Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Leptomeningeal Disease. 
Treatment: Proton Beam Therapy (PBT), pre-service: 77525 Proton treatment delivery; complex, A9552: Fluorodeoxyglucose f-18 FDG, diagnostic, per study-dose, up to 45 millicuries, 77523 Proton treatment delivery; intermediate, 77520 Proton treatment delivery; simple, without compensation. 

The insurer denied: Proton Beam Therapy (PBT), pre-service: 77525 Proton treatment delivery; complex, A9552: Fluorodeoxyglucose f-18 FDG, diagnostic, per study-dose, up to 45 millicuries, 77523 Proton treatment delivery; intermediate, 77520 Proton treatment delivery; simple, without compensation. 

The denial is overturned. 

This is an adult female with mantle cell lymphoma diagnosed in last year status post chemotherapy with complete response. She relapsed in earlier this year and underwent stem transplant. The patient developed leptomeningeal involvement and was treated with chemotherapy. Her magnetic resonance image showed improvement but still with evidence of residual of leptomeningeal disease. Proton beam therapy is being requested for craniospinal radiation therapy. 

The health plan should cover the proposed treatment. 

There are multiple peer reviewed studies demonstrating potential advantages of proton beam therapy for craniospinal radiation therapy compared to conformal photon radiation therapy. 

Published studies of proton beam therapy to craniospinal radiation therapy fields substantially reduced the dose to the cochlea and vertebral bodies and virtually eliminated the exit dose through thorax, abdomen, and pelvis. Single institutional studies with small number of patients reported of reduced acute treatment-related squeals and myelosuppression with proton beam therapy to the craniospinal axis. 
In this patient's clinical condition of leptomeningeal involvement of lymphoma, multiple normal tissues such as optic nerve / chiasm / optic tract / pituitary gland / thyroid gland / pharynx / esophagus / lung / heart / breast / small bowel / kidney / bone marrow / uterus / ovary are in close proximity to the radiation therapy fields. Craniospinal photon beam therapy carries significant risk of radiation damage to these normal tissues in this adult female including thyroid / ovarian hormonal dysfunction and lifetime risk of breast cancer. Proton beam has the advantage of being able to deposit the intended dose of radiation to the tumor with sharp dose fall off from normal tissues, thus improving probability of local control with reduced complication (Ref #3). Proton beam with superior dose conformity can deliver a high dose to the tumor with maximum sparing of adjacent optic nerve / chiasm / pituitary gland / gastrointestinal tract and ovaries and will decrease risks of such complications in this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Leptomeningeal Disease. 
Treatment: Proton Beam Therapy (PBT), pre-service: 77525 Proton treatment delivery; complex, A9552: Fluorodeoxyglucose f-18 FDG, diagnostic, per study-dose, up to 45 millicuries, 77523 Proton treatment delivery; intermediate, 77520 Proton treatment delivery; simple, without compensation. 

The insurer denied: Proton Beam Therapy (PBT), pre-service: 77525 Proton treatment delivery; complex, A9552: Fluorodeoxyglucose f-18 FDG, diagnostic, per study-dose, up to 45 millicuries, 77523 Proton treatment delivery; intermediate, 77520 Proton treatment delivery; simple, without compensation. 

The denial is overturned. 

The patient is an adult female with a diagnosis of mantle cell lymphoma status post multiple courses of systemic therapy as well as palliative radiation to the left axilla/arm to eight gray per one fraction (8Gy/1fx). The patient was subsequently found to have leptomeningeal disease status post additional systemic therapy and intrathecal chemotherapy but with residual extensive disease. Craniospinal radiation therapy was recommended, and proton therapy was requested. 

The health plan should cover the proposed treatment. 

Studies have shown that proton therapy can reduce dose to the surrounding critical structures compared to photon-based radiation for craniospinal irradiation. A 2018 study performed a dosimetric comparison of five different techniques for craniospinal irradiation. The authors concluded that "The investigated modern radiotherapy techniques demonstrate superior dosimetric results compared to 3D-CRT. The lowest mean dose for organs at risk is obtained with proton therapy". 

Another 2014 study from Barney et al. reviewed medical records for 50 patients (aged 16 to 63 years) with malignancies of varying histologies treated consecutively with vertebral body-sparing proton craniospinal irradiation (p-CSI) at MD Anderson Cancer Center from 2007 to 2011. The authors concluded that "This large series of patients treated with p-CSI confirms low rates of acute toxicity, consistent with dosimetric models. Vertebral body-sparing p-CSI is feasible and should be considered as a way to reduce acute gastrointestinal and hematologic toxicity in adults requiring CSI". 

