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

Diagnosis: Abdominal pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male who initially presented to the emergency department for concerns of abdominal pain, nausea, vomiting, and dizziness. Pertinent history included hepatocellular carcinoma with metastasis to the hepatoduodenal ligament / periportal nodes status/post (s/p) radiation and on Keytruda, biliary obstruction with distal common bile duct (CBD) stricture s/p stent placement, hypertension, and diabetes mellitus. 

The inpatient hospital admission was not medically necessary. In this particular situation, the patient was stable without significant warning signs or symptoms. A comprehensive evaluation was performed including laboratory testing and abdominal imaging which did not reveal an acute pathological process. General surgery and gastroenterology consultations were obtained whom did not recommend intervention. Treatment plan included mainly supportive care. Following observation care, there was no further nausea or vomiting and abdominal pain was controlled with an oral regimen. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Kidney Stone
Treatment: Inpatient admission
The insurer denied the inpatient stay.
The health plan's determination is overturned.

The patient is a male with history of nephrolithiasis and cholecystitis who presented to the emergency room (ER) with persistent flank pain. He was seen in the ER 2 days prior with flank pain and was found to have a 4 millimeter (mm) right ureteral stone with moderate hydronephrosis. His pain improved in the ER and he was discharged on pain medications and Ciprofloxacin. He presented with a recurrence of his symptoms. He had no fever or chills. He had some burning upon urination. He was hemodynamically stable. His labs showed leukocytosis with his white blood cell count (WBC) 17.5, hemoglobin (Hb) 10.8, platelets (Plt) 462 and serum creatinine (Cr) was 1.34. The computed tomography (CT) of his abdomen and pelvis showed a 4 millimeter (mm) renal stone and moderate hydronephrosis. His urinalysis was positive and he was diagnosed with a urinary tract infection (UTI). He was started on intravenous (IV) hydration and IV Ceftriaxone. He was seen by urology and a cystoscopy was performed. A stent was also placed as the stone was considered to be difficult to retrieve. He was given IV narcotics and IV Toradol due to significant pain. After the stent placement, he was discharged home on oral antibiotics. His serum Cr improved as well.

The patient failed outpatient and observation treatment and presented 2 days after with similar symptoms. The patient needed better pain control. He was treated with IV hydration, IV Ceftriaxone, IV Morphine and IV Dilaudid. Urology was unable to retrieve the stone and a stent was placed. With IV hydration and after the stent placement, his Cr improved and he was discharged home. This was his second admission within a couple of days and the patient failed the outpatient treatment. Due to the failed outpatient therapy, he was meeting the inpatient admission criteria. The patient had a UTI, acute kidney injury and a need for IV pain medications beyond the period of observation that was making him a candidate for an inpatient admission [1,2].
The care provided to the patient was not appropriate for an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibroids.
Treatment: Hysterectomy.
The insurer denied: Hysterectomy.
The denial is: Upheld.

This patient is a gravida (G)2 para (P)2 female who is under consideration for hysterectomy given an enlarged uterus due to fibroids. The patient is noted to have undergone ultrasound that noted a uterus of 11.1 x 5.8 x 10.3 centimeters (cm) (per ultrasound) in an anteverted position with endometrial thickness of a total of 8.4 millimeters (mm). The cervix is normal on exam. A fibroids of 7.6 x 7.0 x 7.1 cm is noted. This is subserous in position in the right posterior position. The patient is reported to have pressure in the bowel and bladder. There is statement that the fibroid has rapidly increased in size. There are cancers in the family to include prostate and pancreatic. There is a history of loop electrosurgical excision procedure (LEEP), and the patient has a bilateral tubal ligation that is for contraception. Ovarian views were normal on ultrasound. The patient was offered options for surveillance, myomectomy or hysterectomy. She had reassuring myRisk results. There was a variant of undetermined significance in adenomatous polyposis coli (APC) but no change in management was made per notes. This is linked to pancreatic cancer.
In this case, the patient appears to have already undergone hysterectomy based upon pathology report that noted normal right and left tubes and a total hysterectomy with no significant histologic abnormality and disordered proliferative endometrium. There was a leiomyoma. The subject under review is the medical necessity for hysterectomy.

The health plan's determination is upheld in whole. 

Based upon a review of the single encounter for a solitary fibroid and no trial of medical management, there would not have been medical necessity for performance of hysterectomy. There was a statement of a rapidly enlarging fibroid but there is no evidence of any assessment beyond a single ultrasound of the myopia. There were no features to support malignancy. Indeed, this was also excluded on pathology. In the case of a solitary fibroid with no prior comparison to support the statement of a rapidly enlarging leiomyoma, the patient would be treated with medical management prior to surgical management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer/Salivary Gland Cancer. 
Treatment: Abiraterone Acetate 250 milligram (mg) tabs. 

