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

Diagnosis: stroke.
Treatment: Home health care. 
The insurer denied Private Duty Nursing Services with a Registered Nurse or Licensed Practical Nurse (LPN): 13 Hours per Day, 7 Days per Week - Total of 91 Hours per Week. The health plan's determination is overturned. 

The patient is a male with past medical history of embolic cerebrovascular accident (CVA), urinary incontinence, bowel incontinence, chronic anticoagulation, hypertension, and depression who had been hospitalized with embolic CVA with transfer to rehabilitation and was rehospitalized. The patient was then transferred to a traumatic brain injury (TBI) unit and subsequently transferred back to the hospital. The patient was transferred to rehabilitation for COVID (Coronavirus disease) 19 and brain swelling.

Private Duty Nursing Services with a Registered Nurse or Licensed Practical Nurse (LPN): 13 Hours per Day, 7 Days per Week - Total of 91 Hours per Week is medically necessary for this patient.
The patient has documented medical necessity for skilled nursing needs by his medical provider. The patient had a complicated and complex past history over the previous 7 months with multiple hospitalizations related to complications from his condition. The patient has had complications from his gastrostomy and from his complex medical regimen with anticoagulation. The patient receives all/most of his nutrition from gastrostomy feedings. The patient's family is not available to provide this care and this care is out of the scope of practice of a home health aide. In addition, the patient has decubitus ulcer of the sacral area which requires assessment and management. In addition, given his medical diagnoses, he is at risk for acute respiratory decompensation and requires monitoring. According to the healthcare advocate, there was not an alternate facility that could meet the patient's needs and therefore his family took him home. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, private duty nursing services with a registered nurse or LPN, 13 hours/day, 7 days/week, to total 91 hours/week are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute myeloblastic leukemia, in remission. 
Treatment: Letermovir (Prevymis). 

The insurer denied Letermovir (Prevymis). 
The determination is upheld. 

The patient has a history of acute myelogenous leukemia. The patient has received 7 plus (+) 3 induction and intermediate dose cytarabine (IDAC) consolidation. She achieved a complete response and had an unrelated haploidentical cord cell transplant following fludarabine/melphalan/total body irradiation (TBI) conditioning. The donor was cytomegalovirus (CMV) negative (-). The patient is CMV positive (+). Letermovir has been recommended for CMV prophylaxis and is under review for medical necessity. 

No. The Letermovir (Prevymis) is not medically necessary for this patient. 

This patient is in the late post-engraftment period. In this clinical scenario, there is a paucity of data indicating that Letermovir is superior to standard treatment. Letermovir has not been evaluated in this clinical scenario and while it offers potential theoretical benefits, it has not been established that these translate to a clinically meaningful improvement in outcomes. For this reason, this approach is not recommended by the peer-reviewed literature, in national guidelines, nor by the authors of UpToDate. For these reasons, medical necessity cannot be established for this service.
Appeal type: Medical necessity
Decision: Upheld

Cancer
Radiation therapy

Diagnosis: cancer
Treatment: proton beam therapy
The insurer denied proton beam therapy. The health plan's determination is upheld. 

This is the case of a male patient with nasopharynx cancer. He is being evaluated for Proton beam radiation therapy (RT). This is the subject of review.

Outpatient Proton Beam Radiation Therapy is not medically necessary for this patient.

Generally accepted standards of medical practice in the United States for Head and neck cancer are photon based 3D or intensity modulated radiation therapy (IMRT) radiation treatments. Although with IMRT, dose to certain critical structures may be higher, it is still considered an acceptable to use IMRT in this setting and the difference between the two plans may not be considered clinically significant.

Currently, there is no clinical data in the medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for head and neck cancer. In this setting, there is no published literature that compares clinical outcomes of proton beam radiotherapy compared to standard photon techniques. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques.

