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

Summary Reviewer 1

A 29-year-old female enrollee has requested reimbursement for human papilloma virus (HPV) testing performed on 9/29/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue.  The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting. The patient has a history of high-risk HPV genotype 16. She has not been consistent with her follow-up. Recent changes in the American Society of Colposcopy and Cervical Pathology (ASCCP) guidelines have moved to a risk-based assessment for the management of cervical cancer screening. HPV testing is the preferred manner of assessing risk. In this case, because data is missing, the guideline algorithm recommends clinical judgment. Therefore, HPV testing performed on 9/29/20 was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 29-year-old female enrollee has requested reimbursement for human papilloma virus (HPV) testing performed on 9/29/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that the patient has a history of high-grade HPV testing in 2017. Her testing in 2020 showed atypical squamous cells of undetermined significance (ASCUS) cytology with HPV. On 9/29/20, the records noted that she was evaluated with a Pap smear one year prior, and her gynecologist recommended colposcopy following an abnormal Pap smear. There is no clinical documentation from her gynecology visit, and documentation states that the patient was lost to follow-up at this time. The ASCCP guidelines support clinical decision making in situations where patients have been lost to follow-up. Given the patients history of high-grade HPV followed by ASCUS testing, a one-year follow-up co-test is appropriate and consistent with standard therapy. Therefore, HPV testing performed on 9/29/20 was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 29-year-old female enrollee has requested reimbursement for human papilloma virus (HPV) testing performed on 9/29/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. The American Society for Colposcopy and Cervical Pathology issued its Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. The recommendations noted, After abnormal cervical cancer screening test results for patients 25 years or older, colposcopic biopsy results, or treatment of histologic high-grade squamous intraepithelial lesion (HSIL), surveillance with either HPV testing alone or cotesting is preferred (AI). Surveillance with cervical cytology alone is acceptable only if testing with HPV or cotesting is not feasible. This recommendation was based on the following rationale, Individuals treated for histologic HSIL or with a recent abnormal screening test result have an elevated risk of cervical precancer warranting close follow-up. HPV testing and cotesting are more sensitive than cytology alone in detecting CIN 2+ in both the post-colposcopy and post-treatment settings. Based on these recommendations and on the fact that this patient has not been following up as recommended, the HPV testing was likely to have been more beneficial than a Pap smear alone. Therefore, HPV testing performed on 9/29/20 was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 57-year-old female enrollee has requested reimbursement for myocardial perfusion imaging test performed on 1/31/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the patient has some chest/epigastric symptoms and mild hypertension. Her baseline EKG is described as abnormal as well. The planned orthopedic surgery with general anesthesia would be considered an intermediate risk surgical procedure in terms of cardiac complications. She has some risk factors for coronary artery disease and an inability to exert herself enough to determine reasonable functional capacity due to knee arthritis, so the assessment of functional capacity as a risk marker is not possible in this situation. In addition, she is not asymptomatic, as she has some epigastric discomfort symptoms as well as a baseline abnormal EKG, and the description and presentation of angina pectoris can be more often atypical in women as well. Based on these preoperative factors, her limited mobility (impairing an assessment of her functional capacity) and her epigastric symptoms, a pharmacologic nuclear stress test was reasonable and medically indicated to assess cardiac risk in this patient prior to the planned orthopedic surgery. Therefore, the myocardial perfusion imaging test performed on 1/31/20 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 42-year-old male enrollee has requested reimbursement for substance abuse treatment provided form 6/25/19 through 7/02/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Per the American Society of Addiction Medicine (ASAM) criteria, substance abuse residential treatment was medically necessary. The records document longstanding heavy alcohol use which posed a serious danger to his liver and brain health. He reported a history of persisting anxiety and depression since age ten. The clinical notes documented poor insight and judgment, and he presented with no clear plan on how to change. The patient had multiple prior relapses, including a relapse just after his discharge from admission 10 days prior to the admission at issue. The records noted limited support, marital separation, and he associated with others who consumed alcohol. Patients requires safe and stable living environments in order to develop their recovery skills. Given the severity of the patients illness, residential treatment was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patients illness. Therefore, substance abuse residential treatment provided from 6/25/19 through 7/02/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 44-year-old female enrollee has requested authorization and coverage for Nucala 100 mg SQ every 4 weeks. