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

Diagnosis:  Watershed distribution stroke, Right frontal cortical ischemic stroke.
Treatment:  Powered brace (MyoPro G).

The insurer denied coverage for a powered brace (MyoPro G).  The denial is upheld.

This is a male patient with a history of sleep apnea, hypertension, diabetes, chronic kidney disease, hyperlipidemia, and implantable loop recorder placement.  The patient had two strokes (watershed distribution stroke and right frontal cortical ischemic stroke) with resultant left upper extremity hemiplegia that remains non-functional.  Under review is a requested powered brace. 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the requested powered brace (MyoPro G) is best described for this patient as investigational/experimental.  The quality and quantity of data in the current peer-reviewed scientific medical literature is inadequate to conclude the clinical utility, safety and efficacy of MyoPro G for the treatment of this patient's clinical condition.  The studies are plagued by limited sample size, lack of control group and retrospective.  The device is not proven medically necessary for this particular patient. 

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested powered brace is not medically necessary.
 
The carrier's denial of coverage for MyoPro G should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bipolar Disorder 
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was upheld. 

This is a female patient who was admitted for inpatient mental health treatment due to mood and psychotic symptoms including paranoia, illogical, and disorganized thinking, thought blocking and poverty of thought content, sad mood, hopelessness, poor sleep and eating, poor concentration, and inability to work.  The patient's concentration was impaired and her memory was impaired. The patient reportedly had a diagnosis of Bipolar Disorder with psychotic features and Cannabis Use Disorder.  The patient's history was significant for past psychiatric hospitalizations.  The patient's treatment included frequent monitoring observation for safety, individual and group therapy and Abilify.  The patient clinically improved and was discharged home.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with aggression, homicidal or suicidal intent, plan, or behavior, psychotic symptoms, or severe agitation are candidates for inpatient hospitalization.  In this case, this patient had initially presented with mood and psychotic symptoms including paranoid, illogical, and disorganized thinking, thought blocking and poverty of thought content, sad mood, hopelessness, poor sleep and eating, poor concentration, and inability to work. However it was reported that the patient did not report further paranoid, illogical, and disorganized thinking, thought blocking and poverty of thought content, sad mood, hopelessness, and there was no reports that she was a danger to self or others then.  

There were no reports of manic episodes, aggression, disruptive behavior, paranoid delusions, hallucinations, disorganized speech or thought process, suicidal or homicidal ideation, plan, or intent, or severe agitation.  There were no reports of acute medical instability of severe withdrawal requiring hospital treatment then. The patient was calm, flat in affect, withdrawn and guarded but there were no reports of paranoia, illogical, and disorganized thinking, thought blocking and poverty of thought content, sad mood, hopelessness, hallucinations, suicidal or homicidal ideation. There were no reports of paranoia, illogical, and disorganized thinking, thought blocking and poverty of thought content, sad mood, hopelessness, hallucinations, suicidal or homicidal ideation.  
Based on the review of the medical record there were no reports of specific identifiable or quantifiable treatment objectives that could only be achieved in a 24-hour acute inpatient hospital setting or that could not be achieved in a less restrictive level of care then. 

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

The carrier's denial of coverage for inpatient level of care should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  DJD (degenerative joint disease).
Treatment:  Increase to 36 Hours of Personal Care Assistance per Week.

The insurer denied an Increase to 36 hours of Personal Care Assistance per week.  The health plan's determination is overturned. 

The patient is a female with past medical history of chronic knee pain, advanced degenerative joint disease (DJD), urinary incontinence, obesity, depression and gastroesophageal reflux disease (GERD), who had been assigned 28 hours/week of PCA (personal care assistance) / CDPAS (Consumer Directed Personal Assistance Services) based on the assessment tool.  The patient was assessed at extensive assistance with tasks of stairs and transportation and limited assistance for tasks of bathing, personal hygiene, dressing upper and lower body and toilet use.  For tasks of walking, locomotion and toilet transfer, the patient was assessed at supervision assistance only.  She was assessed at set up assistance with tasks of managing finances, managing medication and phone use.  The patient was assessed as independent with tasks of bed mobility and eating.