Also, the ASTRO (American Society for Radiation Oncology) emerging technology committee report on proton therapy specifically states that there is insufficient data to recommend proton beam therapy for routine head and neck radiation therapy outside of clinical trials.
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 woman who presented to the emergency department (ED) with epigastric/right sided abdominal pain nausea and dry heaves. She has a history of obesity and is status post roux en Y gastric bypass 20 years ago. At the time of presentation, the patient was without fever and the heart rate was 105/minute. She had a tender abdomen per the examination and her pain rating was 10/10. The white blood cell (WBC) count was normal at 10.1. The complete metabolic panel was normal. A computed tomography (CT) scan and ultrasound showed findings of gallstones and duodenitis and anatomic changes of prior gastric bypass. An abdominal ultrasound did not show findings consistent with acute cholecystitis. She was initially treated with intravenous (IV) fluid and IV antibiotics. Magnetic resonance cholangiopancreatography (MRCP) was performed and showed cholecystitis. 

The inpatient hospital admission was not medically necessary. This patient could have been safely and appropriately treated at a lower level of care. This patient was admitted to the hospital with the diagnosis of abdominal pain/cholelithiasis/cholecystitis. The indication for cholecystectomy was established. The patient was treated non-operatively during this admission with planned outpatient follow up. There were no hospital complications or other clinical issues that mandated an inpatient designation. She remained stable and was discharged from the hospital.

A lower level of care would have permitted for the ED and surgical assessment, imaging, lab data, IV (intravenous) fluid, IV antibiotics, IV antiemetics, and overnight monitoring. The patient remained clinically stable as supported by the corresponding medical records. She was tolerating a full liquid diet and oral analgesia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis.
Treatment: Inpatient admission.

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

The patient is a female. She presented with itching.

There was no abdominal pain, nausea, vomiting or fever. She was hemodynamically stable and noted to be jaundiced. Labs revealed elevated liver enzymes. US (ultrasound) revealed gallstones but no evidence of cholecystitis. MRCP (Magnetic Resonance Cholangiopancreatogram) revealed a normal common bile duct. She tolerated a diet.

The patient underwent liver biopsy in IR (interventional radiology), and was discharged.

No, the Inpatient admission was not medically necessary.

The patient presented with painless jaundice. While she had gallstones, there was no evidence of biliary obstruction or acute cholecystitis or cholangitis. The most likely etiology for her jaundice and abnormal LFTs (liver function tests) was a hepatitis, either viral or autoimmune. As she was hemodynamically stable, tolerating a diet, was not vomiting, had no fever, sepsis or obstruction, acute inpatient hospital stay was not medically necessary. A lower level of care was appropriate, and she was medically stable for discharge on day two, for an outpatient liver biopsy. Acute inpatient hospital stay was not medically necessary.

Yes, as acute inpatient hospital stay was not medically necessary, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Exertional dyspnea/chest pain.
Treatment: Transthoracic echocardiogram.

The insurer denied a transthoracic echocardiogram.  The health plan's determination is overturned.

The patient is a woman who complained of exertional dyspnea and chest pain. Her cardiac risk factors include hypertension, hyperlipidemia (low density lipoprotein (LDL) cholesterol level was 157), prediabetes (hemoglobin A1c was 5.8%), and obesity. She is scheduled to have bariatric surgery. When seen, her physical exam was remarkable for a systolic murmur. An electrocardiogram showed sinus rhythm with low QRS voltage and nonspecific repolarization abnormalities. Her previous cardiac evaluation included an echocardiogram that showed a low normal left ventricular ejection fraction (50%), left ventricular hypertrophy, mitral annular calcification and trace mitral and tricuspid regurgitation.

Transthoracic Echocardiogram is medically necessary for this patient. 

This woman, with multiple cardiac risk factors, has complaints of exertional dyspnea and chest pain. She has a history of a low normal left ventricular ejection fraction (LVEF) by echocardiogram. In the report by Yeboah et al., patients with low normal LVEFs were shown to be at increased risk for the development of heart failure over a 10-year follow-up period (hazard ratio 3.64, as compared to patients with normal LVEFs). A transthoracic echocardiogram (TTE) was recommended for this patient. This would provide information as to the patient's LVEF, diastolic function and valvular function. Per the 2011 Appropriate Use Criteria for Echocardiography (1), TTE is considered appropriate in the evaluation of patients with symptoms, such as chest pain and dyspnea, that are potentially cardiac in etiology.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hypertension.
Treatment: Bystolic 5 milligram (mg) tab.