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the request for Nucala has not been established as medically necessary for treatment of the patients medical condition. Nucala is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with severe asthma despite maintenance treatment with an inhaled steroid and a long term adrenergic agonist. In this case, the patient has asthma, however the documentation submitted for review does not support the patient has severe asthma. In addition, the patient has vocal cord dysfunction. Nucala is not FDA approved for the treatment of vocal cord dysfunction. In sum, there is insufficient documentation to substantiate that this patient has severe asthma. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. Given the above reasons, the requested medication is 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 20-year-old female enrollee has requested reimbursement for acute inpatient psychiatric treatment from 9/15/15 through 11/8/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. By 9/15/15, the patient was not a danger to herself or others. She was not aggressive or violent.   She denied and did not demonstrate self-harm or eating disorder urges.   She was cognitively intact and she was not gravely disabled. She was cooperative and participating in her treatment plan.  Through the balance of her stay she remained overall euthymic with bright affect.  Although nursing assessments reported her as delusional, this was not described and no auditory or visual hallucinations were endorsed. For most of her hospitalization leading up to the dates in dispute, she was described as euthymic with congruent affect. Her behavior had stabilized and there was no evidence that stepping her down to a lower level of care would have resulted in immediate acute inpatient re-hospitalization.  She tolerated medication changes without incident.  At this point, she did not require 24-hour a day, seven days a week supervision. She could have safely continued treatment at an ambulatory level of care such as partial hospitalization program. As such, acute inpatient psychiatric treatment services from 9/15/15 through 11/8/15, were not medically necessary. Therefore, for 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 57-year-old male enrollee has requested reimbursement for automated nerve conduction testing performed on 10/20/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The study by Schmidt and colleagues compared the specificity and sensitivity of a hand-held nerve conduction study device for the detection of lumbosacral radiculopathy with a standard electrodiagnostic study. The authors noted correlation between the electrodiagnostic findings and the automated hand-held surface testing in only a small number of the patients studied. The authors concluded that it was unlikely that larger study numbers would have increased specificity to acceptable levels. In sum, the services at issue were 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 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 57-year-old male enrollee has requested reimbursement for automated nerve conduction testing performed on 10/20/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that in this case, the patient underwent a multilevel cervical discectomy and fusion procedure with instrumentation. Intraoperative neurophysiologic monitoring was performed during the procedure to include automated nerve conduction testing. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this testing. According to the technological review, Morse concluded that the diagnostic accuracy of NC-stat (automated nerve conduction testing) is not yet demonstrated in the scientific literature to be equivalent to traditional or gold-standard testing methods. Moreover, the study by Schmidt and colleagues concluded that the automated device accurately recorded raw data, but the interpretations provided were overly sensitive and lacked the specificity necessary for a screening or diagnostic examination. Therefore, the automated nerve conduction testing performed on 10/20/15 have not been established as 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 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 57-year-old male enrollee has requested reimbursement for automated nerve conduction testing performed on 10/20/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the automated nerve conduction studies in dispute performed during surgery are not supported in the peer-reviewed literature. Intraoperative monitoring utilizing automated nerve conduction testing on peripheral nerves during surgery was not indicated. There is a lack of support in the medical literature supporting nerve conduction velocity monitoring on peripheral nerves during cervical spine surgery. As such, the automated intraoperative nerve conduction studies were 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 1


