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

Diagnosis: Meningioma.
Treatment: Current Procedural Terminology (CPT) code 78608: Brain imaging- positron emission tomography (PET) scan.

The insurer denied coverage for Current Procedural Terminology (CPT) code 78608: Brain imaging- positron emission tomography (PET) scan.  The denial is overturned. 

This is a male patient with a past medical history of anxiety, cerebral cavernous malformation, hypercholesterolemia, meningioma, radiculopathy of the lumbar spine rheumatoid arthritis, seizure disorder, obstructive sleep apnea, hypertension, depression, and chronic back pain. He has a surgical history of a subtotal resection of an atypical meningioma. It had a proliferation marker (Ki-67) labeling index (Li) of less than 1% but was deemed atypical on the basis of brain invasion. The focus that could not be resected was located where the vein of Labbe entered the straight sinus. It had grown on surveillance, and he had been referred for the consideration of stereotactic radiosurgery (SRS). The patient's provider documented an extensive discussion entailing his initial work-up, surgery, and subsequent follow-up. The provider noted that they had discussed the utility of Gallium (Ga)-68 Dotatate imaging to aid in discriminating post-operative fibrosis from recurrent/residual meningioma. A Gallium-68 Dotatate positron emission tomography (PET) scan was requested. 

The patient had subtotal resection of the tumor, and it has recurred. The Attending Physician (AP) is considering treatment with SRS. He is requesting a Ga-68 Dotatate PET scan. The patient's tumor is noted to expresses somatostatin receptors. This will be imaged well by a modality such as the Ga-68 Dotatate PET scan. Per guidelines, whenever possible, SSR[Somatostatin Receptor]-PET computed tomography (CT) and magnetic resonance imaging (MRI) should be performed to minimize studies that will identify all tumor, both SSR positive and negative. The imaging, including the MRI, will also allow the AP to perform treatment planning for the SRS. Milker-Zabel, et al showed improvement in target volume definition in 73% of patients using this approach. The Dotatate PET scan is reasonable and medically necessary for treatment of the patient and can be approved in this clinical situation.

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 Current Procedural Terminology (CPT) code 78608: brain imaging- positron emission tomography (PET) scan is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral OA of knees, rotator cuff syndrome, and diabetes.
Treatment: Personal Care Services (PCA level 1)
The insurer denied the Personal Care Services (PCA level 1)

The denial is upheld.

The patient is a male. He has conditions including bilateral OA (osteoarthritis) of knees, rotator cuff syndrome, and diabetes.  The patient is appealing denial of level 1 PCA (personal care assistance) services.

The patient lives alone.  Assessment performed shows his functional status is independent with the exception of managing medications.  He requires limited assistance with managing medications.  He uses a cane and knee braces for assistive devices.  He uses Medicaid transportation to get to and from appointments.  Physician's order form notes the patient has limited walking, prolonged standing, stair use, squatting, bleeding, lifting and reaching up.  Notes the patient needs help with light housework, laundry, cooking, and cleaning.

No, the Personal Care Services are not medically necessary.

Medically necessary services are those which are as follows: safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is not medically necessary, because it is not consistent with generally accepted national standard of medical practice.

According to the New York State Department of Health Guidelines for Personal Care Aide Services, Level I PCA (personal care aide) Services shall be limited to the performance of nutritional and environmental support functions. Level II shall include the performance of nutritional and environmental support functions and personal care functions.

The assessment performed shows the patient is independent with ADLs (activities of daily living) and IADLs (instrumental activities of daily living), with the exception of managing medications. The patient's level of functioning does not require PCA (personal care aide) services. Assistance with medication management can be accomplished with a home health aide.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Human epidermal receptor 2 positive (her2+) breast cancer.

Treatment: Phesgo.

The insurer denied coverage for Phesgo.

The denial is overturned.

This is a female patient with human epidermal receptor 2 positive (her2+) breast cancer treated with docetaxel+Herceptin+Perjeta.  The treating provider has stopped docetaxel and asked to change to Phesgo.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  The coverage of Phesgo is considered medically necessary for this patient.