The health plan denied the requested medication Abiraterone Acetate 250 milligram (mg) tabs as not medically necessary. The health plan's determination is upheld. 

This is a male with stage IVA salivary duct carcinoma. The patient has undergone resection and adjuvant proton therapy with concurrent cisplatin. The patient was subsequently placed on Bicalutamide and Lupron with a complete response in imaging. The patient developed progressive disease and was started on Carboplatin+nab-Paclitaxel. 

Abiraterone Acetate 250 milligram (mg) tabs have been recommended and is under review for medical necessity. 

The health plan's determination of medical necessity is upheld, in whole. 

High quality data supporting the use of Abiraterone in this clinical scenario has not been published. While there is data supporting treatment that targets the androgen receptor in relapsed disease, this data does not include Abiraterone. For these reasons, this agent is not recommended by the National Comprehensive Cancer Network (NCCN) Guidelines nor by the authors of UpToDate. Support in the peer-reviewed literature is not available. This agent was evaluated in a clinical trial (NCT02867852) but these results have not been presented. For these reasons, medical necessity has not been established for this service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Attention Deficit Hyperactivity Disorder (ADHD).
Treatment:  Vyvanse 50 MG (milligram) OR (oral) CAPS (capsules).

The insurer denied Vyvanse 50 MG OR CAPS. The health plan's determination is upheld.

The patient is a young male with history of attention deficit hyperactivity disorder (ADHD). His psychiatrist has switched the patient from Adderall XR (extended release) to Vyvanse, which is not covered by his plan. He is also taking Intuniv.

Vyvanse 50mg (milligrams) is not medically necessary for the patient. The plan alternatives, Focalin XR and Ritalin LA (long acting) have not been tried and Vyvanse would not be more advantageous given the patient's medical presentation.

The patient has tried and failed Adderall XR. It is noted that he has poor appetite on this medication, and effects are wearing off. He has not had trials of Ritalin LA (long acting) or Focalin which is supported by review of pharmacy claims. Ritalin LA and Focalin would be reasonable alternatives given the patient's symptoms and therapeutic failure of Adderall XR, as these medications are effective and are Food and Drug Administration (FDA) approved medications to treat ADHD in adolescents.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer of left chest wall and regional lymph nodes
Treatment: Proton Beam Therapy (PBT)
The insurer denied Proton Beam Therapy (PBT).
The health plan's determination is overturned.

The patient is a female with a history of multifocal left breast cancer. She was recommended to proceed with a course of preoperative systemic therapy and postoperative external bream radiotherapy with curative intent.

The requested health service or treatment of Proton Beam Therapy (PBT) is medically necessary for this patient. The treating provider supplied a proton and photon plan comparison which revealed that the patient cannot be treated safely or effectively with the use of photon radiation. The photon plan resulted in excessive and potentially dangerous exposure to the patient's heart and left lung. If delivered, the photon plan would result in an unacceptable and unnecessary risk for cardiopulmonary morbidity and mortality. The proton radiation plan was able to significantly reduce the exposure to the patient's heart and lung tissue, thereby minimizing the patient's risk for high grade toxicity. Proton radiation is supported by the American Society for Radiation Oncology (ASTRO) Model Policy as the provider has shown that photon radiation cannot meet nationally accepted treatment planning objectives with regard to normal tissue avoidance. Proton radiation is supported by numerous high quality prospective clinical outcomes reported in the peer reviewed medical literature. It is frequently utilized for similar patients in the oncology community at specialized sites with expertise in proton radiation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Skilled Nursing Facility
The insurer denied the skilled nursing facility stay. 
The health plan's determination is upheld.

The patient is a male with history of history of (h/o) atrial fibrillation (A fib), heart failure, and diabetes mellitus. He was admitted to a skilled nursing facility at a Skilled Nursing Facility (SNF) level of care due to generalized weakness and fatigue following the treatment for acute pneumonia. He continued to get better and finished the treatment course of antibiotics. He was mobile, ambulatory without any assistance. It was documented that he was ambulatory for greater than 350 feet and did not require any assistive device. There were no complex nursing and therapy needs for the patient. He was not a danger to self. 

Based on the review of the records, medical literature and current best practices, the health plan did act reasonably in its determination of the medical necessity and in patient's best interest. The patient has a history of A fib, heart failure, diabetes mellitus, and was admitted to a skilled nursing facility at a SNF level of care due to generalized weakness and fatigue following the treatment for acute pneumonia. He was on antibiotics at the time of admission. He worked with physical therapy (PT) and occupational therapy (OT) and gradually his functional status improved. He was not requiring any assistive device and did not require a 1 to 2 person assist. 

