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

Summary Reviewer 2


A 63-year-old male enrollee has requested authorization and coverage for transcatheter radiofrequency ablation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees paroxysmal atrial fibrillation.   The physician reviewer found the records document that this patient was symptomatic having sustained a cryptogenic cerebrovascular accident prior to the initiation of anti-coagulation treatment. The provider noted that the patients work as a contractor places him at considerable risk if lifelong anti-coagulation were required. In addition, he cannot tolerate the use of anti-arrhythmic therapy, which could provoke prolonged episodes of asystole prompting the need for permanent pacing. Furthermore, the patient is currently experiencing frequent symptoms associated with periods of atrial fibrillation with rapid ventricular response as well as bradycardia in the form of dyspnea and unexplained weakness. For these reasons, the patient would best be served by pulmonary venous isolation with his providers recommendation to employ radiofrequency ablation as the technique to accomplish this therapy. Accordingly, the requested transcatheter radiofrequency ablation 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 service 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 63-year-old male enrollee has requested authorization and coverage for transcatheter radiofrequency ablation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees paroxysmal atrial fibrillation.  The physician reviewer found the guidelines from the Heart Rhythm Society give a Class I recommendation for ablation if the patient has failed at least one Type I or Type III anti-arrhythmic medication. This patients records do not document that he has been treated with a medication that meets these criteria. Trial of such medication might require use of a permanent pacemaker or close electrocardiography monitoring while on a medication trial to see if the patients bradycardia is worsened. The guidelines also state that a patient with a high congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke (CHADS) score would need to stay on long-term anti-coagulants for stroke prevention even after successful ablation. All told, this patient has not met the established criteria for medication trial, and thus the requested transcatheter radiofrequency ablation is not supported 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 requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 61-year-old female who has been diagnosed with amyotrophic lateral sclerosis. In a letter dated 12/03/19, the provider noted that the patient has significant arm and leg weakness. The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment. This patient has been diagnosed with amyotrophic lateral sclerosis. She requires significant assistance with movement in bed, per the medical records. Due to poor mobility in bed, the patient is at high risk for decubitus ulcers. These ulcers can lead to significant infections and can cause the patient to develop sepsis. The Freedom Bed will assist the patient in maintaining movement while in bed, thereby reducing the likelihood of developing decubitus ulcers. Therefore, the use of the Freedom Bed is indicated to reduce pain and risk of complications. Per Bromberg and colleagues, there is a specific timeline for the need for durable medical equipment for patients with amyotrophic lateral sclerosis. This includes the use of items similar to the Freedrom Bed. Therefore, the requested Freedom Bed is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 57-year-old female enrollee has requested reimbursement for residential treatment provided from 6/02/16 through 6/11/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. On admission, there was no documentation showing that the patient was in withdrawals, or at risk for imminent withdrawals. There was no Clinical Institute Withdrawal Assessment (CIWA) and no vital signs. The patient denied suicidal or homicidal ideation, and there were no signs of her being a danger to herself or others.  There were no emotional, behavioral, cognitive, or impulsive symptoms to would warrant this level of care.  She was medically and psychiatrically stable.  She received aversion treatment, which is not standard of practice in the community. Relaxation treatment, group, individual, and family therapies, as well as the Prozac and Strattera, could all have been administered on an outpatient basis.  There were no signs of impulsivity, aggression, agitation, depression, mania, hallucinations, or other significant symptoms necessitating 24/7 medical and nursing monitoring.  She could have been safely and effectively treated at a lower level of care, along with community supports, such as the Alcoholics Anonymous program and medication-assisted treatment. Thus, residential treatment provided from 6/02/16 through 6/11/16 was 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 51-year-old female enrollee has requested authorization and coverage for the LINX reflux management system lower esophageal sphincter augmentation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that the records indicate that this patient has GERD as based on pH recording and her disease progression to Barretts esophagus. However, LINX is not indicated for patients with Barretts esophagus. Further, implantation of LINX in this patients case must be approached with caution given her documented esophageal dysmotility. As such, the LINX reflux management system lower esophageal sphincter augmentation is not likely to be more beneficial for treatment of this patients medical condition than standard GERD management treatment options. Based upon the information set forth above, the requested service is 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 51-year-old female enrollee has requested authorization and coverage for the LINX reflux management system lower esophageal sphincter augmentation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the requested LINX reflux management system lower esophageal sphincter augmentation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service is 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 51-year-old female enrollee has requested authorization and coverage for the LINX reflux management system lower esophageal sphincter augmentation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that the U.S. Food and Drug Administration (FDA) approved the LINX reflux management system for lower esophageal sphincter (LES) augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. This patient meets these criteria. A recent study comparing the LINX procedure with laparoscopic fundoplication found that GERD patients had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms (Reynolds, et al). Given these findings, the requested LINX reflux management system lower esophageal sphincter augmentation 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 service 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 Upheld

