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

Diagnosis: Acute Myeloid Leukemia

Treatment: Sprycel in combination with Decitabine

The insurer denied coverage for Sprycel in combination with Decitabine.

The denial is upheld.

The patient is a male with acute myeloid leukemia (AML) with KIT [proto oncogene] mutation treated in the past with gemtuzumab, cytarabine, decitabine, FLAG-IDA [fludarabine, cytarabine (Ara-C), granulocyte- colony stimulating factor (G-CSF) and idarubicin] venetoclax plus azacitidine, and a clinical trial. The treating provider has requested the use of dasatinib.

Rios A, et al notes, "CBF [core binding factor] leukemia chimeric proteins disrupt normal hematopoiesis by recruiting histone deacetylases and DNA [deoxyribonucleic acid] methyltransferase 1 to CBF target genes, resulting in increased chromatin deacetylation and promoter hypermethylation. KIT mutations result in constitutively activated promotion of leukemic cells survival. Screening for KIT mutations...uring induction or salvage therapy could be important for the treatment of CBF leukemias with an analogous impact..."      

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

While early small phase I/II (one and two) studies suggest activity of dasatinib in the treatment of AML there is insufficient literature that has shown that this drug leads to improved clinical outcomes in the treatment of AML.

Sprycel in combination with Decitabine does not have final approval from the appropriate regulatory bodies for this diagnosis. Sprycel in combination with Decitabine is not a Food and Drug Administration (FDA) approved use of either agent for AML.     

This patient is not a good candidate for Sprycel in combination with Decitabine. There is no evidence that dasatinib with decitabine will be effective to treat this patient with multi-relapsed AML.     

Sprycel in combination with Decitabine is not the best available treatment for this patient at this time. The requested treatment is not likely to be more beneficial than any other existing standard health service. There are no viable treatment options for this individual outside of a clinical trial.                                                      

The carrier's denial of Sprycel in combination with Decitabine should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 
Treatment: Inpatient admission. 

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

The patient is a male. He has past medical history of coronary artery disease, hypertension, hyperlipidemia, cerebrovascular accident and type II diabetes. He presented to the emergency department with right upper quadrant abdominal pain. 

Right upper quadrant ultrasound and CT (computed tomography) A/P (abdomen and pelvis) were performed, revealing gallstones and possible inflammation around the gallbladder. The patient was admitted with diagnosis of acute cholecystitis. HIDA (hepatobiliary iminodiacetic acid scan) showed biliary dyskinesia with EF (ejection fraction) of 15%. He was taken to the OR (operating room) and underwent uncomplicated lap cholecystectomy. He tolerated the procedure well. Postoperatively, he was tolerating PO (by mouth), voiding, ambulating, and his pain was controlled. He was then discharged to home. 

No, the Inpatient admission was not medically necessary. 

There is no documentation of Sepsis, perioperative complications, hemodynamic instability, or need for reoperation.  This patient's condition was such that he could have been treated at a lower level of care. 

Therefore, given the above, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain. 
Treatment: Radiofrequency Ablation. 

The insurer denied Radiofrequency Ablation. The health plan's determination is overturned. 

The patient is a male with complaints of left greater than right low back pain. Pain began after a motor vehicle accident. He denies radiating pain. He has been doing physical therapy for 1 year since the accident and has had 2 medial branch blocks with local anesthetic on 2 separate days. The patient was found to have 80% relief after each injection. 

There is a plan for radiofrequency ablation of the nerves near the joints of low back. 

The Radiofrequency Ablation of the Nerves Near the Joints of Low Back is medically necessary for this patient. 

In this case, the patient presented with complaints of low back pain. The patient's pain is mainly axial. There are no radicular symptoms noted. The patient has failed physical therapy. He underwent 2 distinct sets of diagnostic medial branch blocks, each leading to at least 80% relief. The standard of care after such a treatment is radiofrequency ablation. 

The patient has low back pain, mainly axial, without any radicular symptoms. He has failed a lower level of care and underwent 2 sets of successful medial branch blocks. Given all of the above, the requested Radiofrequency Ablation of the nerves near the joints of low back is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hemiplegia and hemiparesis. 

Treatment: Personal Care Aide (PCA) Level 2 Services of 12 hours per day, 7 days per week for a total of 84 hours per week. 

The insurer denied coverage for PCA Level 2 Services of 12 hours per day, 7 days per week for a total of 84 hours per week.     

The denial is overturned. 