The request for continued SNF level of care was not medically necessary and the patient was appropriate at lower level of care. He did not have any complex nursing needs. The patient remained stable and was ready to be discharged by the end of his coverage [1,2]. Based on the documentation provided there are no clear indications as to why the patient would need continuous SNF care. As per the Centers for Medicare and Medicaid Services (CMS) regulation, the patient was suitable to be discharged from the SNF [2]. Therefore, I agree with the health plans recommendations.

Based on review and the review of literature, the patient did not have any complex nursing, PT or OT needs beyond the coverage approved by the health plan. The patient was appropriate for a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines.
Treatment: Nurtec ODT (orally dissolving tablet) 75mg (milligrams) 16 tablets per 30 days.
The insurer denied:  Nurtec ODT (orally dissolving tablet) 75mg (milligrams) 16 tablets per 30 days.
The denial is upheld.

The patient is an adult female. The request is for the use of Nurtec ODT (orally dissolving tablet) for prevention of migraine. The provider indicates that the patient has daily headaches.

The health plan denied coverage of the request for 16 tablets per 30 days and indicated that the quantity limit is eight tablets per 30 days. This determination is being appealed.

The requested health service is not medically necessary.

The provider indicates that the patient has episodic migraine; however, the provider also indicates that the patient has daily headaches. Daily headaches are not consistent with a diagnosis of episodic migraine, which requires fewer than 14 headache days per month. If a patient has more frequent headaches, such as daily headaches, the diagnosis is more consistent with chronic migraine. Nurtec ODT (orally dissolving tablet) is only FDA (United States Food and Drug Administration) approved and literature supported for prevention of episodic migraine. If the patient does have daily headaches, Nurtec ODT (orally dissolving tablets) 16 tablets per 30 days is not approved for treatment of the patient's condition. When the treatment regimen is not FDA (United States Food and Drug Administration) approved or literature or compendia supported for the patient's condition, it cannot be medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept Procedure
The insurer denied: Intracept Procedure
The denial is: Upheld

This is a male diagnosed with back pain. Records show that the patient was recommended to undergo the Intracept procedure, which was denied by the insurance carrier as experimental and investigational. The provider is appealing this determination, which is the subject of this review. There is a letter of appeal from the provider stating that they disagree with denial of the Intracept procedure (intraosseous ablation of the basivertebral nerve). The provider states that this is an innovative procedure to address chronic low back pain identified by Modic changes and fulfills a treatment gap for patients with chronic back pain. The provider notes that the patient has a history of low back pain beginning over six months ago. He has had multiple treatments including heat, ice, lumbar epidural steroid injections, medication management and physical therapy. Medication has included non-steroidal anti-inflammatory drugs (NSAIDs). Pain is impacting activities of daily living and household chores as well as leisure activities and sitting. Nothing has provided significant or sustained relief. The pain is rated on average at 7/10. The patient had a magnetic resonance imaging (MRI) performed demonstrating degenerative endplate changes at disc spaces lumbar (L)5 - sacral (S)1 and therefore this is the source of the patient's back pain.

The proposed health service or treatment Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Records provided note the patient has chronic back pain with radiculopathy and has failed to improve with conservative treatment, although the most recent progress note appears to indicate the patient was recommended to undergo facet medial branch blocks and possible facet joint radiofrequency ablation with no indication of that treatment failed. The provider notes that the patient has degenerative endplate changes on MRI and feels that this is the source of the patient's pain.
However, this procedure remains experimental and investigational as there is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy. This treatment is not currently considered standard of care in the general medical community. there is no evidence to suggest that this procedure is likely to be more beneficial than other standard treatments for the patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept Procedure
The insurer denied: Intracept Procedure
The denial is: Overturned

The patient is a male who has a 6-month history of low back pain. Most of his pain in the lower back. His pain is worse with sitting and forward bending. Pain level is 7/10 with negative impact on his quality of life (QOL). He has tried pain medications, physical therapy (PT), lumbar medial branch block (MBB) and lumbar steroid injections without adequate improvement. Physical exam (PE) was unremarkable. Magnetic resonance imaging (MRI) revealed disc bulges at lumbar (L) 4/5 and L5/sacral (S)1 with Modic type 2 changes at L5/S1.

The issue is whether Intracept procedure likely to be more beneficial for this patient than any standard treatment.

The proposed Intracept procedure is likely to be more beneficial than any standard treatments.

