Persius/hicric huggingface dataset:
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Functional impairment

Treatment: continued inpatient admission at an alternate level of care

The insurer denied coverage for continued inpatient admission at an alternate level of care

The denial is upheld

This is a patient with chronic medical problems including heart failure, stroke, chronic obstructive pulmonary disease (COPD) and atrial fibrillation. He was admitted to a skilled nursing facility (SNF) and received occupational and physical therapy. Under review is the medical necessity for continued inpatient admission at an alternate level of care.

The patient may have had impairments and functional deficits appropriate for admission to the SNF.  However, there are no occupational therapy or physical therapy notes submitted for review documenting any specific functional improvement during the time period under review.  The provided clinical notes are insufficient to support the medical necessity for continued inpatient admission at an alternate level of care. There were no specific acute medical or complicated nursing issues that required continued inpatient admission at an alternate level of care.  In addition, the patient did not have a discharge plan established and there were no specific clinical variables that needed to be resolved before the discharge was complete for time period under review.  

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the continued inpatient admission at an alternate level of care is not substantiated.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Digestive System/ Gastrointestinal/food bolus.
Treatment: Inpatient Hospital Stay.
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male admitted to the hospital. The patient presented with a food bolus in the esophagus after a steak dinner. This has happened previously without a workup. He was given glucagon and had a computed tomography (CT) scan of the neck. There was no benefit from the glucagon. The patient underwent an emergent esophagogastroduodenoscopy (EGD), and the material was pushed into the stomach. An underlying Schatzki's ring was seen. The patient tolerated the procedure well. He was placed on a liquid diet for 12 hours and then discharged.
At issue is the medical necessity of the inpatient hospital services.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient hospital services was not medically necessary for this patient. Food impactions, once relieved by endoscopy, takes care of the acute problem. Once awake, patients usually feel much improved and can begin taking by mouth (PO) liquids once fully alert. Assuming the patient did not have a perforation, aspiration pneumonia, or other complication, the patient can go home an hour or two after the procedure with someone accompanying them. There is no need to monitor for 12 hours in a hospital setting. Therefore, the inpatient hospital services were not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-small cell lung cancer
Treatment: Genetic Testing (Molecular Comprehensive Genomic Profile)
The insurer denied: Genetic Testing (Molecular Comprehensive Genomic Profile)
The denial is: Overturned

The patient is a female with newly diagnosed, advanced non-small cell lung cancer. Tissue is not available for genomic profiling and the patient's cancer has not been evaluated previously. The Guardant360 assay was obtained. The subject under review is the medical necessity for the Genetic testing (Molecular comprehensive genomic profile).

The requested testing is medically necessary for this patient.
The use of next generation sequencing gene panels to guide the treatment of patients with metastatic non-small cell lung cancer is recommended by the National Comprehensive Cancer Network (NCCN) Guidelines, which state "It is recommended at this time that when feasible, testing be performed via a broad, panel-based approach, most typically performed by next generation sequencing (NGS)." The assay in question is Food and Drug Administration (FDA) approved and evaluates the cancer for the recommended biomarkers - epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), v-ros UR2 sarcoma virus oncogene homolog 1 (ROS1), met proto-oncogene (MET), rearranged during transfection (RET), human epidermal growth factor receptor 2 (HER2), v-raf murine sarcoma viral oncogene homolog B1 (BRAF), Kirsten rat sarcoma (KRAS), and tropomyosin receptor kinase (TRK).
The authors of UpToDate state "next generation sequencing (NGS) overcomes many of the shortcomings of direct sequencing and allele-specific testing. It retains sensitivity even in specimens with low tumor cellularity, which is an improvement over direct sequencing, and can identify new abnormalities, which would not be detected by allele-specific testing. Moreover, NGS can often detect abnormalities that would historically be tested by fluorescence in situ hybridization (FISH)." Finally, NGS panel testing has been demonstrated in multiple trials, to be less expensive than single gene testing for the recommended biomarkers. The service under review is not the subject of ongoing investigation for these purposes.
For these reasons, the use of this assay in this scenario is considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis secondary to pyelonephritis
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient hospital admission as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with a past medical history (PMH) of hypertension (HTN) and diabetes mellitus type 2 (DM2) who was admitted with complaints of lower back pain associated with fever, dysuria, and flank pain. The patient's vital signs were notable for a pulse of 126 beats per minute (bpm) and a temperature of 101.3F. Her physical exam was notable for an ill-appearance and was significant for left and right costovertebral angle (CVA) tenderness. The patient's lab work was notable for a positive urine culture. Imaging studies included a computed tomography (CT) anterior/posterior (A/P) which showed no obstructing stones or hydronephrosis. The patient was diagnosed with sepsis secondary to pyelonephritis and was treated with intravenous fluids (IVF) and intravenous (IV) antibiotics. The patient was discharged in stable condition.