The Increase to 36 Hours of Personal Care Assistance per Week medically is necessary for this patient.

The patient had a change in her functional abilities since her "in person" assessment tool performed, and this was not taken into account by the insurer in its denial of increased PCA/CDPAS service hours.

The patient did not have another assessment tool performed due to her change in functional status.  The patient's PCP provided a letter stating the patient's ability to ambulate had worsened due to chronic DJD, and the patient stated she had increase needs with activities of daily living (ADL) due to recent Covid infection.  The patient does not have an informal helper and was receiving no PCA/CDPAS on Sundays.  The patient's CDPAS could change the day of the week to help the patient, but this does not take into account the extra assistance needed with ADL's of meal preparation, bathing, personal hygiene, dressing, walking, locomotion, transfer toilet and toilet use on other days.  Personal care services are medically necessary under Medicaid 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: Stage IV breast cancer with multiple brain metastases
Treatment: IGRT
The insurer denied the IGRT.
The denial is overturned. 

The patient is a female with stage IV breast cancer with brain metastasis.  Palliative brain radiation therapy with 3D (three-dimensional) conformal radiation therapy was recommended, and IGRT (image-guided radiation therapy) was requested.  

Yes, the IGRT is medically necessary.

Image guided radiotherapy (IGRT) is a method of tumor localization during the delivery of radiation therapy.  This procedure is performed during the actual radiation therapy delivery session.  It is a technique used to compensate for the movement of the tumor and/or patient during radiation therapy.  It provides accurate and objective monitoring of the patient's alignment and motion as well as the tumor's position.  The information from IGRT is used to adjust the patient's position for optimal radiation dosing to the target area while sparing adjacent healthy tissue or organs.  IGRT is typically used in patients with tumors located near or within critical structures and/or in tissues with setup variations.  IGRT is an FDA-approved procedure and it is not subject to IRB (institutional review board) review.

In this case, the patient is a female with stage IV breast cancer with brain metastasis.  Palliative brain radiation therapy with 3D conformal radiation therapy was recommended, and IGRT was requested.  Typically, palliative brain radiation requires conventional conformal radiation therapy.  Routine port films are also needed for target localization and quality assurance.  In this case, the facility only has a Tomotherapy unit, which does not have the capability of taking port films.  For target localization and verification, the Tomotherapy unit uses Image-guided radiation therapy (IGRT) with megavoltage CT (computerized tomography) imaging.  Since target localization and verification is a crucial procedure for radiation therapy, and IGRT is the only way the Tomotherapy unit can perform this task, IGRT is medically necessary for this patient at this time.

In regard to the health plan's position, while it is true that the patient's diagnosis of brain metastasis usually does not warrant the use of IGRT, this case is an exception. Target verification and localization with either port films or IGRT is an essential part of radiation delivery to ensure accurate treatment delivery. This facility only has a Tomotherapy unit, which does not have the capability of taking port films. IGRT in this case is the only way of target verification and localization and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive system /Gastrointestinal/ Crohn's disease  
Treatment: Pharmacy /Prescription drugs 
The insurer denied Stelara 
The denial is overturned in whole

This is patient who has severe Crohn's disease. The patient  has tried and failed 5-aminosalicylic acid (5-ASA) agents, and steroids and most recently an anti-tumor necrosis factor (TNF) agent Remicade despite an escalated dose. Because of  prior exposure to an anti-TNF agent the attending gastroenterologist would like to start  Stelara to treat  severe Crohn's disease since it has different mechanism of action than anti TNF agents.
Yes, the requested health service/treatment of Stelara is medically necessary for this patient.
The standard of care when a patient fails one class of biological therapy used to treat inflammatory bowel disease (IBD) is to switch to an agent from a different class i.e. with a different mechanism of action. Humira is an anti TNF agent in the same class as Remicade and should not be used in this patient. Although Entyvio is approved for the management of both ulcerative colitis and Crohn's disease, current evidence suggests that Entyvio is more effective for ulcerative colitis than Crohn's disease.
Since this patient has been treated with an anti TNF agent (Remicade) in the past, it is appropriate to start him on a biological agent with a different mechanism of action. Crohn's disease results from a pathological immune response to luminal antigens in genetically predisposed individuals. Since the causes of Crohn's disease are complex and only partially understood, treatment is based on the empiric use of anti-inflammatory drugs. Although multiple therapies for Crohn's disease currently exist, a substantial proportion of patients are unresponsive to conventional agents.