Summary Reviewer 1


A 52-year-old female enrollee has requested reimbursement for the risk of ovarian malignancy algorithm (ROMA) test provided on 6/22/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees irregular menstrual bleeding and ovarian cyst. The physician reviewer found that ovarian cancer screening includes evaluation of symptomatology, ultrasound and tumor marker levels to assess an individual patients risk. CA-125 is the gold standard tumor marker. Although new tests have been developed to predict a patients risk, the data is conflicting. Emerging literature recommends the ROMA test as a useful component in evaluating patients with ovarian/adnexal masses. The ROMA test is especially useful for its negative predictive value. Moore and colleagues noted that the ROMA test detected 94% of the women with an invasive epithelial ovarian cancer and 85% of the women with early-stage epithelial ovarian cancer in the initial validation trial. For this patient, a CA-125 of 36 in a perimenopausal female would likely be considered negative by most providers. However, the provider recommended a ROMA test for confirmation. In this clinical setting, repeating the CA-125 level alone without the addition of the HE-4 would have been sufficient to determine whether the patient was at an elevated risk for ovarian cancer. Thus, the ROMA test provided on 6/22/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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 52-year-old female enrollee has requested reimbursement for the risk of ovarian malignancy algorithm (ROMA) test provided on 6/22/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees irregular menstrual bleeding and ovarian cyst. The physician reviewer found this patient had a cystic ovarian mass that was managed expectantly. A ROMA test was done to further support this treatment plan. No surgery was planned at the time the test was performed. As noted by Ueland and Li, the ROMA test was approved by the U.S. Food and Drug Administration (FDA) in 2011 to further assess the likelihood of malignancy in women who are planning to have surgery for an adnexal mass. There is a very specific indication for the ROMA test. This indication did not exist in this case. Therefore, the ROMA test performed on 6/22/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, which was expectant management. 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 52-year-old female enrollee has requested reimbursement for the risk of ovarian malignancy algorithm (ROMA) test provided on 6/22/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees irregular menstrual bleeding and ovarian cyst. The physician reviewer found the American College of Obstetrics and Gynecology (ACOG) and the Society of Gynecologic Oncologists (SGO) have addressed the issue of the application and use of tumor markers in the evaluation of a pelvic/adnexal mass. The guidelines suggest the evaluation of symptomatic patients should include physical examination, possible transvaginal ultrasonography, and measurement of levels of the serum tumor marker CA-125. The underlying goals of management are to help direct patients suspected of having ovarian cancer. These findings also help gynecologic surgeons to comprehensive surgical staging and cyto-reductive surgery. However, the ACOG and SGO guidelines do not support the addition of HE-4 in this clinical setting. The patients presentation warrants surgical intervention with a preoperative evaluation by gynecologic oncology and did not require additional testing with HE-4 prior to this referral. Thus, the ROMA test provided on 6/22/15 was not likely to have yielded further information relevant to this patients management beyond that anticipated with standard CA-125 testing and proper clinical examination. 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 Upheld

