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

Diagnosis: severe COPD (chronic obstructive pulmonary disease), emphysema, and pulmonary fibrosis
Treatment: 12-month rental of a Home Ventilator (E0466)
The insurer denied the 12-month rental of a Home Ventilator (E0466).
The denial is upheld.

The patient is a male with severe COPD (chronic obstructive pulmonary disease), emphysema, and pulmonary fibrosis. He is on supplemental oxygen. He is now prescribed trilogy non-invasive home ventilator. This request was denied by the health plan due to lack of medical necessity, since the patient has not tried and failed BIPAP (bilevel positive airway pressure) therapy. This denial is being appealed.

No, the requested health service is not medically necessary.
The patient has chronic respiratory failure due to severe COPD (chronic obstructive pulmonary disease) and pulmonary fibrosis. However, there is no clinical documentation of hypercapnia with Paco2 (arterial carbon dioxide partial pressure) above 52 mmHg (millimeters of mercury) while awake. There is no clinical documentation of trial and failure of BIPAP (bilevel positive airway pressure). The use of trilogy noninvasive home ventilator is not considered the current standard of clinical practice in patient who has severe COPD (chronic obstructive pulmonary disease)/emphysema but no evidence of hypercapnia while awake and no trial and failure of BIPAP (bilevel positive airway pressure).

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The use of trilogy non invasive home ventilator is not considered the current standard of clinical practice in patient who has severe COPD (chronic obstructive pulmonary disease)/emphysema but no evidence of hypercapnia while awake and no trial and failure of BIPAP (bilevel positive airway pressure).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory failure, septic shock, endocarditis

Treatment: Continued care in a skilled nursing facility (SNF)

The insurer denied coverage for continued care in a skilled nursing facility (SNF)

The denial is upheld

This patient has chronic medical problems including hypothyroidism, esophageal cancer, and diabetes mellitus. He presented to the rehabilitation facility after a complicated hospital course (respiratory failure, septic shock, and endocarditis). At the skilled nursing facility (SNF), the patient received physical and occupational therapy as well as skilled wound care.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the patient was initially appropriate for the SNF rehabilitation level of care (1, 2, 3). He had functional deficits and wound care needs that were amenable to rehabilitation at the SNF level of care. According to the therapy notes, the patient was at the independent to supervision level for functional mobility (bed mobility, transfers, and ambulation with rolling walker). He generally required minimal assistance for activities of daily living. There was reportedly difficulty obtaining visiting nursing services. However, continued care could have been safely rendered at a lower level; such as via long term care or home with visiting nursing for total parenteral nutrition (TPN), intravenous (IV) levothyroxine and colostomy services. There were no acute medical or complicated nursing issues that required continued care in an SNF.

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued care in a SNF was not medically necessary.

The insurer's denial of coverage for the continued care in a skilled nursing facility (SNF) from is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of Breath and Alcohol Abuse
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a male who was admitted for exertional shortness of breath, orthopnea and alcohol abuse. He was treated with intravenous diuresis for acute decompensated diastolic congestive heart failure (CHF) and new-onset ascites. He responded well with improved leg edema, weight loss and shortness of breath. He also required Clinical Institute Withdrawal Assessment Alcohol (CIWA) protocol, as well as antibiotics for lower extremity cellulitis. 

The health plan deemed the full admission as not medically necessary citing absence of severe problems such as low blood pressure, very low oxygen, heart attack, dangerous heart rhythm, persistent confusion, kidney failure or signs of severe alcohol withdrawal.

Yes, the proposed inpatient admission was medically necessary.
The full inpatient admission to manage acute decompensated diastolic congestive heart failure (CHF) with intravenous diuretics was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Among other symptoms, this patient was reporting orthopnea on presentation and was deemed to have decompensated New York Heart Association (NYHA) Class IV congestive heart failure (CHF) symptoms. The medical literature demonstrates reduced readmission for managing acute decompensated heart failure patients as inpatient with full admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gingival Recession.

Treatment: D2740, porcelain crown to tooth 7.

The insurer denied coverage for D2740, porcelain crown to tooth 7.  The denial is overturned.