A 39-year-old male enrollee has requested authorization and coverage for Stelara (ustekinumab). The Health Insurer has denied this request indicating that the requested medication is investigational for treatment of the enrollees medical condition. The physician reviewer found that the advent of anti-tumor necrosis factor (TNF) therapy has been a major advance in the medical management of Crohns disease. However, a significant proportion of patients with Crohns disease do not respond adequately to treatment with these agents. Primary and secondary nonresponse to anti-TNF therapy represents a common clinical challenge, and highlights the need for the development of additional medication options for Crohns disease.  Ustekinumab is a fully human immunoglobulin G1 monoclonal antibody, which blocks activity of IL-12 and IL-23 through binding the p40 subunit. Relative to the use of ustekinumab in Crohns disease, Sandborn and colleagues demonstrated in a randomized, placebo-controlled study of 526 subjects that Patients with moderate-to-severe Crohns disease that was resistant to TNF antagonists had an increased rate of response to induction with ustekinumab, as compared with placebo. Patients with an initial response to ustekinumab had significantly increased rates of response and remission with ustekinumab as maintenance therapy. Furthermore, Kopylov and colleagues cohort of 38 patients with severe anti-TNF resistant Crohns disease, an initial clinical response to subcutaneous ustekinumab was observed in 73.7% of the patients. In addition, the initial response was successfully maintained in the majority of patients for up to 12 months. Finally, Stelara was first approved by the U.S. Food and Drug Administration (FDA) for the treatment of moderate to severe plaque psoriasis in 2009, and later approved for the treatment of active psoriatic arthritis in 2013. The drug holds considerable promise in non-pregnant Crohns disease patients, and appears to be one of the remaining few treatment options available to the patient at this time. Given the above, Stelara is likely to be more beneficial for treatment of the patients Crohns disease than available standard therapy. Based upon the information set forth above, the requested medication 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 39-year-old male enrollee has requested authorization and coverage for Stelara (ustekinumab). The Health Insurer has denied this request indicating that the requested medication is investigational for treatment of the enrollees medical condition. The physician reviewer found that Stelara (ustekinumab) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy (such as Remicade and Humira), which applies to this case (Sandborn, et al). Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year (Kopylov, et al). A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-TNF medications, which the patient has failed (Tuskey and Behm). A recent study demonstrated that a significant majority of patients who have failed an anti-TNF medication are able to achieve and maintain response with Stelara (Wils, et al). In sum, the clinical literature supports the use of Stelara in this case given the patients treatment failure of anti-TNF therapy. Based upon the information set forth above, the requested medication 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 39-year-old male enrollee has requested authorization and coverage for Stelara (ustekinumab). The Health Insurer has denied this request indicating that the requested medication is investigational for treatment of the enrollees medical condition. The physician reviewer found that in this case, the patient presents with refractory Crohns disease manifest by severe ileitis. There is sufficient support in the peer-reviewed literature for Stelara to be utilized in this clinical setting. The study by Sandborn and colleagues found that patients with moderate to severe Crohns disease resistant to tumor necrosis factor (TNF) antagonists had an increased rate of response to induction with ustekinumab compared with placebo. In addition, the authors concluded that Patients with an initial response to ustekinumab had significantly increased rates of response and remission with ustekinumab as maintenance therapy. In light of lack of viable options to treat this patient with refractory, progressive Crohns disease and support in the peer-reviewed literature, Stelara medication is 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 medication 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 1

A 28-year-old female enrollee has requested authorization and coverage for ReActiv8 implantable peripheral nerve stimulation. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition.  At issue is whether the requested device is likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that Neuromodulation has efficacy for post-laminectomy syndrome. Spinal cord stimulation has traditionally been offered in the neuromodulation space, but peripheral nerve stimulation offers a less invasive treatment option. Peripheral nerve stimulation is a minimally invasive, nondestructive treatment option for low back pain that is primarily axial. In patients who have tried conservative care, including a multimodal treatment approach, peripheral nerve stimulation is a minimally invasive treatment option. The current medical evidence supports the requested device in this clinical setting. Therefore, ReActiv8 implantable peripheral nerve stimulation is likely to be more beneficial for treatment of the patientas medical condition than any available standard therapy.