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

Diagnosis: Syncope. 
Treatment: Inpatient stay. 

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

The patient is a man with a history of hypertension who was admitted to the hospital. He presented with loss of consciousness. He reported feeling fatigue since that morning and then going to work as a taxi driver. When he returned home that evening, he reported onset of nausea. At that point, he sat down in his chair and asked his daughter for water, after which he lost consciousness. His daughter assisted him to the ground, and he did not strike his head. There was no reported seizure like activity, and his pulse was subsequently noted to be non-palpable by his daughter. She initiated cardiopulmonary resuscitation (CPR) after which he regained consciousness. He denied fevers, chills, chest pain and palpitations. Vital signs showed temperature 102.6 Fahrenheit, heart rate 110, and blood pressure 144/85. On physical examination, heart was regular, breath sounds were normal, neck was supple, abdomen was soft and there was no neurologic deficit. Labs showed white blood cell (WBC) 14.2, hemoglobin 14.4, platelets 258, sodium 132, potassium 3.6, creatinine 1.06 and calcium 9.1. Head computed tomography (CT) was negative for acute stroke. Chest x-ray was negative for pneumonia. An electrocardiogram (EKG) showed sinus tachycardia with no evidence of ischemia. The patient was admitted for syncope and sepsis with concern for encephalitis. 

The inpatient hospital admission was medically necessary. The patient was suspected of having seizures versus encephalitis in the setting of presyncope, and he was empirically treated with intravenous (IV) antibiotics due to the acuity of the concern. In addition, he met sepsis criteria with tachycardia, fever, and leukocytosis along with suspected infection. Because of the acuity of the patient's presentation and the increased risk for an adverse outcome, it was appropriate to treat the patient at the inpatient level of care.
The patient was found to have leukocytosis, high fever, and tachycardia at the time of arrival in the emergency department, along with symptoms of pre-syncope and possible encephalitis. Encephalitis is associated with high morbidity if not treated early and the patient's presentation was concerning for a neurological process. Although ultimately the lumbar puncture demonstrated no evidence of an acute infection, the patient's level of care was appropriate considering the initial concerns about encephalitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class II Occlusion. 
Treatment: Braces and adjustment to braces. 

The insurer denied braces and adjustment to braces. The health plan's determination is upheld. 

The patient in question is a male with a Class II occlusion with 6 millimeter (mm) overjet and 5 mm overbite. The maxillary and mandibular arches have minor crowding. He is treatment planned for orthodontics with elastics and headgear to correct his malocclusion, but this was denied by the health plan. 

Braces and adjustments to braces are not medically necessary for this patient. The patient does have a deep bite; however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Although the narrative indicates a posterior crossbite, the supplied photos do not show any crossbites. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 6mm overjet, but this amount of overjet does not affect oral health related quality of life. If his teeth were aligned, it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health. Therefore, the requested Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite.
Treatment: Comprehensive orthodontic treatment.
 
The insurer denied Comprehensive orthodontic treatment.  The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth #10. She presents with a Class III malocclusion with mild crowding in the maxilla and mild spacing in the mandible. She has a posterior crossbite on tooth #3. She is treatment planned for 24-30 months of orthodontics to address the crowding and crossbites.

Comprehensive orthodontic treatment is medically necessary for this patient.
This patient presents with an anterior crossbite on tooth #10, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
If left untreated the damage that will occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Radiology Services (including Ultrasound) 
The insurer denied positron emission tomography (PET) scan as not likely to be more beneficial than standard treatments. 
The denial was upheld. 

This patient is a male, with a history of benign prostatic hyperplasia (BPH) and hernia repair, who was found to have evidence of sclerosing mesenteritis incidentally on a computed tomography (CT) scan of the abdomen to evaluate kidney stones. Therefore, the provider ordered a positron emission tomography (PET) scan to rule out lymphoma as a cause of his sclerosing mesenteritis. The PET scan did not reveal evidence of malignancy.

At issue is whether PET scan is likely to be more beneficial than any standard treatment or treatments for this patient.

The health plan's determination regarding the proposed health service or treatment is upheld in whole.

The proposed health service or treatment PET scan was not likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.