The Intraosseous nerve ablation procedure (Intracept) was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrating the efficacy of this intervention. This patient's persistent back symptomatology is consistent with vertebrogenic pain. His pain is severe enough to have a negative impact on his activities of daily living (ADLs). He has tried pain medications, PT, lumbar medial branch block (MBB) and lumbar steroid injections without adequate improvement. Further interventions are medically necessary to improve his pain and function. Other potential treatment options are long-term use of medications (opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario, the Intracept procedure is the appropriate next step intervention for this patient's persistent back pain.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type I diabetes

Treatment: DME (durable medical equipment)- Insulin Pump (E0784 x 1)

The insurer denied coverage for DME - Insulin Pump (E0784 x 1)

The denial is overturned

 
The patient has a medical diagnosis of Type 1 diabetes mellitus and is on an insulin pump. He is status post renal transplant. Per the encounter notes, time in Range (TIR) was 88% and average blood glucose (BG) was 132mg/dL (milligrams/deciliter) with a predicted hemoglobin A1C (glycated hemoglobin) of 6.6%. The risk of hypoglycemia was 2%. He continued to enjoy excellent glycemic control before, during, and after a recent COVID-19 infection with acute renal rejection. He had a glycated hemoglobin (A1C) of 6.5%. The patient was doing well overall and was planning to upgrade from Medtronic 670G to Medtronic 770/780G in the coming year.

The patient has type 1 diabetes with an insulin pump that is broken and irreparable. He has been on pump therapy for years and is using a hybrid closed loop system. If he does not upgrade there is a high risk that he will have deterioration of glucose control and develop worsened complications. Therefore, the Insulin Pump (E0784 x 1) is considered medically necessary for this patient.

"In a meta-analysis of trials comparing the use of any hybrid closed-loop system with any insulin-based treatment in nonpregnant patients with type 1 diabetes, the proportion of time spent near normoglycemia (70 to 180 mg/dL) over 24 hours was modestly, albeit significantly, higher with the hybrid closed-loop system (weighted mean difference 9.62 percent, 95% CI (confidence interval) 7.54-11 percent). Overall, the incidence of severe hypoglycemia was low in both groups." (Bekiari, et al., 2018).

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 DME - Insulin Pump (E0784 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neutropenia
Treatment: Full Hospital Admission
The insurer denied: Full Hospital Admission
The denial is: Upheld

The patient is a female who presented to the emergency room with fever and chills. The patient is currently receiving capecitabine as an outpatient. The patient was tachycardic with a temperature of 38 degrees Celsius at the time of presentation. She had an unremarkable evaluation including a chest x-ray and urinalysis in the emergency room. Laboratory studies were unremarkable. The patient was admitted for inpatient care and started on vancomycin and Zosyn. The patient was discharged. The medical necessity for a full hospital admission is the subject under review. 

A full hospital admission was not medically necessary for this patient. This patient had mild neutropenia and was afebrile at the time of her evaluation in the emergency room. She was admitted without evidence of a source of infection and was administered intravenous (IV) antibiotics and supportive care. The patient did meet National Comprehensive Cancer Network (NCCN) high risk criteria. The authors of UpToDate state "...patients who meet all criteria for being at low risk for complications of neutropenic fever can be treated as outpatients...The initial therapy for neutropenic patients who are being considered for outpatient management and who have evidence of a systemic inflammatory response syndrome (SIRS) or a sepsis syndrome (SIRS plus a clinical focus of infection) should be administered under observation to ascertain tolerance and ensure timeliness of administration of the first dose. We favor monitoring patients for at least four hours after the initial dose of antibiotics before sending them home." Support for this hospitalization is not present in the peer-reviewed literature nor in national guidelines. For these reasons, medical necessity cannot be established for this hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-Small Cell Lung Carcinoma
Treatment: Proton Beam Radiation Therapy and Laryngoscopy
The insurer denied: Proton Beam Radiation Therapy and Laryngoscopy
The denial is: Upheld

The patient is a female with history of ypT1bN2M0 (after treatment tumor, node, metastasis) (stage IIIA) non-small-cell lung carcinoma (NSCLC) of her right lower lobe status/post (s/p) neoadjuvant systemic therapy followed by surgical resection. She was also found to have synchronous metastatic papillary thyroid cancer as well as synchronous contralateral stage I NSCLC s/p resection. She has been recommended to proceed with a course of postoperative radiotherapy. The subject under review is the medical necessity for proton beam radiation therapy and laryngoscopy.

The requested proton beam radiation therapy and laryngoscopy are not medically necessary for this patient. Proton radiation is considered not the standard of care for the patient's lung cancer as it is the subject of ongoing clinical trials and there is a lack of expert consensus regarding its role in the patient's setting (proton radiation remains controversial for management of the patient's malignancy). The provided proton/photon plan comparison shows that photon-based intensity modulated radiation therapy (IMRT) is able to provide adequate safety/precision as the normal tissue exposure was able to meet nationally accepted treatment planning objectives. The patient has not received prior thoracic radiation, nor does she have a genetic/comorbid condition that increases her risk for normal tissue toxicity.