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

Diagnosis: Hyperlipidemia.

Treatment: Repatha Sureclick 140 mg/ml PEN INJCTR.

The insurer denied coverage for Repatha Sureclick 140 mg/ml PEN INJCTR.

The denial is upheld. 

This male patient has a history of chronic hyperlipidemia, coronary arteriosclerosis and cardiomyopathy. A computed tomography angiogram (CTA) showed a total calcium score of 845 and noted findings consistent with extensive atherosclerotic plaque burden with a very high coronary cardiovascular disease risk. The patient was asymptomatic. The patient's stress echocardiogram showed moderate to severe global left ventricular systolic dysfunction. The patient's lipid panel was significant for HDL cholesterol of 39, which was below low normal. The patient's physical examination was unremarkable. The patient's magnetic resonance imaging (MRI) study showed dilated cardiomyopathy with left ventricular ejection fraction 22%; no evidence for infarct (no scarring and mild concentric hypertrophy), mid myocardial enhancement in the basal inferior wall, basal inferolateral wall more suggestive of infiltrative disease, trace mitral regurgitation and no stenosis. The patient did not tolerate the statin medication Zetia. Thus, Repatha was prescribed. 

Based on the review of the medical record, this patient was found to have cardiomyopathy that was out of proportion to the extent of coronary artery disease present. Moreover, this patient's cardiac magnetic resonance imaging (MRI) findings were suggestive of infiltrative myocardial disease. There was no objective evidence of a prior myocardial infarction with myocardial scarring. From review of the records, the patient had no history of clinically evident atherosclerotic cardiovascular disease. Despite the presence of coronary calcium, the use of PCSK9 inhibitors for patients with asymptomatic atherosclerosis, or for prevention of a first cardiovascular event, is a matter of ongoing clinical investigation and is therefore, inappropriate and not medically necessary. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for Repatha Sureclick 140 mg/ml PEN INJCTR is not substantiated.  The insurer's denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Guillain-Barre Syndrome (GBS)
Treatment: Sensory Neuropathy Syndrome panel genetic testing
The insurer denied the Sensory Neuropathy Syndrome panel genetic testing.
The denial was overturned.

This is a female patient with a history of Guillen Barre syndrome (GBS). The Neurology Telehealth Progress Notes noted that the patient had a skin biopsy revealing a small fiber neuropathy. The provider noted these findings were more consistent with an acute small fiber neuropathy post infection. A sensory variant of GBS could still be a differential. An autoimmune small fiber neuropathy was another possibility. The provider requested genetic testing for sensory neuropathy to rule out to TTR amyloidosis and carrier for Fabry's disease as well as HNPP, SCN9/10.
	
The appeal letter indicated the patient had a 6-month history of legs and arms paresthesia and numbness. The skin biopsy revealed a small fiber neuropathy. The symptoms were worsening instead of improving. The provider recommended obtaining a panel for autoimmune sensory neuropathy performed at a neuromuscular laboratory. This was noted to be the only laboratory in the United States of America (USA) that could perform the testing. The provider noted that there was literature to support the possibility of an autoimmune small fiber neuropathy in children. The antibodies are against TS-HDS and FGFR3. If these antibodies are positive it was stated the patient would benefit from immunoglobulins IV or other immunosuppressive medications. The medical/therapeutic management will change significantly. The provider requested the patient be allowed to get these test for better diagnosis and further treatment.

The requested service is supported by current peer-reviewed medical literature and is likely to be more beneficial than any of the standard treatments/procedures for this patient. Given that the patient's symptoms are worsening, present treatment is insufficient. IVIg and immunosuppression are reasonable considerations but require a diagnosis (as these interventions carry appreciable risk). The requested service/recommended laboratory studies are to determine the appropriate treatment for this patient. Therefore, the requested service is likely to be more beneficial than other procedures.

The carrier's denial of sensory neuropathy syndrome panel genetic testing should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Guillain-Barre Syndrome (GBS)
Treatment: Sensory Neuropathy Syndrome panel genetic testing
The insurer denied the Sensory Neuropathy Syndrome panel genetic testing.
The denial was upheld.