In a study by Kopylov and colleagues 38 patients (18 males, median age 35.5 years) with Crohn's disease resistant to anti-TNF agents at 3, 6, 12 months and at last follow up were enrolled. The most frequent loading schedule (73.7%) was 90 mg at weeks 0, 1 and 2, while 73.7% were treated with maintenance regimen of 90 mg every 8 weeks. The majority of patients (73.7%) had an initial clinical response, of whom 80% had sustained response at 6 months. Among the patients who showed a response at 6 months, 88.9% continued to maintain a clinical response at 12 months. At their last follow up (7.9  5.2 months); 71% maintained response while 73.3% were in corticosteroid-free remission. There was a need for dose escalation (n = 18) (mostly by interval reduction in 17 out of 18 patients) in 47.7% and this was successful in a majority (61.1%) of them. This would suggest that further dose optimization of ustekinumab may be needed in Crohn's disease.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Inpatient hospital

Diagnosis: CRPS; POTS
Treatment: Acute Rehab
The insurer denied acute rehab treatment. The health plan's determination is overturned. 

The patient is a female with a history of complex regional pain syndrome (CRPS), chronic intractable migraine, hypermobility syndrome, postural orthostatic tachycardia syndrome (POTS), dysautonomia, gastroparesis, pain related anxiety, and depression. She has had functional decline in spite of outpatient therapies. The pandemic has also limited access to appropriate outpatient services. Under review is the patient's treatment in an acute rehabilitation facility.

The acute inpatient rehab admission is medically necessary for this patient. Intense exercise therapy has been shown to be effective in initially treating CRPS in pediatric patients and is associated with a low long-term symptom rate. Inpatient rehabilitation can help support pediatric patients and also remove them from possible exacerbating environmental and familial stressors that might be contributing. A multi-disciplinary approach, including therapy, psychological, and medical support. In addition, some evidence suggests that intensive comprehensive rehabilitation program may help modify neural pathways contributing to pain. This patient has clearly failed reasonable outpatient therapy attempts with documented reported compliance with home exercise program and acceptance of a broad array of treatment modalities.
Appeal type: Medical necessity
Decision: Overturned

Skin Disorder
Pharmacy/prescription drug

Diagnosis: alopecia areata
Treatment: Tofacitinib compound  
The insurer denied the Tofacitinib compound. The health plan's determination is overturned. 

The patient is a female with alopecia areata, treated with topicals and systemic steroids. The patient has responded well to topical Tofacitinib. The provider requesting continuation of the Tofacitinib compound.

The Tofacitinib compound is medically necessary for this patient.
Current evidence based literature supports the use of JAK-kinase inhibitors for alopecia areata, especially universalis as there are no other effective therapies, and therefore Tofacitinib can be expected to provide a greater therapeutic outcome. It is also generally considered medically necessary to continue a patient on a therapy to which they have favorably responded.
A wide range of treatments have been used for the management of alopecia areata, most of which are not highly effective. Treatments include topical or intralesional corticosteroids, topical minoxidil (2% or 5%), topical anthralin, systemic corticosteroids, cyclosporine, and other immunosuppressants. A dependable and safe treatment for extensive disease (totalis or universalis) has yet to be found. Given the rarity of the disease, large randomized controlled trials are extremely difficult.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lung Mass
Treatment: Chest CT scan
The insurer is denied coverage for chest CT scan.
The denial is overturned.
This is a female patient who presented for an evaluation of a chest mass. The patient reported a constant dry cough which initiated after her return from a trip. The patient stated that she felt like it felt like asthma. The patient's physical examination revealed there was a 3.9 x 4.1 cm chest wall mass. The patient's pulmonary effort was normal and the breath sounds were normal. The patient underwent a chest x-ray which revealed a prominent cardiophrenic angles density of approximately 5 cm that may represent a mass or prominent cardiophrenic fat. A follow-up computed tomography (CT) scan of the chest was recommended. The provider indicated that the patient showed a mass that was 3.9 x 4.1 cm. Therefore, the CT scan of the chest was requested with and without contrast. The patient's CT scan was performed the results of the CT scan was normal.