Based on the submitted documentation which includes copies of bitewing and periapical radiographs, narrative letter from the dentist and insurer correspondence, it appears that this patient presented for dental care. A failing long standing crown restoration, was noted on #7 which exhibited gingival recession. Currently the dentist is requesting replacement of the crown due to periodontal concern and crown margin exposure leading to tooth sensitivity. 

Review of radiographs supports the recommended treatment. Tooth #7 exhibits a crown with open margins on both the mesial and distal aspects of the tooth as well as possible recurrent caries, consistent with a failing existing restoration. There is ample coronal structure remaining. This tooth will have adequate residual coronal structure for support of a replacement crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be replacement crown which would have an excellent long-term prognosis with the recommended treatment.

Porcelain crown to tooth 7 is medically necessary as the radiographic documentation supports this service, and this service would be a standard of care in general dental practice.

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

The insurer's denial of coverage for D2740, porcelain crown to tooth 7 is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

The patient is a female with known seizure disorder. She presented with complaint of increased seizure frequency over ten days prior. She was admitted to the acute inpatient service and had MRI (magnetic resonance imaging), EEG (electroencephalogram) and medication adjustments. She was discharged home.

No, the Inpatient admission was not medically necessary.

The patient has a known seizure disorder and known abnormal MRI (magnetic resonance imaging) with intracranial mass. She was established on an outpatient anticonvulsant regimen and was following with neurology and neurosurgery. At presentation, her neuro-imaging was stable and her examination was normal. There was no documented reason the monitoring, diagnostic studies and medication adjustments could not have been safely and effectively completed at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral palsy, epilepsy, dysphagia, scoliosis, spastic quadriplegia. 
Treatment: Durable medical equipment (DME), the CoughAssist T70 device. 

The insurer denied coverage for durable medical equipment (DME), the CoughAssist T70 device. 

The denial is overturned.  

This is the case of a child with a history of cerebral palsy, epilepsy, dysphagia, scoliosis, spastic quadriplegia, gastrostomy tube, valgus leg deformity, and global developmental delay. The physician taught the family manual chest physiotherapy (CPT) to be done daily and increased in frequency with respiratory illness. The patient was prescribed a mechanical insufflation-exsufflation (MI-E) CoughAssist T70 device due to a less than optimal cough to aid in airway clearance by increasing her cough reflex to move secretions. 

The CoughAssist device is indicated for any patients unable to cough or clear secretions effectively due to reduced peak cough expiratory flow (less than 5- liters/second), resulting from high spinal cord injuries, neuromuscular deficits or severe fatigue associated with intrinsic lung disease. 

Use of CoughAssist may be of particular importance for patients on any type of noninvasive ventilation, since suctioning is difficult without a tracheal or endotracheal tube in place. Exsufflation with negative pressure enhances or replaces the patient's natural cough, providing the necessary removal of secretions. 

In a study, the patients, the respiratory outcomes were examined in a group of neuromuscular patients which included almost 50 patients the median duration of use was 13.4 months (range, 0.5 to 45.5 months). Five patients chose not to continue MI-E therapy. Chronic atelectasis resolved in 75% (percent) patients after beginning MI-E therapy, and five patients experienced a 35 Percent reduction in the frequency of pneumonias. This study underlines the importance of overall respiratory benefit in patients with NMD (Neuromuscular Disorders). 

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

The insurer's denial of coverage for durable medical equipment (DME) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia.
Treatment: Full hospital admission.

The insurer denied coverage for full hospital admission.  The denial is upheld.

The patient has a history of iron deficiency anemia. She was sent to the emergency room (ER) for blood transfusion in preparation for a hysteroscopy dilatation and curettage (D&C). Hemoglobin (hgb) level was 6.3. The patient was admitted and received 3 units of packed red blood cells. She underwent a dilation and curettage (D&C) with hysteroscopy. There were no complications. An additional unit of packed red blood cells was given. She was discharged later that day in stable condition.

This patient was referred by her obstetrics and gynecology for blood transfusion because of anemia in preparation for a D&C. She denied shortness of breath or chest pain. She was admitted for the same issue and transfused. She was admitted and received 3 units of packed red blood cells (PRBC) and underwent a hysteroscopy D&C. She was transfused with 1 more unit post-operatively and discharged home.

This patient was admitted for blood transfusion prior to a D&C. Transfusions today are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). So, the need for transfusion is not a reason for admission. The patient could have been transfused as an outpatient and then undergone the hysteroscopy D&C the next day. Note that the patient was not actively bleeding.