At issue is the medical necessity for the inpatient hospital stay.

I overturn, in whole, the health plan's determination of medical necessity.

The hospital stay was medically necessary at an inpatient level of care.

The patient has a history of HTN and DM2 who presented to the emergency department (ED) with a high-fever and tachycardia with clinical evidence of acute pyelonephritis. The patient was provided with IV antibiotics and hydration, to which the patient responded well. This patient met sepsis criteria with tachycardia and fever, increasing the clinical risk of monitoring this patient at a lower level of care than inpatient, especially given her history of diabetes and ill-appearance on admission. The patient required close monitoring, aggressive IV hydration, IV antibiotics, and cultures to ensure that the sepsis was adequately controlled, lactate was not up-trending, and that they did not become more hemodynamically unstable. Overall, this patient required an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a patient with a past medical history (PMH) of rheumatoid arthritis (RA), gastroesophageal reflux disease (GERD), Crohn's disease, and alcohol abuse who was admitted with complaints of (c/o) dizziness worse with head movement. Her vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), positive (+) Dix-Hallpike test, no focal deficits, alert and oriented, hyperreflexia in upper extremities (UE) / lower extremities (LE), absent reflexes in the ankles. Lab work was unremarkable. A computed tomography (CT) scan of the head showed no acute intracranial pathology. An electrocardiogram (EKG) showed normal sinus rhythm (NSR), no acute ischemia. The patient was diagnosed with dizziness and treated with meclizine, neuro-checks, radiological and biochemical work-up, and neurology consultation. The patient was discharged against medical advice (AMA). At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with dizziness and vertigo associated with head movement. The patient did not have any acute hearing loss, double vision, fixed neurologic deficits, severe headache, associated head trauma, fever, high clinical suspicion for central vertigo or cerebrovascular accident (CVA), cerebellar infarct or hemorrhage, vertebrobasilar insufficiency, acute suppurative labyrinthitis, intractable nausea/vomiting or inability to ambulate. All imaging performed showed no acute intracranial pathology, the patient remained hemodynamically stable, and the noted neurological findings were suspected secondary to peripheral neuropathy. The patient was treated with meclizine and fluids and received a thorough work-up, despite eventually leaving AMA. Given the patient's clinical stability and provided interventions and clinical monitoring, these could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Ventricular Dysfunction

Treatment: LifeVest device rental, HCPC (Healthcare Common Procedure Coding System) Code K0606RR

The insurer denied coverage for the LifeVest device rental, HCPC Code K0606RR.

The denial is overturned.

This is the case of a female patient that presented to the hospital with an acute cerebrovascular accident. Past medical history was significant for vasovagal syncope, implantable loop recorder, paroxysmal atrial fibrillation, breast cancer status post left mastectomy, and chronic obstructive pulmonary disease. Upon arrival to the hospital, her physical examination was significant for right hemiparesis and aphasia. She was treated with tissue plasminogen activator (tPA). Of note, a 12-lead electrocardiogram (EKG) demonstrated sinus rhythm with an anteroseptal myocardial infarction of undetermined age. Echocardiogram was significant for a depressed left ventricular ejection fraction (LVEF) of 30-35 percent. The patient was treated with metoprolol therapy and recommendations for external LifeVest defibrillator placement were made pending an ischemia work up. A life vest was placed shortly thereafter. Follow up plans were made for a coronary angiography in order to determine etiology and potentially treat her left ventricular dysfunction. Additional guideline directed medical therapies were not tolerated due to vasovagal syncope and hypotension. Medical records document failure to undergo coronary angiography months later. 