This is a female patient who has a six-month history of leg and arm paresthesia and numbness. The patient has undergone a skin biopsy revealing a small fiber neuropathy. The patient's symptoms have worsened and it has been recommended that she receive further testing which includes the testing in question. It has been recommended she undergo laboratory testing and have a panel obtained for autoimmune sensory neuropathy. The physician's letter of medical necessity indicates that there is literature to support the possibility of an autoimmune small fiber neuropathy in children and if the antibodies are positive the patient would benefit from IVIG or other immunosuppressive medication. The patient initially reported she felt sick and she was tested for influenza B for which she was positive. The next day she was unable to walk and had numbness and tingling in her legs. She was admitted and treated for GBS. The physician indicated the patient did undergo a lumbar puncture revealing a normal protein and normal cells with elevating opening and closure pressures. The patient has not completely recovered and has episodic numbness and tingling. She was readmitted to the hospital for left arm weakness with leg numbness and tingling and tested positive for corona virus. The documentation does indicate the patient has started physical therapy however she has had to stop due to the ongoing pandemic. She does not have any family history of neuropathy. It was recommended the patient undergo a sensory neuropathy panel.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. There is very little literature to support the need for such a sensory panel in adolescence. Almost all of the literature is for adults. Although the CSF is normal, the clinical notes seem to imply that she improved (although not fully) which is consistent with a diagnosis of GBS. Any other type of neuropathy which could be identified by such a sensory panel would not improve. In summary - such a sensory panel is not clinically indicated.

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of sensory neuropathy syndrome panel genetic testing should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Guillain-Barre Syndrome (GBS)
Treatment: Sensory Neuropathy Syndrome panel genetic testing
The insurer denied the Sensory Neuropathy Syndrome panel genetic testing.
The denial was upheld.

This is a female patient with a history of Guillain-Barre Syndrome (GBS). A progress note documented that the patient had a skin biopsy revealing a small fiber neuropathy. The provider requested genetic testing for sensory neuropathy.

The appeal letter indicated the patient had a 6-month history of legs and arms paresthesia and numbness and her skin biopsy revealed small fiber neuropathy. The symptoms were worsening. The provider recommended obtaining a panel for autoimmune sensory neuropathy. The provider stated that there was literature to support the possibility of an autoimmune small fiber neuropathy in children. The provider noted that the medical/therapeutic management of the patient would change significantly based on the results of the testing. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome as no large long-term studies are noted showing benefit to genetic testing. Oaklander, et al. noted, "Although insufficient screening risks missing potentially curable causes, excess screening is expensive, ineffective, and can lead to more testing, risk, worry, and cost. Thus, the sensitivity, specificity of association, and cost-effectiveness of specific blood tests should be defined to guide decisions about how to screen iiSFPN patients for causality."

Collection of venous blood by venipuncture is not the best available treatment for this patient at this time as no large long-term studies are noted showing benefit to genetic testing.  

The above service is not indicated. No large long-term studies have shown clinical benefit or need with neuropathy patients. Therefore, there is no clear benefit that has been noted with genetic testing to warrant its use.

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of sensory neuropathy syndrome panel genetic testing should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac  circulatory problems/other 
Treatment: Inpatient hospital 
The insurer denied the inpatient hospital stay
The denial is upheld in whole 