Milliman Care Guidelines (MCG) lists the clinical indication for inpatient care for patients with anemia. These include active massive hemorrhage, active hemolysis, cognitive impairment, orthostatic changes, heart failure, chest pain, and syncope. 

This patient was stable and did not have any of the above. The admission was not medically necessary.

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

The full hospital admission is not considered medically necessary for this patient. 

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-Back pain.
Treatment: Pharmacy/Prescription Drugs-Pregabalin
The health plan denied the treatment with Pregabalin as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient is diagnosed with Cervicalgia, Degenerative Disc Disease, Cervical; Lumbar Degenerative Disc Disease, Vertigo, Foot Pain, Paresthesias, and Syncope. In a letter of appeal, the physician indicates that the patient has neuropathic pain secondary to ilioinguinal neuropathy. Pregabalin was prescribed. The drug was denied as off-label. The physician has appealed the determination.

The requested health service/treatment of Pregabalin Capsules is not medically necessary for this patient. In order for a drug to be medically necessary, use of the drug must be clinically appropriate and within generally accepted standards of medical practice. While pregabalin is used for some types of neuropathic pain, such as diabetic neuropathy and pain due to spinal cord injury, data are lacking to show that the drug is safe or effective for treatment of ilioinguinal neuropathy. While there are a number of proposed treatments for ilioinguinal neuropathy, including pharmacotherapies, the efficacy of these approaches is limited. There are no high-quality studies to support the use of pregabalin or pregabalin over other common neuropathic pain treatments such as gabapentin or tricyclic antidepressants for this particular indication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs/Taltz (ixekizumab). 
The insurer denied Taltz (ixekizumab).
The denial is upheld. 

The patient is a male with Plaque psoriasis. His body surface area affected is 20%. He has tried and failed clobetasol, triamcinolone and mometasone ointment. He has been recommended Taltz (ixekizumab).
At issue is the medical necessity of Taltz.

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

The requested health treatment of Taltz (Ixekizumab) is not medically necessary for this patient.
According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines Cosentyx, Stelara and Humira are effective treatments for the management of psoriasis. (1, 2) Within the peer-reviewed literature, Garnock-Jones writes "Subcutaneous secukinumab is an effective and generally well tolerated first-line treatment for moderate to severe plaque psoriasis." (3) Moreover, according to Burness et al. "well-designed randomized clinical trials demonstrated that adalimumab 40 milligrams (mg) every other week (eow) effectively reduced the signs and symptoms of psoriasis and improved dermatology-specific and general measures of health-related quality of life, with these benefits sustained during long-term treatment." (4) Additionally, Langley et al. writes "Treatment with ustekinumab for up to 5 years was safe and effective." (5)
Therefore, according to the evidence-based literature, the preferred agents are appropriate agents for the treatment of the patient's psoriasis and Taltz is not medically necessary. The formulary medications should be tried and failed prior to initiating Taltz. It is noted that the patient has tried and failed topical therapies. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Taltz prior to the formulary alternatives such as Cosentyx, Stelara, or Humira.
Therefore, the requested health treatment of Taltz (Ixekizumab) is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lynch syndrome and ovarian cancer.
Treatment:  Radiation therapy for metastases other non-bone: 25 fractions (treatment sessions) of intensity modulated radiation therapy (IMRT) image guided radiation therapy (IGRT).
The insurer denied Radiation therapy for metastases other non-bone: 25 fractions (treatment sessions) of intensity modulated radiation therapy (IMRT) image guided radiation therapy (IGRT).

The determination is upheld.

The patient presented with ovarian cancer several years ago. The patient underwent surgery followed by chemotherapy and underwent lymph node dissection for retroperitoneal node recurrence. She received multiple courses of different chemotherapy A recent computed tomography (CT) scan showed bulky retroperitoneal and pelvic adenopathy. She is being evaluated for radiation therapy (RT) using intensity modulated radiation therapy (IMRT). At issue is the medical necessity of radiation therapy for metastases other non-bone: 25 fractions (treatment sessions) of intensity modulated radiation therapy (IMRT) image guided radiation therapy (IGRT).