Guideline statements from the Heart Rhythm Society/American Heart Association and the American College of Cardiology (HRS/AHA/ACC) specify that external life vest defibrillator therapy should be utilized during periods when patients are at risk of sudden cardiac death and require further cardiac workup/treatment (2-6). This patient had an increased risk of sudden cardiac death given her depressed LVEF. She was not a candidate for cardiac catheterization with revascularization due to her acute stroke. In a real-world study of patients treated with external LifeVest defibrillators, almost 5 percent of subjects received lifesaving therapy (5). The vest trial specifically studied patients at risk of sudden cardiac death following myocardial infarction. In an analysis, wearing a LifeVest defibrillator was associated with a 57 percent reduction in arrhythmic death and a 74 percent reduction in mortality (7). 

Based on current available guidelines and clinical trial data the proposed treatment was medically necessary and was beneficial for the patient. 

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient. External LifeVest defibrillator therapy was medically necessary.

The insurer's denial of coverage for the LifeVest device rental, HCPC Code K0606RR is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease.
treatment: Stelara 90 mg every 4 weeks.
The insurer denied Stelara 90 mg every 4 weeks. 
The health plan's determination is overturned.

This patient is a young male with a history of Crohn's disease. He has tried and failed Humira. He was started on Stelara standard dose, however, he continued to have evidence of disease activity.

Stelara 90 milligrams (mg) every 4 weeks is medically necessary.
Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease and ulcerative colitis in adults. Despite the lack of FDA approval for pediatric patients, there are many peer reviewed publications supporting the efficacy and safety of Stelara in children with inflammatory bowel disease. This patient has a history of refractory Crohn's disease which failed anti tumor necrosis factor alpha (Humira) and many other therapies. The patient also failed to respond to Stelara standard dose (90 mg every 8 weeks) and continued to have an active disease.
Therefore, escalation of Stelara to 90 mg every 4 weeks is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

mental health
Home health care

Diagnosis: panic disorder/anxiety
Treatment: Home health care
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 5 Days per Week x 6 Hours per Day (Monday-Friday) and 2 Days per Week x 5 Hours per Day (Saturday-Sunday) - Total of 40 Hours per Week. The health plan's determination is overturned.

The patient is a female with past medical history of traumatic brain injury, osteoarthritis, epilepsy, urinary incontinence, sleep disorder, and anxiety who had been assigned CDPAS (Consumer Directed Personal Assistance Services) services 4 hours/day, 7 days/week, to total 28 hours/week based on assessment performed "in-person" assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, stairs, transportation, equipment management, and bathing. With tasks of dressing upper/lower body, walking, locomotion, transfer toilet and toilet use the patient was assessed at limited assistance while supervision with task of phone use. The patient was assessed at independent with tasks of personal hygiene, bed mobility, and eating.

Consumer Directed Personal Assistance Services (CDPAS): 5 Days per Week x 6 Hours per Day (Monday-Friday) and 2 Days per Week x 5 Hours per Day (Saturday-Sunday) - Total of 40 Hours per Week are medically necessary for this patient.
There is documentation from the patient's medical provider of medical necessity of increased services. The patient's health care advocate documented the requested increase in CDPAS services would provide coverage outside of the time the patient doesn't have informal help. The patient's video assessment likely underestimated her needs. The assessment noted the patient required at least limited assistance with tasks of walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS 5 Days per Week x 6 Hours per Day (Monday-Friday) and 2 Days per Week x 5 Hours per Day (Saturday-Sunday) - Total of 40 Hours per Week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obsessive-compulsive disorder (OCD). 
Treatment: Clomipramine Capsules 25 Milligrams. 

The insurer denied: Clomipramine Capsules 25 Milligrams. 
The denial is overturned. 

This case involves an adult male diagnosed with obsessive-compulsive disorder (OCD) and comorbid major depressive disorder and unspecified anxiety disorder and treatment with clomipramine at the effective dose of 25 milligrams daily. The patient has failed to sustain a response or remission, or tolerance to Zoloft, Prozac, Luvox and Paxil all of which are suggested formulary alternatives under the patient's health plan. There is no mention of combination or augmentation therapy in this case. 

The health plan has denied coverage of clomipramine on the basis of a coverage exclusion indicating that of the preferred list of formulary alternatives, three should be tried and fail prior to allowing a coverage exception in keeping with plan guidelines and prior authorization criteria. 

The correspondence from the health plan references generic formulations of the following: Zoloft, Prozac, Luvox and Paxil. 