The insurer denied coverage for Bystolic 5 mg tab. The denial is overturned.

This patient has hypertension. Blood pressure was effectively controlled with Bystolic 10mg. The patient's doctor documents an allergic reaction to the generic form of Bystolic (nebivolol). Alternative formulary agents are documented to be ineffective in controlling blood pressure. These agents include, atenolol, bisoprolol, carvedilol, labetalol, and metoprolol. 

Based on the information provided, the formulary medication (nebivolol) is likely to cause an adverse reaction. In addition, the other formulary drugs have been documented to be ineffective. The requested drug has successfully controlled blood pressure for approximately a year and a half. Studies have demonstrated that a small number of individuals require use of name brand medications following use of generic formulations. (2) In this case the patient has been maintained on Bystolic for several years and has noted intolerance to generic formulations and inefficacy to other formulary medications. 

The requested drug is likely to be more effective than the formulary drugs.

The insurer's denial of coverage for Formulary Exception for Bystolic 5 milligram (mg) tab is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain and swelling in the left leg and left knee pain. 
Treatment: Left lower extremity magnetic resonance imaging (MRI). 

The insurer denied coverage for left lower extremity MRI. 

The denial is upheld. 

This is the case of an adult female with a history of falls, pain and swelling in the left leg and left knee pain. X-ray of the left knee following a fall was negative. MRI of the left ankle showed peroneal tenosynovitis, inframalleolar peroneus brevis tendinopathy, scarring-remodeling, evidence of sinus tarsi syndrome, posterior tibial and flexor tenosynovitis and calcaneal enthesopathy. The patient was evaluated at the hospital for left leg pain and cardiac complaints. Testing was negative for deep vein thrombosis, and the patient was instructed to schedule an MRI of the left tibia/fibula. An MRI of the left knee showed a new radial tear, mild to moderate patellofemoral compartment arthrosis and small knee joint effusion with mild synovitis; the proximal tibiofibular joint was normal. X-rays of the left foreleg showed no fracture or other acute abnormality. 

The indications for an MRI are to help a physician in establishing a pain generator. There should be consistency of the clinical record with a complete history and physical examination. There should be a differential diagnosis. A course of conservative management should be provided prior to special imaging. There should be documentation in the medical record by treating practitioner of possible surgical intervention or change in treatment. There should be evaluation for "red flags". For example: tumor, infection, fracture. None of these has been considered. The facts are the injured woman has complaints to several body parts and multiple imaging studies had been completed. There is no differential diagnosis provided by physician. There is no plan for possible surgery. There were no documented physical findings to suggest pathology to the left area. 

MRI for "pain" is not an established indication. Without specifics about why the doctor wants this test, it clearly is not indicated at this time. 

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

The insurer's denial of coverage for left lower extremity magnetic resonance imaging (MRI) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis Vulgaris
Treatment: Cosentyx, pre-service
The insurer denied the Cosentyx, pre-service
The denial is upheld.

The patient is a male. He has a medical history of plaque psoriasis, body surface
area 41% (percent). He has tried and failed topical steroids, Humira, and Tremfya. There is no reason given for the appeal of the denial.

No, the use of Cosentyx is not medically necessary for this patient.

According to the documentation provided for review, the patient has not tried and
demonstrated an inadequate treatment response or intolerance to Otezla, Skyrizi,
and Stelara, which are supported as standard, first-line therapy options. There is no
documentation of elevated liver function tests, recurrent infections, or underlying
disease or malignancies that would contraindicate the use of the plan's preferred
biologics. Current medical literature corroborates the safety and non-inferior or
superior efficacy of these preferred medications in this clinical scenario. Therefore,
this request for Cosentyx is not medically necessary at this time.

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

Diagnosis: Cardiomyopathy. 
Treatment: Inpatient admission. 