This is a male patient who has a past medical history of vascular dementia after multiple brain infarcts, seizures, atrial fibrillation, acute kidney injury, hypertension, hyperlipidemia, hemorrhagic stroke with residual right hemiplegia, thyroid disease. He is minimally verbal and wheelchair bound. The patient was hospitalized due to a gastrointestinal bleed, seizure and symptomatic anemia.  He was hospitalized again due to a diagnosis of a breakthrough seizure.  Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and his wife were present on the call. The patient's wife is supportive and involved in his care. They live on the 11th floor of an elevator accessible building. The patient requires assistance with his activities of daily living (ADLs) and instrumental activities of daily living due to his history of a cerebrovascular accident causing hemiplegia and hemiparesis which affects the right dominant side.

Needs are: 

-Total dependence for meal preparation, ordinary housework, managing finances, managing medications, phone use, managing stairs, shopping, transportation and toilet use.;
-Maximal assistance for bathing, dressing his upper and lower body, walking, toilet transfer and locomotion (wheelchair);
-Extensive Assistance for personal hygiene, bed mobility and eating;
-Cognition: 	There is severe impairment. 
-Continence: 	There is urinary and bowel incontinence. Pull-ups are used.


An increase to personal care aide (PCA) level 2 services of 12 hours per day, 7 days per week for a total of 84 hours per week is being requested.

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

The patient has dementia and is aphasic and has right -sided (dominant) weakness. He is bedbound. He needs maximal assistance or is dependent for all ADLs. He is incontinent of bowel and bladder and cannot manage bed positioning or toileting without assistance.  He uses diapers. He is at high risk for pressure sores.  His wife is an informal caregiver and cannot provide the necessary hours. 
 
The provision of diapers and durable medical equipment (DME) such as alternate pressure beds is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers" In https://www.ncbi.nlm.nih.gov/books6430/ updated 11/15/2018 changing diapers regularly and positioning are also necessary.

The patient cannot be left alone and has unscheduled and scheduled personal care needs 24/7. The request for increased hours is approved. 

The insurer's denial of coverage for the requested PCA Level 2 Services of 12 hours per day, 7 days per week for a total of 84 hours per week is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Ulcerative Colitis; pancolitis.
Treatment: Xeljanz.

The health plan denied the Xeljanz. The reviewer has overturned in whole the health plan's determination. 

The patient is diagnosed with ulcerative colitis. The patient was diagnosed in the past with pancolitis. The patient was started on Prednisone and then began Entyvio. Prior to full induction loading, the patient was hospitalized and received high dose infliximab for acute severe ulcerative colitis. The patient ultimately flared again and was hospitalized for high dose steroids. A flexible sigmoidoscopy confirmed very active disease (Mayo 3) (Mayo Score for Ulcerative Colitis Activity). The patient also has a peripheral arthropathy.
The patient's provider has recommended treatment with Xeljanz. This request was denied by the plan and considered not medically necessary, stating the patient must fail 2 of the preferred formulary alternatives including Humira, Stelara, and Simponi.

I agree with the perspective of the providers that Xeljanz would be the appropriate, medically necessary treatment for the patient at this juncture of care. The patient was a primary non-responder to infliximab; therefore, trying another anti-TNF (Tumor necrosis factor) medication such as Humira or Simponi would be predicted to not be effective. The patient is on high dose steroids and at high risk for deteriorating to the point of needing hospitalization and possibly a colectomy. Xeljanz has a much quicker onset than Stelara, which could take several weeks to months to provide significant improvement. [1-3]. This recommendation would be consistent with recently published American Gastroenterological Association (AGA) guidelines. [3].
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis
Treatment:  Personal Care Services 10 hours, 7 days a week for a total of 70 hours per week (HP approved 49 hours)
The insurer denied the Personal Care Services 10 hours, 7 days a week for a total of 70 hours per week (HP approved 49 hours)
The denial is overturned. 

The patient is a female with a medical history including osteoporosis with recent falls, poor memory, hearing loss and depression.  She weighs 92 lbs.  She lives alone in a two-bedroom apartment on the second floor.  She has been approved for personal care services for 7 hours per day, 7 days per week (total 49 hours) for approximately five months.  Her son is appealing for an increase in personal care services to 10 hours per day, 7 days per week (total 70 hours) to better assist in the evening with sleep and medication preparation.  Due to public health concerns, attached denial letter indicates that these evening assessments are done over the phone.  Specifically, the son is concerned that his mother has walked down the stairs alone at night and turned on the stove, and also falls asleep during dinner and toileting.  Attached documentation indicates that she needs assistance with cooking, cleaning, laundry, shopping, dressing, toileting and personal hygiene.  She walks with a walker and lacks bladder control.  She sustained two recent falls without injury. Per attached, based upon Uniform Assessment system (UAS) evaluations, the Hours Evaluation for Paraprofessional Support (HELPS) tool, MD and case manager letters, and the NYSDOH guidelines, the requested increase in personal care services hours was denied. Appeal is for an increase in personal care services to 10 hours per day, 7 days per week (total 70 hours)