At the time of her admission, the patient with history of Wegeners granulomatosis with polyangiitis and Ehlers Danlos Syndrome. the patient  was diagnosed years prior, presenting with pulmonary hemorrhage, had been well controlled on Imuran and the patient was followed by a rheumatologist.
No, the inpatient hospital admission was not medically necessary for this patient.
This patient's underlying medical condition, Wegener's granulomatosis without renal manifestations, maintained on Imuran, made the treating physicians in the ED appropriately cautious when they saw and diagnosed her with influenza B. Because of her elevated CK level, they asked the patient to return and the repeat CK was still elevated, so they admitted the patient  for IV hydration. Neither her physical examination nor her laboratory findings suggested dehydration or any complications from Wegener's or influenza, apart from the elevated CK. The patient was not clinically worse . She did not have electrolyte or kidney problems. Influenza is well known to cause myositis, which would explain the CK elevation, leg pain, and pain with ambulation.
Myositis involving the legs bilaterally is a well-known clinical finding in patients with influenza.  It causes pain in both legs, typically the thighs, and if the creatine kinase (CK) is measured, it will be elevated, because the muscles are inflamed.  Creatine kinase is an enzyme found in skeletal muscles, such as the muscles of the legs and thighs.  So, when influenza causes inflammation of the muscles, the CK levels rise.  
In severe cases, rhabdomyolysis can occur.  This is a condition most commonly caused by trauma, where the muscles are directly injured (such as crush injuries and over-exercise), although there are some case reports of this occurring with infections such as influenza. If severe and left untreated, this condition can cause kidney damage and require dialysis. Kidney damage is heralded by electrolyte abnormalities and a rise of creatinine. The treatment is aggressive fluid hydration. 
This patient did not have an injury. The patient  was known to have influenza. The patient  did not exhibit evidence of early renal disease and was managed in the lower level setting with aggressive fluid hydration.  This hydration could have been continued in a lower level of care setting, therefore the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cellulitis.
Treatment:  Acute inpatient stay.

The insurer denied coverage for acute inpatient stay.  The denial is upheld.

This patient is a female with past medical history significant for neurofibromatosis, asthma, and status post hernia repair, who presented to the emergency department with complaints of right arm erythema, swelling, and pain following insect bites.

Vitals on presentation included: Temperature 36.5 C, Blood Pressure 139/85, Pulse 73, Respiratory Rate 14, oxygen (O2) saturations 97% on room air (RA).  Laboratory results included the following:  white blood cell count (WBC)-6.96, HGB-15.8, HCT-46.1, creatinine-0.7, and glucose-100.

The patient was started empirically on intravenous antibiotics (clindamycin) for a right forearm cellulitis.  Antibiotics were switched to Cefazolin.  The patient remained afebrile and hemodynamically stable.  She was discharged to continue outpatient management and oral antibiotics (Keflex).

According to the documentation, the patient presented with a right arm cellulitis.  Otherwise, she was afebrile and hemodynamically stable with no evidence for systemic toxicity.  Laboratory values were unremarkable, including normal WBC.  Moreover, the patient did not require surgical intervention.  Based on these findings, the patient did not fulfill criteria for acute inpatient admission.  The patient was stable for observation level of care.

The health acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the acute inpatient stay is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental fracture.
Treatment:  Dental Services - treat teeth #3-#6 and #12-14.

The insurer denied the Dental Services - treat teeth #3-#6 and #12-14.  The denial is upheld. 

The patient is a female requesting dental crowns on teeth #3-6,12-14.  She presents with a dental fracture to the maxillary ridge and damage to teeth #7-11 due to an accident.

No, the proposed treatment of crowns on teeth #3-6 and #12-14 is not medically necessary.

The records submitted do not indicate the level and severity of pathology present in teeth #3-6 and #12-14 to justify crown placement.  The records do not support fracture or damage to these teeth which would indicate crown placement.

The proposed treatment of dental crowns are not substantiated by the information in the records.

The Provider's narrative is vague and not sufficiently quantitative to the level of the amount of the clinical crown that is compromised on teeth # 3-6, #12-14.  There is no objective evidence as to the condition of these teeth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Problems (skeletal Class III, Class III canines, edge to edge overbite, moderate spacing and posterior crossbite).
Treatment:  D8080 braces.

The insurer denied coverage for D8080 braces.  The denial is upheld. 

This patient is a female child, who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics, due to skeletal Class III, Class III canines, edge to edge overbite, moderate spacing and posterior crossbite.  The orthodontist did not provide a completed Handicapping Labio-Lingual Deviation (HLD) index to support orthodontic care.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index, attaining only 11 points on review by their internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation index is utilized.  This index provides 6 specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.  In this case, the treating orthodontist does not provide a completed HLD index.