Based on the review of the medical record and literature, the chest computerized tomography (CT) scan is considered medically necessary for this patient. The patient had an abnormal chest radiograph finding that is suspicious for an intra-thoracic mass. The radiologist recommended a chest CT for further evaluation and the patient was evaluated clinically. The standard of care for more definitive evaluation of an intra-thoracic mass is cross-sectional imaging with a chest CT or chest magnetic resonance imaging (MRI) with contrast. The chest CT with contrast provides a more sensitive evaluation of the intra thoracic anatomic structures that provides guidance for further management and treatment.

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

Based on the above, the medical necessity for the requested chest CT scan is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain 
Treatment: Inpatient hospital stay 

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

This is a male patient with a history of hypertension, diabetes mellitus, myocardial infarction who was treated with 3 stents to the RCA, polysubstance abuse and immunocompromised status. The patient had been discharged. He presented to the Emergency Department (ED) with complaints of worsening chest pain that worsened with deep inspiration. Labs drawn showed abnormal troponinT levels of 0.99 and 1.04. An electrocardiogram (EKG) was performed that showed ST elevation in inferior leads with no reciprocal changes and the ST elevations persisted over serial EKGs with no significant change. Cardiology was consulted. The patient was admitted to telemetry and monitored. His symptoms were consistent with post-myocardial infarction pericarditis, and the patient was also found to have acute kidney injury. An echocardiogram was performed which showed mild global left ventricular hypokinesis with no pericardial effusion. His symptoms improved after initiation of high dose aspirin and colchicine. The patient was discharged home with outpatient follow up planned. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The acute inpatient admission was not medically necessary. 

The patient presented with pleuritic chest pain consistent with pericarditis. The ECGs did not show any acute changes and the TnT levels were not consistent with an acute event but rather residual of the recent MI. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met. There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. The observational level would have been appropriate. 

The carrier's denial of coverage for inpatient hospital stay is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncopal Episode
Treatment: Inpatient hospital admission
The insurer is denied coverage for the inpatient hospital admission.
The denial is upheld.
This is a male patient with a past medical history of hypertension, hyperlipidemia, depression, anxiety, benign prostatic hyperplasia, kidney stone, and a new diagnosis of Parkinson's disease, with concern for multiple system atrophy. The patient was brought to the Emergency Room (ER) by ambulance following a syncopal episode. The patient reported that he developed acute right flank pain while walking and had shortness of breath. The patient passed out with no recollection of the events. The witnesses reported that the patient suddenly sat down, vomited, and then passed out; there was no head trauma. In the ER, the patient had another episode of shortness of breath, syncope, and vomiting. The patient's blood pressure was 144/76 and his pulse was 87 and had a 95% on room air. The patient had TnT of 0.019 and .01ng/ml. The patient's echocardiogram revealed normal ejection fraction, normal, right ventricular systolic function, and mildly increased left ventricular wall thickness and grade 1 (mild) left ventricular diastolic dysfunction. The patient's computed tomography (CT) scan of the abdomen and pelvis revealed central low attenuation within the prostate gland. The patient's CT scan of the head showed no acute pathology. The patient had no acute events overnight. The patient was discharged in stable condition.

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. While the patient had a syncopal episode, the patient presented himself to the Emergency Department (ED) in a hemodynamically stable condition, being well awake and oriented and no neurologic, respiratory, orthopedic, metabolic, or infectious issue. The minimal change in troponin (TnT) level was not diagnostic of an acute event and with normal electrocardiogram (EKG) and no echo finding of regional left ventricular asynergy, not of clinical concern. There was no indication for an inpatient status in absence of a specific diagnosis or a documented significant risk of deterioration. The patient was stable and could have been monitored at a less intensive level of care, such as observation status.

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.