Phesgo is approved for use to treat her2+ breast cancer.  The National Comprehensive Cancer Network  (NCCN) (2021) states that this agent can be substituted for Herceptin/Perjeta at any time.  As this individual is on Herceptin/Perjeta for metastatic her2+ breast cancer substituting these agents with Phesgo is appropriate.  The use of this formulation of Herceptin/Perjeta compared to intravenous (IV) Herceptin/Perjeta will reduce chair time and contact time in the hospital setting, reducing the risk of transmission of coronavirus disease 2019 (COVID-19) which would make this appropriate during the global pandemic as this agent can be administered in 15 minutes compared to 3 hours for Herceptin/Perjeta. 

As per Up to Date "Subcutaneous forms of trastuzumab as well as trastuzumab and pertuzumab have received approval by the US [United States] Food and Drug Administration based on similar pathologic complete response rates as the IV forms of these therapies when used with chemotherapy in the neoadjuvant setting."

According to Kirschbrown, W. P., et al. (2019), "Adding pertuzumab to trastuzumab (both monoclonal antibodies targeting human epidermal growth factor receptor 2 [HER2]) has proven survival benefits when combined with chemotherapy for patients with HER2-positive breast cancer.  The combination of pertuzumab and trastuzumab together in 1 vial for subcutaneous (SC) administration is being developed as a ready-to-use formulation to reduce the treatment burden on patients while improving healthcare efficiency..."                                                         

The insurer's denial of coverage for Phesgo is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronavirus disease 2019 (COVID-19), elevated blood sugar, dehydration, pneumonia.

Treatment: Out-of-network inpatient stay.

The insurer denied coverage for the out-of-network inpatient stay.

The denial is overturned.

This is a female patient with a past medical history of Type 2 diabetes mellitus (DM), polycystic ovary syndrome (PCOS), and uncontrolled asthma.  She was seen in the Emergency Room (ER) with shortness of breath, weakness, decreased oral intake, chest tightness and wheezing.  On admission, her blood sugar (BS) was 330.  Vital signs and physical exam showed sinus tachycardia at 115 beats per minute (bpm) and a dry mouth.  The chest x-ray (CXR) showed pneumonia.  The patient tested positive for coronavirus disease 2019 (COVID-19).  She was noted to have an elevated anion gap at 20 and elevated lactate at 6.2.  Her hemoglobin A1c (HbA1c) was 12.1 %.  She was admitted to the floor and given intravenous (IV) fluids and insulin. Endocrine consult was obtained and she was discharged in stable condition. 

The patient was noted to have an elevated blood sugar, elevated anion gap, dehydration, pneumonia, and positive COVID-19.  Given her clinical presentation, her needs could not have been safely treated at a lower level of care.

Per Kodner, C. et al. (2017), "Uncontrolled blood glucose levels in hospitalized patients with diabetes are associated with potential harms such as deleterious effects on wound healing, increased risk of infection, and delays in surgical procedures or discharge from the hospital."

Per Wu, S., et al. (2020), "Longer duration of hospitalization among non-severe COVID-19 patients is associated with having fever, bilateral pneumonia on CT [Computed Tomography] scan and diabetes."

Per George, P. M., et al. (2020), "The COVID-19 pandemic has led to an unprecedented surge in hospitalised patients with viral pneumonia.  The most severely affected patients are older men, individuals of black and Asian minority ethnicity and those with comorbidities. COVID-19 is also associated with an increased risk of hypercoagulability and venous thromboembolism.  The overwhelming majority of patients admitted to hospital have respiratory failure and while most are managed on general wards, a sizeable proportion require intensive care support."                                                         

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

The inpatient stay is considered medically necessary for this patient.

The insurer's denial of coverage for out-of-network inpatient stay is overturned.  Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Inpatient Hospital. 
The insurer denied inpatient admission. 
The denial is upheld.

The patient is a female who initially presented to the emergency department with concerns of left pain of greater than a month duration as well as an intermittent headache worse on the left side with associated speech change, blurry vision, and lightheadedness of one week duration. Pertinent history included anxiety and previous evaluation for migraine headaches in which she was advised treatment for trigeminal neuralgia.

The patient was admitted with a treatment plan of telemetry, neurological checks, aspirin, and additional diagnostic tests.  The patient was documented as walking from chair to bed without any difficulty and without any complaints. Neurology consultation was obtained who had an impression of headache, blurred vision, and intermittent speech with recommendations to rule out transient ischemic attack (TIA) and multiple sclerosis. Recommendations were for a carotid ultrasound and if that was unremarkable to get an outpatient magnetic resonance imaging (MRI). Carotid ultrasound did not reveal significant stenosis. Attending physician noted the reason for continued hospitalization was for an MRI in the morning. An MRI of the brain did not reveal acute intracranial pathology. The patient was deemed medically stable and discharged.
The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld.

No. Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

In regard to the level of care required, the patient did not have clinical indications for admission to an acute inpatient level of care. The patient did not have hemodynamic instability, focal neurologic signs or symptoms that persist or recur, immediate inpatient procedure needed (e.g., endarterectomy), cardiac arrhythmias of immediate concern, clinically significant cardiac disorder identified that requires inpatient care (e.g., severe valvular disease, cardiomyopathy, atrial myxoma), or severe hypertension that persists past the observation time frame requiring inpatient treatment. In addition, the patient did not have parenteral anticoagulation required as indicated by temporary subtherapeutic anticoagulation unacceptable (e.g. embolic, venous thromboembolism [VTE] within past 12 months, underlying malignancy, mechanical heart valve, known hypercoagulable state), and a contraindication to use of direct thrombin inhibitor (e.g., dabigatran) or oral coagulation factor Xa inhibitor (e.g., rivaroxaban, apixaban) is present (e.g., severe thrombocytopenia, allergy, creatinine clearance [CrCl] less than 30 milliliters [mL]/minute [min]/1.73 meters squared [m2], pregnancy, liver disease with coagulopathy, or mechanical heart valve).[2]

The patient could have been managed at a lower level of care status.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Mental Health. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Concerta 27mg extended release. 
The denial is upheld.

The patient is a male with request for Concerta 27 milligrams (mg) extended release for the treatment of attention deficit hyperactivity disorder (ADHD). The request is for a formulary exception. Per the documentation, the patient is new to this provider's practice. The patient has had hives in the past secondary to the generic version and required the brand name medication, which he has previously had success with. The request is to continue to name brand version of medication given his positive response. Per records, the patient tried Adderall and did not do well, for unknown reasons. The patient has also tried Intuniv. There is no indication the patient has tried other medications other than generic Concerta, or methylphenidate ER (extended release).

The health plan's determination is upheld.

There is no indication the patient has tried and failed amphetamine-dextroamphetamine extended-release; dexmethylphenidate extended release; dextroamphetamine extended release; Vyvanse capsule/chewable. Per records, the patient tried Adderall and did not do well, for unknown reasons. The patient has also tried Intuniv. There is no indication the patient has tried other medications other than generic Concerta, or methylphenidate ER.
There is no documentation that the formulary medications would be ineffective or would cause adverse effects for this patient which would support or require the use of the non-formulary drug in this case.
The patient can try the formulary alternatives.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive and functional impairment.
Treatment: Personal Care Services Level 2 of 24 hours per day, 7 days per week (live in).
The insurer denied coverage for Personal Care Services Level 2 of 24 hours per day, 7 days per week (live in).

The denial is overturned. 

This is a female patient with a past medical history of heart failure, atrial fibrillation, aortic stenosis, spinal stenosis and frequent urinary tract infections (UTIs).  Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her daughter were present on the call. The patient lives alone in a 2 bedroom apartment. Both of the patient's daughters are involved in her care and assist her with her activities of daily living and instrumental activities of daily living, as needed.

The patient has cognitive and functional impairment from multiple co-morbidities. Her aide and two Medical Doctors (MDs) have noted that she is bedbound. They also note that the patient needs turning and positioning (T&P) every two hours. The patient has a history of frequent UTIs and skin breakdown. She has urinary incontinence and using pullups alone is not sufficient to prevent these complications of incontinence. She cannot be left potentially all night wet. She is not able to perform these functions on her own. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the plan's interpretation of the patient's needs. 

The insurer's denial of coverage for the requested Personal Care Services Level 2 of 24 hours per day, 7 days per week (live in) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Juvenile Rheumatoid Arthritis
Treatment: Ilaris
The insurer denied the Ilaris
The denial is overturned.

This case involves a female who has been diagnosed with systemic juvenile idiopathic arthritis by a board-certified pediatric rheumatologist.  She has been treated with non-steroidal anti-inflammatory drugs (NSAIDs), oral corticosteroids, and most recently, canakinumab.  The patient's symptoms and labs have improved significantly following initiation of canakinumab therapy.  The provider is asking to continue to treat this patient with canakinumab.