Sclerosing mesenteritis is a rare disease entity with a prevalence reported to be less than 1%. Sclerosing mesenteritis is a comprehensive term used to describe three almost similar clinical entities including mesenteric panniculitis, retractile mesenteritis, and mesenteric lipodystrophy which only differ by their histology. The etiology of sclerosing mesenteritis is uncertain, but the disease has been associated with trauma, autoimmune disease, surgery, and malignancy. The typical presenting symptom is the abdominal pain, but sclerosing mesenteritis has a broad constellation of presenting symptoms which often makes consideration of the diagnosis unlikely. Treatment for this little-understood disease ranges from surgical intervention for patients presenting with obstructive symptoms to immunosuppressive medical therapy for patients presenting with pain. Abdominal imaging is the mainstay for the diagnosis of the sclerosing mesenteritis, and the advent of the CT scan has drastically improved the diagnostic incidence of sclerosing mesenteritis. Although sclerosing mesenteritis can be visualized on an abdominal ultrasound, CT scan, and magnetic resonance imaging (MRI), the CT scan is the most utilized imaging modality recorded in the literature. One of the specific CT scan signs to diagnosis sclerosing mesenteritis is a "fat ring sign" but presence of "pseudo-capsules" also raise the suspicion of sclerosing mesenteritis. Infrequently, a sign of "misty mesentery" has also been described which is an increase in mesenteric attenuation with the presence of small nodes in the absence of a discrete soft-tissue mass suggestive of sclerosing mesenteritis.

Therefore, the proposed treatment of PET scan is not likely to be more beneficial than any standard treatment or treatments for the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Radiology Services (including Ultrasound) 
The insurer denied positron emission tomography (PET) scan as not likely to be more beneficial than standard treatments. 
The denial was upheld. 

The patient is a male with sclerosing mesenteritis. A computed tomography scan of the abdomen and pelvis showed a misty mesentery suggestive of sclerosing mesenteritis. Oncology recommended a positron emission tomography (PET) scan. A PET scan  showed no fludeoxyglucose (FDG) avid lesions to indicate malignancy, and no lymphadenopathy by size criteria.

At issue is whether the PET scan is likely to be more beneficial than any standard treatment or treatments.

The health plan's determination regarding the proposed health service treatment is upheld in whole.

The proposed health service or treatment PET scan is not likely to be more beneficial than any standard treatment or treatments for this patient.

Sclerosing mesenteritis, and related conditions including mesenteric adenitis, can mimic malignancy or be found in patients with malignancy. [1-3] PET scans can localize malignancy, and one small study showed that a negative PET scan has high diagnostic accuracy in excluding tumor. [4,5] However, newer literature does not recommend the use of a PET scan for the evaluation of sclerosing mesenteritis, citing missed and inaccurate diagnoses. [6-9] For these reasons, a PET scan is not supported as likely to be more beneficial than any standard method for diagnosis of this patient's sclerosing mesenteritis.

Therefore, the PET scan is not likely to be more beneficial than any standard treatment or treatments for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Radiology Services (including Ultrasound) 
The insurer denied positron emission tomography (PET) scan as not likely to be more beneficial than standard treatments. 
The denial was upheld. 

The patient is a male with a past medical history of benign prostatic hyperplasia (BPH) and hernia repair. He was found to have sclerosing mesenteritis as an incidental finding on a computed tomography (CT) scan. There was no associated pathologic lymphadenopathy and no specific mass identified, only misting of the mesentery.

The patient's provider recommended a positron emission tomography (PET) scan to determine whether the site of sclerosis was metabolically active and therefore more worrisome for potential malignancy.

At issue is whether the PET scan is likely to be more beneficial than any standard treatment or treatments.

The health plan's determination regarding the proposed health service or treatment is upheld in whole.

The proposed health service or treatment of PET scan is not likely to be more beneficial than any standard treatment or treatments for the patient.

Sclerosing mesenteritis is a rare non-neoplastic disorder characterized by fat necrosis, chronic inflammation, and fibrosis, typically of the small bowel mesentery. Prior abdominal surgery or trauma, autoimmunity, infection, ischemia, and malignancy have been suggested to be involved in the pathogenesis of the disorder. The clinical course of sclerosing mesenteritis is generally benign with a large proportion of patients diagnosed incidentally on imaging obtained for other indications. In a subset of patients, symptoms may arise from a mass effect on the bowel, lymphatics, or vasculature resulting in bowel obstruction, chylous ascites, or mesenteric ischemia.

