and low complication rates. Mirza and colleagues performed meta-analysis of randomized controlled trials comparing microdebrider- and radiofrequency-assisted turbinate reduction. The authors noted better objective and subjective clinical outcomes among patients who underwent microdebrider-assisted turbinate reduction, particularly at long-term follow-up. Overall, there is insufficient high-quality, peer-reviewed, evidence to support the use of inferior turbinate cryotherapy over other available therapies. Therefore, CPT code 31299 performed on 12/22/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 40-year-old female enrollee has requested reimbursement for CPT code 31299 performed on 12/22/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the service at issue in this clinical setting. This patient had already failed optimal medical therapy. The alternative treatment, surgical neurectomy, is well-known to be associated with increased adverse events and complications. There is sufficient evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of chronic rhinitis with cryotherapeutic ablation of the posterior nasal nerves utilizing the ClariFix device. 

A multicenter, prospective, single-arm clinical study by Ow and colleagues showed that cryotherapy significantly and clinically improves rhinitis symptoms and quality of life with outcomes that are durable through 24 months after treatment. The prospective multicenter study by Chang and colleagues demonstrated the Reflective Total Nasal Symptom Score (rTNSS) significantly improved over pretreatment baseline at 1 month, 3 months, 6 months, and 9 months post-procedure. Gerka Stuyt and colleagues performed a prospective single-arm trial at multiple locations within a large health maintenance organization of patients with chronic rhinitis that failed medical therapy and were treated with in-office cryoablation of the posterior nasal nerve (PNN). The authors noted that the Total Nasal Symptom Score (TNSS) 12-hour symptom score significantly improved at 30 days, at 90 days and at one-year post treatment. Therefore, CPT code 31299 performed on 12/22/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 56-year-old male with a ventricular fibrillation cardiac arrest with anterior myocardial infarction. He was resuscitated and referred for percutaneous coronary intervention of left anterior descending artery with drug eluting stent. The patient subsequently had recurrent ventricular fibrillation requiring both lidocaine and amiodarone load to control. He was referred for repeat catheterization which showed distal narrowing of stented segment of left anterior descending artery which was treated with angioplasty and a severe non-culprit lesion in right coronary artery was treated with stenting as well. The patient has requested reimbursement for wearable cardioverter defibrillator. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of this patient.  There is sufficient support for the device at issue in this clinical setting. Given the recurrent episodes, the requirement for multiple anti-arrhythmic medications and the predisposition to life-threatening rhythm disturbances with ischemia, he remained at high risk for sudden death if he were to have early stent thrombosis and/or recurrent ischemia. In the period where medical management and subsequent reassessment of left ventricular function needs to occur (first three months post infarction), the use of an external defibrillator vest is reasonable in the event of another episode of ventricular fibrillation and sudden cardiac death to deliver immediate counter shock therapy. At three months, left ventricular ejection fraction can be reassessed by echocardiogram, along with any further ongoing ventricular rhythm disturbances by Holter monitoring, and a decision about the need for long-term automatic implantable cardioverter defibrillator therapy can be made at that time. In the interim, an external defibrillator vest was a reasonable interim solution to protect against sudden cardiac death. Therefore, the wearable cardioverter defibrillator was likely to have been more effective than other treatment options.  Based upon the information set forth above, the device 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 2

The patient is a 56-year-old male who presented on 7/31/16 with ventricular fibrillation due to an acute anterior myocardial infarction, requiring defibrillation prior to hospital arrival.  He was found to have an occluded left anterior descending coronary artery on urgent catheterization and was treated with coronary stent placement.  Within the next 24 hours, he had recurrent cardiac arrests due to polymorphic ventricular tachycardia thought to be related to ischemia.  Repeat cardiac catheterization was performed, and balloon angioplasty to the left anterior descending preexisting stent and additional stent placement to a severe distal right coronary stenosis both were performed.  There was no recurrent sustained ventricular tachycardia, ventricular fibrillation or cardiac arrest after repeat coronary intervention on 8/01/16.  He was discharged on 8/05/16.  The patient has requested reimbursement for wearable cardioverter defibrillator. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of this patient. This patient presented with a cardiac arrest in the setting of acute myocardial infarction and then had recurrent ventricular tachycardia/cardiac arrest within the first 24 hours of infarction in the setting of recurrent ischemia. In this circumstance, ventricular tachycardia/fibrillation within the first 24 hours of acute myocardial infarction is generally not predictive of subsequent ventricular tachycardia/ventricular fibrillation.  In addition, the patients ejection fraction was not reduced to 35% or less. The documentation does not support the medical need for immediate placement of a defibrillator (wearable or implantable).  Placement of a prophylactic defibrillator is not recommended until a period of time greater than 90 days where continued left ventricular dysfunction (ejection fraction 35% or less) is documented to persist despite appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation. Thus, the wearable cardioverter defibrillator was not likely to have been more effective than other treatment options. Based upon the information set forth above, the device 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.