Other types of radiation therapy such as intensity modulated radiation therapy (IMRT) or tomotherapy has also been used to treat this disease, however, because of the location, size and extent of the disease, they are not the optimal modalities for this patient. A photon/proton therapy comparison plan was also done, and the proton therapy was able to significantly reduce dose to the surrounding critical structures such as the lens and the heart. Proton beam radiation therapy, therefore, is considered medically appropriate for this patient at this time.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Orthopedic/Musculoskeletal/Low Back Pain.
Treatment: Surgical Services/posterior lumbar interbody fusion (PLIF) at the levels of lumbar vertebrae 3-4 (L3-4) and lumbar vertebrae 4-5 (L4-5) with decompressive laminectomy and 1 inpatient bed stay. 
The insurer denied the surgical procedures, posterior lumbar interbody fusion (PLIF) at the levels of lumbar vertebrae 3-4 (L3-4) and lumbar vertebrae 4-5 (L4-5) with decompressive laminectomy and 1 inpatient bed stay. as not medically necessary. 
The determination is overturned, in part.

The patient is a female with a history of low back pain and bilateral leg pain. She underwent physical therapy, chiropractic therapy, injections and medications without relief. She is a current smoker. The neurologic exam shows left leg weakness. The lumbar magnetic resonance imaging (MRI) shows severe spinal stenosis in lumbar vertebrae 3-4 and moderate to severe foraminal narrowing in lumbar vertebrae 4-5. 
At issue is the medical necessity of the requested surgical procedures.

The health plan's determination of medical necessity is overturned, in part.

The lumbar decompression is medically necessary; however, the lumbar fusion is not medically necessary.  
The patient has spinal stenosis (lumbar) L3-5 but there is no spondylolisthesis or instability.  The literature does not support fusion in this circumstance.  Thomes et al cite, "the addition of fusion to decompression did not result in improved outcomes at 3, 12, or 24-month follow-up. The addition of fusion to decompression provides no advantage to decompression alone for the treatment of patients with neurogenic claudication secondary to lumbar stenosis without spondylolisthesis or deformity." 
The decompression is medically necessary and supported by the literature. Lurie et al cite "in the as-treated analysis combining the randomized and observational cohorts of patients with spinal stenosis (SpS) those treated surgically showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over eight years compared to patients treated non-operatively." The North America Spinal Society (NASS) guidelines state "Decompressive surgery is suggested to improve outcomes in patients with moderate to severe symptoms of lumbar spinal stenosis. Surgical treatment may be considered to provide long-term (4+ years) improvement in patients with degenerative lumbar spinal stenosis and has been shown to improve outcomes in a large percentage of patients." 
The 1-day hospital stay for a lumbar decompression is medically necessary due to the length of the surgery, post-operative pain and the use of a post-operative drain.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriatic arthritis
Treatment: Taltz
The insurer denied coverage for Taltz.
The denial is upheld.

The patient is a young adult with a diagnosis of psoriasis and psoriatic arthritis. The patient has 30 percent (%) total body surface area (TBSA) involvement of psoriasis. The patient has failed therapy with only topical steroids and occasional prednisone.  

There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Taltz for this patient's condition as an accepted standard of practice over reasonable alternative formulary medications. The patient has not tried any systemic medications for treatment of his psoriasis or psoriatic arthritis. There is no documentation provided which would indicate a true contraindication to treatment with numerous systemic biologics commonly used in the treatment of both psoriasis and psoriatic arthritis. According to the joint American Academy of Dermatology - National Psoriasis Foundation (AAD-NPF) guidelines for the treatment of psoriasis, Humira and Enbrel have a strength of recommendation of "A" for monotherapy in adult patients with psoriasis vulgaris and are effective treatments for psoriatic arthritis. According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative safe and effective treatments for the management of psoriasis are available and appropriate for this patient. A history of peptic ulcer disease and asthma are not contraindications to the use of any biologic. The preferred agents, Humira and Enbrel or other available alternatives, are effective therapies for the treatment of the patient's psoriasis. The provided medical notes do not provide any evidence of an absolute contraindication for the use of these available alternatives. Therefore, Taltz is not medically necessary for this patient based on the medical documentation provided.

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 Taltz is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibroids
Treatment: Uterine artery embolization, vascular procedure (37242, 37243, 37244) x 1
The insurer denied coverage for uterine artery embolization, vascular procedure (37242, 37243, 37244) x 1.
The denial is upheld.