The patient's physician has requested an exception to the denial of coverage on the basis of the clinical history and treatment failure with formulary alternatives including all of those referenced in the denial determination. The appeal indicates that the continued use of clomipramine is life-saving and essential with regard to the symptoms of obsessive-compulsive disorder with suicidal thought, and the appeal indicates that the patient is not safe without this medication that effectively addresses the patient's clinical conditions including the symptoms related to obsessive-compulsive disorder and depressive disorder. 

The issue under review is clomipramine (Anafranil). 

The proposed treatment with clomipramine is medically necessary for this patient. 

In this case, the clomipramine is prescribed in a patient with obsessive-compulsive disorder (OCD), comorbid major depressive disorder and unspecified anxiety disorder in the context of treatment failure with multiple other antidepressants including all of the suggested formulary alternatives which have failed to produce a response or remission, or did not produce a sustained clinical response, or resulted in intolerance. 
The proposed treatment with clomipramine is reasonable and reflects sound medical judgment with regard to medical necessity and prevailing standards of medical practice. The use of clomipramine in this case is in keeping with Food and Drug Administration (FDA) indications and is considered medically necessary with regard to the plan coverage language and prescription drug plan, as well as the scientific literature and guideline referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thymic carcinoma (squamous cell)

Treatment: Proton beam therapy

The insurer denied coverage for Proton beam therapy

The denial is overturned

 
This is the case of a patient with a history of stage lllA (pT3, pN0, cM0) thymic carcinoma (squamous cell) with invasion in the left upper lobe lung and chest wall, status post resection. Adjuvant radiation therapy with proton radiation therapy is recommended. This is the subject of review.

This is very complex planning with disease near heart and lungs. A comparison of proton beam therapy (PBT) and intensity-modulated radiation therapy (IMRT) is provided.

PBT delivers 445 centigray (cgy) mean dose to heart compared to 1033 cgy by IMRT. This is not acceptable as this would increase heart morbidity and mortality in a young patient with curable disease.  PBT delivers V5 (dose constraint) lung 17% compared to 60% with IMRT. This will increase lung toxicity and morbidity.

Proton beam will reduce secondary malignancy in this young patient with long life expectancy.
Thus, the reviewer approves PBT.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for proton beam radiation therapy (PBRT) with Image Guided Radiation Therapy (IGRT) in 28 treatment sessions (fractions) services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, palpitations, shortness of breath.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female with a past medical history of coronary artery disease (status post coronary artery bypass grafting [CABG] and percutaneous coronary intervention.
[PCIs]), heart failure, hypertension, hyperlipidemia, diabetes, anxiety, asthma, post-traumatic stress disorder (PTSD), and chronic back pain who presented to the emergency department for evaluation of chest pain, palpitations, and shortness of breath. She also reported lower extremity swelling. She stated that for the past week she was experiencing upper respiratory infection (URI) symptoms for which she was prescribed azithromycin. 
Upon arrival to the emergency department, the patient was afebrile. Blood pressure was 149/78, heart rate was 75 beats per minute, respiratory rate was 18, and oxygen saturation was 98.6% on room air. Initial labs were notable for a white blood cell (WBC) count of 6.4, hemoglobin of 11.5, sodium of 138, potassium of 4.8, blood urea nitrogen (BUN) of 18, and creatinine of 0.82. Chest x-ray showed mildly increased interstitial lung markings. The patient was initiated on treatment for heart failure exacerbation and was admitted to the inpatient unit for further care. She was evaluated by cardiology and a myocardial perfusion scan was obtained which showed evidence of transient ischemic dilation without clear evidence of focal ischemia. She had a cardiac catheterization which showed mostly patent coronary arteries except for the right coronary artery (RCA) which was supplied by collaterals. As a result, no percutaneous coronary intervention (PCI) was performed. Her chest pain was thought to be noncardiac in etiology, and 
therefore, no further testing was recommended. Imdur was added to her antianginal regimen. The patient was ultimately discharged with outpatient follow-up.

The inpatient hospital admission was not medically necessary.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. There was no evidence of acute coronary syndrome given that the patient's troponin levels were within normal limits and there were no acute ST-segment changes. Her myocardial perfusion scan did not demonstrate evidence of focal ischemia and cardiac catheterization was free of any acute occlusion. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for the inpatient level of care.