Yes, the increase in personal care service hours are medically necessary.
An increase in personal care service hours to 10 hours per day, 7 days per week (total 70 hours) is being requested for this elderly female patient with osteoporosis and history of recent falls, incontinence and dependence for activities of daily living as described above.  Her son is most concerned about her lack of services in the evening around dinner and bedtime, where she has demonstrated behaviors that put her at significant risk of injury (such as falls at night and home hazards).  The attached denial letter indicates that due to public health concerns, her evening assessments are done over the phone. Evening assessments by telephone alone for this specific patient with significant falls and hazardous home behavior risks are not safe, effective, nor appropriate.  Therefore, an increase in her personal care service hours to 10 hours per day, 7 days per week to provide more comprehensive in-person coverage for evening services is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bladder Cancer
Treatment: Cisplatin, Gemcitabine and Paclitaxel, Pre-service
The insurer denied the Cisplatin, Gemcitabine and Paclitaxel, Pre-service
The denial is upheld. 

The patient in this case, a female, has been diagnosed with muscle invasive bladder cancer. Her cancer is noted to have a plasmacytoid histology, which based on a submitted appeal letter, is associated with worse prognosis.  Neoadjuvant treatment with cisplatin, gemcitabine and paclitaxel has been recommended based on this finding.

No, the proposed treatment with Cisplatin, Gemcitabine and Paclitaxel is not medically necessary.
At the present time the combination of cisplatin, gemcitabine and paclitaxel is not considered a standard treatment option for the neoadjuvant treatment of muscle invasive bladder cancer.  A randomized trial found that this triplet combination did not improve survival compared to standard of care gemcitabine and cisplatin chemotherapy treatment.   While it is noted that this patient has plasmacytoid histology, which is associated with a worse prognosis than typical urothelial carcinoma, there is no evidence that more intensive chemotherapy treatment for this subtype can improve overall health outcomes.  This has not been shown in any prospective trial and is not endorsed as a standard treatment option by the National Comprehensive Cancer Network (NCCN) guidelines.  Therefore, this treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a girl with a history of diabetes mellitus who presented with hyperglycemia. She had a history of inadequately controlled diabetes due to non-adherence with insulin. She reported that she also didn't consistently check her glucose levels. She was in her usual state of health until several weeks prior to presentation when she noted polyuria, fatigue, and intermittent tingling in her left hand. She also noted an increase in her weight. She was sent to the emergency department after a point-of-care glucose test showed a level of 400 in the endocrinology office. Her past medical history is significant for juvenile diabetes mellitus.
She was admitted with uncontrolled diabetes, for evaluation of thyroid dysfunction and borderline tachycardia as well as stabilization of her blood glucose levels along with counseling and education for diabetes care.

The inpatient hospital admission was medically necessary for this patient, in order to provide close monitoring, treatments with insulin and metformin, and needed intensive education to ensure ongoing care and prevent future serious morbidity.
 
This is a teenage girl who presented with persistent hyperglycemia and non-adherence to her insulin therapy and testing regimen. She was evaluated in the pediatric endocrinology office and was sent to the emergency department for further care for hyperglycemia. She was also found to have an elevated thyroid level and a very low thyroid stimulating hormone (TSH), raising concern for Graves' disease. She required prompt evaluation and ongoing treatment and inpatient setting, including repeat laboratory testing, appropriate treatment of her diabetes, and intensive education to ensure future adequate diabetes care. This is particularly important because adolescents with diabetes are at risk for diabetic ketoacidosis, which is a common and potentially fatal complication of type 1 diabetes mellitus. Ensuring appropriate care is critical to prevent this and other serious complications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man who presented to the hospital with a history of progressively worsening abdominal pain, nausea, and vomiting of 1-day duration. His evaluation included physical exam, computed tomography (CT) scan, and labs. He was without fever at the time of presentation and vital signs were normal. Lab data identified an elevated white blood cell (WBC) count of 15.3. His evaluation yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was requested. He was admitted to the hospital. 

The patient underwent laparoscopic appendectomy. 