According to the documentation submitted, this is an adult with a history of irregular menses, cysts, and fibroids. The patient presented to the gynecologist's office for a follow up for fibroids and irregular menses. The patient reported having menses twice a month. The physician discussed medical management versus surgical management of fibroids. The treating practitioner recommended uterine artery embolization. 
 
Uterine artery embolization (UAE) is a minimally invasive treatment for uterine leiomyomas (fibroids). The procedure is a percutaneous angiographic procedure performed with video fluoroscopic imaging with injection of embolic agents into the uterine artery. Ideal candidates for UAE include women with heavy menstrual bleeding or dysmenorrhea caused by intramural fibroids, who are premenopausal, and who have no desire for future pregnancy.

Prior to performing any procedure on a patient with abnormal uterine bleeding, an endometrial biopsy needs to be performed to rule out other causes of the bleeding and most importantly to rule out any serious pathology like cancer. The provider mentioned in his progress note that an endometrial biopsy will be performed to rule out a serious pathology, but there was no documented evidence that an endometrial biopsy was performed for this patient. As such, the requested treatment is not considered medically necessary for this patient at this time.

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

The insurer's denial of coverage for the uterine artery embolization, vascular procedure (37242, 37243, 37244) x 1 is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Paranoid schizophrenia 

Treatment: Continued Long-Term Care Placement (LTC)

The insurer denied coverage for continued LTC

The denial is upheld 

This is an adult patient with chronic medical problems including heart failure, atrial fibrillation, and paranoid schizophrenia. The patient was admitted to the skilled nursing facility (SNF). The patient was switched to LTC coverage. The facility is having difficulty with the patient's discharge placement, particularly due to the underlying psychiatric condition. Under review is the medical necessity for continued LTC.

The patient's clinical condition and functional ability are not at a level as to require LTC for the time period under review. The patient is essentially modified independent for activities of daily living and functional mobility. This physician does note the patient's behavior changes, reported risk to self/others and the diagnosis of paranoid schizophrenia for the time period under review. The clinical records also document the patient's refusal of care. The clinical records do not document a level of care that requires LTC. The more appropriate venue for the patient during the time period under review is a psychiatric facility/unit for treatment of the underlying psychiatric condition. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, attending physician's recommendation and applicable accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based. From a physical medicine and rehabilitation perspective, continued LTC placement is not medically necessary. 

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 continued Long-Term Care Placement (LTC) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Down syndrome, asthma, learning disability
Treatment: Increase Consumer Directed Personal Assistance Services from 12 Hours per Week to Nine Hours per Day Six Days per Week, a Total of 54 Hours per Week
The insurer denied: Increase Consumer Directed Personal Assistance Services from 12 Hours per Week to Nine Hours per Day Six Days per Week, a Total of 54 Hours per Week
The denial is overturned

The patient is an adolescent child with known asthma, Down syndrome, and development delay. The patient was assessed by a specialist in the field and found to need support in basic life functioning such as cleaning and dressing.

The proposed treatment is medically necessary.

The patient requires therapy and support for basic life skills as the patient was assessed by a specialist in the field and was found to be unable to appropriately and safely care for herself and clean herself. The patient's wellbeing and safety require the prescribed therapy and care. As per the evaluation submitted, the patient does not meet appropriate assessment markers to be self-sufficient. As the patient was reviewed by a specialist in the field and was not found to be self-sufficient in these basic life activities, the prescribed treatment in support is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Fibroids.
Treatment: Radiofrequency Ablation (0404Tx1).

The insurer denied: Radiofrequency Ablation (0404Tx1).  The denial is upheld.

The patient is an adult female with a history of symptomatic fibroids and menorrhagia. She consulted her gynecologist who prescribed Relugolix and the patient declined. Transcervical radiofrequency ablation was recommended and planned.

The health plan should not cover the proposed treatment.

The medical records and medical literature were thoroughly reviewed. Options for minimally invasive uterus-sparing alternatives for the treatment of uterine fibroids, within the standard of care, include myomectomy and uterine artery embolization. The Sonata device is a new Food and Drug Administration (FDA) approved minimally invasive treatment for uterine fibroids that uses radiofrequency energy to destroy fibroid tissue. The novel use of radiofrequency ablation under laparoscopic and intraabdominal ultrasound guidance to treat patients with symptomatic myomas was first introduced in 2002. This has prompted the development of Sonata, which carries out transcervical ultrasound-guided radiofrequency volumetric thermal ablation of uterine myomas in symptomatic women. The key feature lies in the inherent and immediate proximity of the transducer to the target (fibroid), allowing the use of higher frequencies with significantly increased resolution. Transcervical fibroid ablation (TFA) has certain advantages that might appeal to patients, including a noninvasive delivery method, uterine preservation, ability to treat a wide range of fibroid types, avoidance of general anesthesia, and rapid recovery and return to activities of daily living (ADLs) following the procedure. The procedure is incisionless and preserves the uterus. Unlike operative hysteroscopy, transcervical fibroid ablation is designed for ablation of most nonpedunculated fibroid types.