Regardless, in this case, the clinical circumstance does not meet the insurer and plan criteria to justify orthodontic care.  This reviewer concurs with the HLD index of the insurer attaining 11 points (i.e., 5 mandibular protrusion, 2 labiolingual spread, 4 posterior unilateral crossbite).

The Pre-Service request for D8080 braces is not considered medically necessary for this patient.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The medical necessity for the Pre-Service request for D8080 braces is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Subjective complaints of numbness in the right arm, agitation, shakes, and hand tremors. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient with a past medical history of spinal cord compression and multiple orthopedic surgeries. The patient presented to the Emergency Department (ED) with subjective complaints of numbness in the right arm, agitation, shakes, and hand tremors. The patient's blood pressure was 156/91. The patient's heart rate was 108. The patient's computed tomography (CT) of the cervical spine revealed that the patient was status post anterior cervical discectomy and fusion (ACDF) of C5-7. There was no acute fracture or dislocation. There were degenerative changes resulting in moderate to severe bilateral neuroforaminal stenosis at C5-7. The patient's CT of the brain revealed no acute intracranial hemorrhage or transcortical artifact. The patient was admitted for work-up.  Neurology evaluated the patient and Psychiatry was consulted. Psychiatry noted that the patient may have an unclear mood disorder. The patient was stabilized and discharged. 

According to the records, there is no clear evidence of acute change in the patient's neurological examination suggestive of acute stroke. There was no acute motor, sensory or visual deficit that suggested an acute stroke. There was no instability, new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure. Therefore, the patient's condition did not fulfill criteria for the acute inpatient care admission. 

As per literature review, the inpatient hospital admission was not medically necessary for this patient. The patient developed a transitory subjective complaint of numbness in the right arm, agitation, shakes, and hand tremors with non-focal, neurological examination and a negative imaging of the head and cervical spine; there was no new pathology. The patient's clinical condition was stable. The patient's condition could have been safely managed at a lower level of care, such as observation status. 

The inpatient hospital admission was not considered medically necessary for this patient. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance use. 
Treatment:  Inpatient admission.

The insurer denied coverage for the inpatient admission.  The denial is overturned. 

This is a male patient, who was admitted to an inpatient hospital for heroin detoxification.  The patient presented with withdrawal symptoms, including gastrointestinal upset and aches, nausea, diarrhea, chills, goose bumps, and generalized body aches.  The patient reportedly was using up to 8 bags of heroin daily.  The patient also reportedly was using cannabis.  The patient reported 27 pounds weight loss with a body mass index (BMI) of 16.9.  The patient's substance use history was significant for 6 past inpatient substance detoxification treatments and 2 inpatient substance rehabilitation treatments.  The patient was also unemployed.  The patient was admitted and was treated with a methadone taper. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  In this case, this patient had been using heroin daily and cannabis, and he was at risk for death from overdose of heroin and also at risk for severe withdrawal. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of heroin daily including up to 8 bags of heroin daily despite 6 past inpatient substance detoxification treatments and 2 past inpatient substance rehabilitation treatments.  The patient also required and received detoxification medication, methadone, to modify his withdrawal from heroin.  The patient presented with a long history of polysubstance use including heroin and cannabis, and needed 24-hour treatment then, as he was at risk for worsened withdrawal symptoms including severe withdrawal and even overdose.  The patient also had active withdrawal symptoms including gastrointestinal upset and aches, nausea, diarrhea, chills, goose bumps, and generalized body aches and was at risk for severe withdrawal and could not detoxify outside of this hospital setting.  The patient likely would have relapsed again, as evidenced by his history of relapsing after 6 past inpatient substance detoxification treatments and 2 inpatient substance rehabilitation treatments. 

Based on the review of the medical record and literature, the inpatient admission was medically necessary for this patient's substance detoxification.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for the inpatient admission is substantiated.  The insurer's denial should be overturned.