Yes, the proposed treatment with canakinumab is medically necessary.
Canakinumab is an Food and Drug Administration (FDA) approved therapy to treat systemic juvenile idiopathic arthritis (sJIA) in patients aged two years and older. It is a safe and effective treatment for systemic juvenile idiopathic arthritis (sJIA) based on phase III, randomized, controlled trials.  It is considered a standard of care medication for systemic juvenile idiopathic arthritis (sJIA) in the pediatric rheumatology community. Canakinumab has been Food and Drug Administration (FDA) approved to treat patients younger than age two years with periodic fever syndromes including Familial Mediterranean Fever, Hyperimmunoglobulin D syndrome, and Tumor Necrosis Factor Receptor Associated Periodic Syndrome.  Based on this information, canakinumab should be considered a medically necessary treatment for this patient.

As stated above, canakinumab is a safe and effective therapy for this patient's disease, systemic juvenile idiopathic arthritis (sJIA).  Additionally, the patient has already received an initial dose of canakinumab and her symptoms and labs have already improved.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Knee Osteoarthritis. 
Treatment: Synvisc One Injection. 

The insurer denied the Synvisc One Injection. 
The determination is upheld. 

The patient has a complaint of right knee pain. An office visit documented right knee osteoarthritis for this patient. A cortisone injection was administered on that date and the provider requested authorization for a Synvisc One injection which was done for the contralateral left knee. This provided the patient with good pain relief. The request for the Synvisc One injection in the right knee was denied by the patient's health plan as not medically necessary. At issue in this case is the medical necessity of the requested Synvisc One injection for this patient's right knee. 

The requested health service/treatment of right knee Synvisc-One Injection is not medically necessary for this patient based upon the recommendations of the current, peer-reviewed orthopedic literature with respect to viscosupplementation injections for knee osteoarthritis. The patient has right knee osteoarthritis and a complaint of right knee pain. An article published by Tammachote and colleagues in the Journal of Bone and Joint Surgery concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with Hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." A second article published by Jevsevar and colleagues in the Journal of Bone and Joint Surgery was a literature assessment which concluded that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of HA treatment over placebo. When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of nonblinded or improperly blinded trials." Lastly, the American Academy of Orthopedic Surgeons releases the Treatment of Osteoarthritis of the Knee: Evidence-Based Guideline which determined that viscosupplementation injections done for knee osteoarthritis did not provide a benefit to the patient. Thus, the medical necessity of the requested Synvisc One injection for this patient is not established. This determination is based upon the recommendations of two recent, peer-reviewed articles in the Journal of Bone and Joint Surgery and the American Academy of Orthopedic Surgeons Evidence based treatment guideline on the treatment of knee osteoarthritis. The articles and this evidence based treatment guideline do not recommend the use of viscosupplements for the treatment of knee osteoarthritis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: psoriasis
Treatment: Stelara
The insurer denied Stelara. The health plan's determination is upheld.

The patient is a male with severe psoriasis (over 50% body surface area involvement) for 9 years, and who has scattered erythematous scaly plaques across the arms, wrists, around the eyes, scalp, trunk, legs, and feet. The patient has tried and failed several topical agents, including mometasone, triamcinolone, and hydrdocortisone. Health plan coverage of Stelara (45 milligrams) is under review for medical necessity.

Stelara is not medically necessary for this patient.

The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either oral Methotrexate and/or the biologic agent Enbrel. Therefore, consistent with current medical literature, Stelara is not medically necessary.

Modern dermatology literature supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Stelara, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Stelara is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Trulicity
The insurer denied Trulicity. The health plan's determination is overturned.

The patient is a female with history of type 1 diabetes mellitus.
The coverage request is for Trulicity. The medication was previously denied, this is an appeal initiated by the provider. The medication was previously denied because the patient did need not meet medical necessity criteria under health plan, specifically because the drug is not covered for type 1 diabetes.

Trulicity is medically necessary. This patient has beta cell dysfunction based on lower but still detectable C-peptide levels. Pathogenesis of diabetes mellitus has many subtypes. This patient has negative antibody markers for type 1 diabetes, but an atrophic pancreas on imaging. Thus, the diagnosis of her type 1 diabetes is unclear. She continues to maintain euglycemia even though she is not on prandial insulin. The behavior of her diabetes in response to therapy is akin to type 2 diabetes and the provider endorses good response to Trulicity. Therefore, Trulicity is medically necessary and should be continued.