This patient has symptomatic uterine fibroids and transcervical fibroid ablation is recommended. However, the American College of Obstetrics and Gynecology, in its Practice Bulletin, states: "Laparoscopic radiofrequency ablation can be considered as a minimally invasive treatment option for the management of symptomatic leiomyomas in patients who desire uterine preservation and are counseled about the limited available data on reproductive outcomes. Radiofrequency ablation (RFA) can be delivered by a laparoscopic, transvaginal, or transcervical approach, using ultrasound guidance to induce coagulative necrosis in targeted uterine leiomyomas. All of the approaches are similarly effective in reducing uterine leiomyoma volume and in improving quality of life metrics, but the laparoscopic approach has been studied the most rigorously". The American College of Obstetrics and Gynecology, in its Practice Bulletin, does not support transcervical radiofrequency ablation (RFA) as an effective treatment for this condition. Therefore, the procedure is considered experimental/investigational.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Fibroids.
Treatment: Radiofrequency Ablation (0404Tx1).

The insurer denied: Radiofrequency Ablation (0404Tx1).  The denial is upheld.

The patient is an adult female who has been recommended radiofrequency ablation for treatment of her myomas. Coverage was denied because it is deemed experimental or investigational.

The health plan should not cover the proposed treatment.

The use of radiofrequency ablation to treat myomas is not supported by peer reviewed data given the fact that most studies are small, there are no randomized data, and the follow up time has been short in each of the studies. There are no large prospective studies evaluating the long-term safety and efficacy of this procedure and in older women, there is a yet to be determined risk of ablating a sarcoma. Use of this technology is not supported by peer reviewed data; it is not standard of care, and it is not supported by professional organizations.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever; abdominal pain.
Treatment: Inpatient hospital services.
The insurer denied: Inpatient hospital services.
The denial is upheld.

This patient is an adult female with a diagnosis of kidney stones who recently underwent a ureteroscopy with lithotripsy. She presented to the hospital with complaints of abdominal and flank pain with associated nausea. On presentation she was reportedly afebrile and hemodynamically stable. Labs were grossly normal other than a slightly elevated WBC (white blood cell) count of 11.7. A performed examination was reported as normal. The patient was admitted to the inpatient service and managed with fluids and antibiotics. This patient had an unremarkable hospital stay and was discharged two days later. Medical necessity for inpatient stay is under review. 

The proposed treatment of inpatient hospital services is not considered medically necessary. 

The majority of patients who present with renal colic/UTI (urinary tract infection) can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant 
complications or major issues with pain control. There was no procedure performed. The information provided and the patient's clinical status does not suggest the need for acute inpatient care. Observation status for this patient's clinical presentation and hospital course was considered safe, effective, a generally accepted standard and the most appropriate treatment option. 
Admission status may be changed anytime during observation if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Foot Pain
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The health plan's determination is overturned.

The patient is a male with chronic left foot pain attributed to a left flat foot with a tight Achilles tendon and to decreased femoral anteversion of the left femur. The patient is obese. He underwent a derotational osteotomy of the left proximal femur, secured by internal fixation, and a left calcaneal lengthening osteotomy and Achilles tendon lengthening. The procedure took approximately seven hours. The patient was evaluated by physical therapy and was discharged to home on the second postoperative day.

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

The full hospital admission was medically necessary for the patient. An osteotomy of the femur alone, particularly in an obese patient, is a major surgical procedure that by itself may require inpatient care. In addition, this patient had a calcaneal osteotomy, a procedure that requires non-weight-bearing afterward and is associated with some pain. The combination of these procedures in an obese patient is likely to be associated with a great deal of difficulty regaining ambulation. The patient needs to demonstrate at least the ability to transfer safely before discharge and to be able to enter and leave his home. The care required afterward, and the monitoring required after a seven-hour surgery in an obese patient, is sufficient to merit an inpatient hospital admission, which should be considered medically necessary.