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

This female was hospitalized for elective Implantable Cardioverter-Defibrillator (ICD) insertion. Her personal medical history (PMH) includes advanced cardiomyopathy, HFrEF (heart failure with reduced ejection fraction) with LVEF (left ventricle ejection fraction) 35%, moderate to severe MR (mitral regurgitation), sleep apnea on CPAP (continuous positive airway pressure), HTN (hypertension), HLP (hyperlipidemia), morbid obesity and hypothyroidism. She was deemed high risk by anesthesia, but nonetheless, underwent an uncomplicated single-chamber ICD (implantable cardioverter defibrillator) insertion in the OR (operating room). She was observed overnight and was discharged to home. This is an appeal of the denied claim of the requested Acute Inpatient Hospital Stay was medically necessary for this patient. 

No, the Inpatient admission was not medically necessary. 

In this patient's case, there is no documentation submitted to establish acute inpatient admission is necessary for the single-chamber ICD (implantable cardioverter defibrillator) insertion. This was an elective procedure, and the submitted records document that it was a successful, uncomplicated, and non-transthoracic procedure. Pacemakers, including single chamber pacemaker ICD (implantable cardioverter defibrillator) implants in the OR (operating room) are routinely performed on an outpatient basis with overnight observation. This has become the standard of care and is mandated by CMS (Centers for Medicare and Medicaid Services) unless inpatient criteria for hospitalization are met, including unstable medical conditions like AMI (acute myocardial infarction), acutely decompensated CHF (congestive heart failure), life-threatening cardiac arrhythmia, stroke, procedural complications, or other medical instability or acute care needs that would require acute inpatient management. The ICD (implantable cardioverter defibrillator) implant under the patient's circumstances could have been managed safely and effectively at a lower level of care. Therefore, inpatient admission was not medically necessary, based on the submitted information and the current standard 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: Idiopathic short stature (ISS)

Treatment: Norditropin Flexpro injection

The insurer denied coverage for Norditropin Flexpro injection

The denial is overturned

This is a patient diagnosed with ISS. This request is for Norditropin 1.9 mg (milligrams) 6 times a week. As reported, he is on GH (growth hormone) therapy. His GH stimulation test peaked at 13.1. His pretreatment height velocity is reported to be 3 cm (centimeters)/yr (year). 

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2, [3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD (standard deviations) below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 year of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low IGF (insulin-like growth factor) 1 or IGFBP (insulin-like growth factor binding proteins) 3 or GH stimulation testing with a peak GH less than 10ng (nanograms)/ml (milliliter).
		
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4, [5, [6, [7, [8, [9]. FDA (Food and Drug Administration) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS (standard deviation score) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient had a pretreatment height less than or equal to -2.25 SD. The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. The patient is a continuing therapy patient benefited from growth hormone. Continuation is consistent with generally accepted standards of medical practice until growth plate fusion.

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 Norditropin Flexpro injection is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, vomiting, and right flank pain
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

The patient is a female admitted to the hospital for nausea, vomiting, and right flank pain. Computed tomography (CT) of the pelvis showed mild right distal ureteral calculus situated just proximal to the ureterovesical junction & mild right pelvicaliureterectasis. She was treated with intravenous (IV) fluid and antibiotics then discharged.

The patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolyte disturbance or change in kidney function, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration, and no documentation of refractory pain. She was able to tolerate oral diet and did not require total parenteral nutrition and her condition responded to IV fluid and antibiotics in 24 hours.

Based on the patient's presenting signs/symptoms and the predictability of something adverse that will occur to the patient based on these presenting signs/symptoms, her condition could have been treated safely under a lower level of care. When taking into account the exam, imaging, and lab findings as well as her lack of need for diagnostic testing beyond what was done in the emergency room (ER) and the availability of any additional diagnostic testing as an outpatient, nothing was done for the patient during her inpatient level of care that could not have been or had not already been managed on an observation level of care. Based on all these reasons, she had no requirements for inpatient level of care.

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

The insurer's denial of coverage for an inpatient hospital admission is upheld. Medical necessity is not substantiated.