The requested health service/treatment of radiation therapy for metastases other non-bone: 25 fractions (treatment sessions) of intensity modulated radiation therapy (IMRT) image guided radiation therapy (IGRT) is not medically necessary for this patient. It is not in accordance with generally accepted standards of medical practice in the United States.
This is a highly palliative condition which needs a short course of radiation for symptomatic palliative treatment. However, there is no mention of any symptoms which need palliation.
It was noted that recurrence is in a single site, however, a recent CT scan showed disease in many sites. There is no published data to support IMRT for such a clinical scenario. This is not a retreatment of the same site with radiation where IMRT may be clinically appropriate.
Therefore, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Narcolepsy with cataplexy.
Treatment:  Xyrem.

The insurer denied Xyrem.  The determination is overturned.

This is a patient who suffers from daytime sleepiness. The patient was diagnosed with Narcolepsy type 1 (narcolepsy with cataplexy). The Multiple Sleep Latency Test (MSLT) showed reduced mean sleep onset latency down to 10.40 minutes and 2 sleep onset rapid eye movement (REM) periods. The provider is requesting the coverage of Xyrem. The patient cannot take Wakix, since she is on antihistamine medication.

At issue is the medical necessity of Xyrem.

The requested health service/treatment of Xyrem is medically necessary for this patient.  Narcolepsy is a serious, life-long, potentially disabling disorder. Symptoms are usually first noticed during the early teenage years. There is no known cure for narcolepsy, and no completely adequate treatment is available.

Narcolepsy is a chronic neurological disorder caused by the brain's inability to regulate sleep-wake cycles normally. At various times throughout the day, people with narcolepsy experiences fleeting urges to sleep. If the urge becomes overwhelming, individuals will fall asleep for periods lasting from a few seconds to several minutes. In addition to excessive daytime sleepiness (EDS), three other major symptoms frequently characterize narcolepsy: cataplexy or the sudden loss of voluntary muscle tone; vivid hallucinations during sleep onset or upon awakening; and brief episodes of total paralysis at the beginning or end of sleep.

The Multiple Sleep Latency Test (MSLT) is performed to evaluate the presence of pathological sleepiness and to confirm the diagnosis of Narcolepsy. These individuals are studied during 5 daytime naps taken 2 hours apart. The mean MSLT score is usually less than 8 minutes. Narcolepsy is excluded by the absence of sleep-onset REM (SOREM) periods on the 5-nap MSLT although false negative MSLT has been seen in 20-30% of cases of confirmed narcolepsy with cataplexy.

The review of the patient records revealed that the patient has been complaining of daytime sleepiness. The MSLT showed significant reduction in the mean sleep onset latency down to 10.4 minutes and 2 Sleep onset REM periods. Although the MSLT result was not supportive of the diagnosis of narcolepsy a, the MSLT can be falsely negative in 20-30% of the time. The patient suffers also from cataplexy. The latter is considered very specific for narcolepsy since no other disease can give cataplexy. Therefore, The Xyrem is considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: Spinal cord stimulator
The insurer denied a spinal cord stimulator. The health plan's determination is overturned. 

The patient is a male who has severe low back pain with radiating pain down to BLEs (bilateral lower extremities). Pain level is 8/10. Physical exam (PE) is remarkable for positive straight leg raise (SLR). A magnetic resonance imaging (MRI) is significant for retrolisthesis and moderate disc bulge at L (lumbar)4-5, grade 2 spondylolisthesis L5/S (sacral) 1 with chronic bilateral L5 spondylolysis defect. The patient underwent extensive conservative treatments including physical therapy (PT), pain medications, facet injections, transforaminal injections and radiofrequency ablation (RFA) with no success. He had a surgical evaluation, but was not interested in surgical intervention.

A Spinal Cord Stimulator Trial is medically necessary for this patient.

This patient has severe pain from retrolisthesis and moderate disc bulge at L4-5, and grade 2 spondylolisthesis L5/S1 with chronic bilateral L5 spondylolysis defect. He had failed conservative treatments. He is a candidate for surgery, but is not interested in surgery at this time. His pain is unlikely to improve without further interventions. An alternative option is a spinal cord stimulator (SCS). There is clinical evidence to support the efficacy of SCS for patients with similar spine conditions. Therefore, the requested Spinal Cord Stimulator Trial is medically necessary.