The Inpatient stay was not medically necessary for this patient. The care and treatment provided could have appropriately been rendered at a lower level of care. The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care would have provided for pre-surgical assessment, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring. The records support that the patient was clinically stable and could have been discharged from the hospital on the first post-surgical day. 

Generally accepted medical standards indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the procedure of appendectomy may be performed at a lower level of care. In this case, the patient tolerated oral hydration, diet and medication and pain was well controlled. The lower level of care would have appropriately provided for pre-surgical assessment, laparoscopic appendectomy, and post-surgical monitoring. Inpatient care was not medically necessary in this case per generally accepted medical standards.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cervical spondylosis and lower back pain. 

Treatment: Intracept Procedure (procedure codes C9753, C9752 and 22899). 

The insurer denied coverage for the Intracept Procedure (procedure codes C9753, C9752 and 22899). 

The denial is overturned. 

This is a female patient with a history of cervical spondylosis. The patient has been followed by Pain Management for continued low back pain. The patient's Pain Management Specialist is requesting approval for the Intracept procedure for the patient. 

The patient is diagnosed with spondylosis without myelopathy or radiculopathy, lumbar region. Magnetic Resonance Imaging (MRI) of the lumbar spine (L) revealed Modic endplate changes with right foraminal effacement at L4 - L5 disc space and Modic endplate changes with associated left foraminal stenosis at L5 - Sacral (S) 1. There was worsening of the left L5-S1 foraminal stenosis. The provider noted the patient had a history of low back pain for over a year with multiple treatments including 4 epidural steroid injections, and medication management. The pain had a significant impact on the patient's activities of daily living.  Nothing provided significant sustainable relief.  The severity of pain ranged between 4/10 and 8/10.  The provider noted that the MRI revealed Modic type II changes at L4-L5 and L5-S1 disc spaces. As such, the provider indicated the patient's pain was coming from the vertebrogenic changes. The provider indicated the patient needed relief from the ongoing axial pain. The request was made for the Intracept procedure.  

The latest scientific evidence supports this treatment in a select patient group, and is an approved procedure. The patient appears to be a candidate for the proposed procedure based on inclusion criteria. As the patient has failed more conservative management, the patient appears to be a candidate for this procedure. 

The patient has documented failure to more conservative treatment, therefore it is possible that the patient may likely benefit from the proposed procedure. Each procedure has different risks and benefits and certainly interventional risks increase as compared to non-interventional treatments.  There is also considerable risk with non-treatment of painful conditions. 

The carrier's denial of the Intracept Procedure (procedure codes C9753, C9752 and 22899) should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder
Treatment: Inpatient Hospital
The insurer denied inpatient hospital admission.
The denial is upheld.

The patient is a female with a history of diabetes mellitus (DM) type 2, hypercholesterolemia, hypertension (HTN), and kidney stones with multiple prior urologic surgeries/procedures who presented with a chief complaint of right flank pain for 3 days with dysuria, fevers, and chills. She denied nausea or vomiting.

Vitals on presentation included a temperature of 101.1, a pulse of 112, a blood pressure of 138/74, a respiratory rate of 18, and a room air pulse oximetry of 100%. On exam, she was not in any acute distress and she was with tachycardia and right costovertebral angle tenderness. Labs showed a white blood cell (WBC) count of 11.7, a hemoglobin of 11.7, a creatinine of 1.16, and a blood urea nitrogen (BUN) of 10. A urinalysis showed 11-20 red blood cells (RBCs), greater than (>) 100 WBCs and few bacteria. Imaging showed that she had bilateral nephrolithiasis, with a 3 millimeter (mm) non-obstructing right ureteral stone and left perinephric stranding. She was given intravenous (IV) fluids and IV ceftriaxone and admitted for further management. She underwent a cystoscopy with bilateral ureteral stent placement. Her symptoms improved and she was discharged home on oral antibiotic. Urine culture grew greater than 100,000 colony forming unit (CFU)/milliliter (ml) of Escherichia coli.

The subject under review is the medical necessity of the inpatient hospital admission.

The health plan's determination is upheld in whole.

The inpatient admission is not medically necessary based on the documentation provided. The patient presented with right flank pain and a fever. She was hemodynamically stable. She did not have acute kidney injury or bacteremia. She did not have bilateral ureteral obstruction on imaging or unilateral obstruction of a solitary or transplant kidney. She underwent a cystoscopy with stent placement, but did not require an inpatient-based procedure or have complications that would require inpatient management. There was no other documented clinical condition that required inpatient management or monitoring. The patient could have been safely and effectively managed at a lower level of care status.