Summary Reviewer 

A 29-year-old male enrollee has requested authorization and coverage for implant of neuroelectrodes (InterStim, under fluoroscopy guidance). The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees neurogenic bladder.   The physician reviewer found this patients provider has recommended placement of InterStim for treatment of non-obstructive urinary retention. However, the diagnosis of non-obstructive urinary retention is not supported by the documentation provided for review in this case. The patient has a sensation of incomplete emptying. However, he has never catheterized for urinary retention and the post-void residual was normal at 64 cc on 7/23/15. The urodynamic study reportedly had an elevated post void residual but the study is not available for review. The study also shows detrusor hyperreflexia which can explain nocturia and frequent small voids. This patients symptoms would be best treated by an anticholinergic medication. In addition, it is unclear if the elevated post void residual reported on the urodynamic study is from poor detrusor contraction, detrusor sphincter dyssynergia, or bladder outlet obstruction. This information would only be available from a pressure flow study which is not available for review. Thus, the diagnosis of non-obstructive urinary retention cannot be justified and the requested implant of neuroelectrodes (InterStim, under fluoroscopy guidance) is not supported as medically necessary. Based on the foregoing discussion, the requested service 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 45-year-old male enrollee has requested authorization and coverage for Xanax. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees generalized anxiety disorder. The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. Generally, generic medications vary in bioavailability versus the name brand by no more than 15%.  In this case, the suggestion that the three generics the patient tried were not as effective suggests that the dose was not tailored properly.  The standard practice is to tailor the dose of the generic medication properly prior to prescribing a brand drug. This would be the first appropriate step in drug prescription and evaluation of efficacy.  In this patients case, the use of the brand name Xanax is not medically indicated. Therefore, for the reasons stated above, 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 Overturned

Summary Reviewer 

A 51-year-old female enrollee has requested authorization and coverage for Provigil 200 mg tablets, 60 tablets per 30 days. 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 supports the medical necessity of the requested medication. The medical records indicate that the patient has a long history of hypersomnia. She has been evaluated by multiple specialists in order to maximize her medications. This patient has significant functional problems due to her hypersomnia as well as her bipolar disorder, as referenced by her use of the antipsychotic medication Clozaril, which is typically reserved for recalcitrant illnesses. Based on the records, the requested medication appears to be working well for her, and discontinuation of the requested medication could have significant adverse results. Therefore, Provigil 200 mg tablets, 60 tablets per 30 days are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 45-year-old female enrollee has requested reimbursement for FoundationOne gene testing performed on 3/26/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees adenosarcoma of the cervix.        The physician reviewer found the molecular profiling of an individuals cancer cells is an assay of genomic of molecular abnormalities. The goal would be to identify a target at which a specific treatment could then be offered. Though of real scientific interest, as yet there is a lack of  convincing evidence that the assay adds to the decision making ability to improve patient outcomes. Von Hoff and colleagues, in a pilot study, explored the value of molecular profiling but the results are not convincing. The seriousness of utilizing molecular profiling is expressed in various medical literature but ongoing research must still be explored. In an editorial, Doroshow noted the serious limitations of various non-randomized studies exploring the value of molecular profiling. This viewpoint was also expressed in an editorial by West in 2016.  Moreover, a recent randomized trial did not demonstrate significant clinical benefit from choosing therapy based on molecular targets (LeTourneau, et al).  Therefore, the services at issue were not likely to be superior to any available standard therapy for treatment of this patients cancer. 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 45-year-old female enrollee has requested reimbursement for FoundationOne gene testing performed on 3/26/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees adenosarcoma of the cervix.        The physician reviewer found the services at issue were likely more effective than any standard tests available for treatment of this patients uterine adenosarcoma. Uterine adenosarcomas are rare and generally treated similar to other endometrial stromal tumors. The prognosis is poor once it metastasizes. For patients with recurrent uterine adenosarcoma, there are few data to guide management. However, in this patient, she has exhausted conventional therapies, has a rare cancer and maintains a good functional status. The medical literature supports molecular testing, such as with FoundationOne, to assist in identifying potential markers to help guide therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.