Given the broad differential and the similar imaging findings of several neoplastic processes, a significant number of patients generally undergo a CT guided biopsy to establish the diagnosis. However, the significant challenge is whether an aggressive approach of surgical resection should be pursued. Given the self-limited nature of this condition, diagnostic sampling by CT guided biopsy is the usual approach. In individuals with mesenteritis in a position not favorable for biopsy, the approach is generally to follow with serial imaging to look for progression. Per the literature, there is no use of PET scans as a recommended/commonly utilized test to help in terms of guiding management or follow-up.

Therefore, the treatment of PET scan is not likely to be more beneficial than any standard treatment or treatments for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: rheumatoid arthritis, osteoarthritis of the right knee

Treatment: a right total knee replacement

The insurer is denied coverage for a right total knee replacement

The denial is overturned. 

This female patient has a history of rheumatoid arthritis, osteoarthritis of the right knee and right knee medial compartment arthritis. She is noted to have tried physical therapy. Knee x-rays are noted to reveal medial compartment and patellofemoral compartment moderate osteoarthritis with joint space narrowing and osteophytic changes. The patient was admitted to the Hospital for Special Surgery and underwent a right total knee replacement the same day. She was discharged.

The medical record demonstrated the patient had end stage arthritic involvement to her right knee. She has underlying rheumatoid arthritis. Her physician reported long standing disease which worsened over the past year. Reported treatments received included physical therapy, occupational therapy, multiple anti-inflammatory medications including Prednisone. The records showed functional limitation with need for cane. The physical examination reported several positive objective findings. Her physician documented the radiographic findings. A pain generator had been defined. The records showed no improvement with conservative treatment. Her clinical course would not change with additional non operative treatment. The next step should be surgery. The operation was thus necessary and appropriate. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 
The requested surgical procedure on the thigh region and knee joint (knee replacement); 27447 x 1 and inpatient stay is considered medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Generalized Anxiety Disorder.
Treatment: Trintellix.
The insurer denied the Trintellix.
The determination is overturned.

The patient was diagnosed with generalized anxiety disorder with panic attacks who is prescribed Trintellix (vortioxetine). Trintellix is prescribed in order to address symptoms of generalized anxiety disorder that include hypervigilance, anxious mood, ruminations with excess worry, and generalized symptoms of anxiety as well as frequent panic attacks. The panic attacks are characterized as severe and occurring in clusters with feelings of dread and cardio-respiratory symptoms. There is no substance use disorder or psychiatric comorbidity in this case.
The patient has failed prior treatments with multiple antidepressant medications including selective serotonin reuptake inhibitors [SSRIs] (fluoxetine, sertraline and citalopram), duloxetine, bupropion and mirtazapine. Trintellix was started at 10 milligrams (mg) switching from citalopram. The health plan denied the Trintellix indicating that formulary medications are available and have not been tried.
The health plan documents, as well as case a summary/progress note and correspondence from the health plan and prescribing physician were reviewed. The health plan's formulary, prior authorization criteria and prescription drug coverage language requiring step therapy were reviewed as submitted along with plan guidelines and the Certificate of Coverage.
At issue is the medical necessity of Trintellix (vortioxetine) 10 milligrams (mg) daily.

The requested health service/treatment of Trintellix 10 mg tab is medically necessary for this patient considering the health plan's listed formulary alternatives, the requested treatment with Trintellix represents the next best step in treatment of the patient's generalized anxiety disorder.
In this case, the prescribing clinician has documented that the patient has tried or failed formulary alternatives with a lack of clinical response/efficacy or adverse effect. The patient's proposed treatment with Trintellix is reasonable in view of the multiple failed trials with formulary alternatives including SSRIs (fluoxetine, sertraline and citalopram), duloxetine, bupropion and mirtazapine. The selection of a novel antidepressant, Trintellix, reflects sound medical judgment and is in the best interest of the patient in this case scenario. The patient's prescribing clinician has requested the Trintellix on the basis of the clinical history and current treatment recommendation for the use of Trintellix. The request for the Trintellix to treat generalized anxiety disorder is reasonable in this case scenario and is considered medically necessary, clinically appropriate and is in accordance with generally accepted standards of medical practice; This answer is consistent with the guidelines and scientific literature referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gall Bladder Cancer.
Treatment: Trastuzumab, Pre-service.

The insurer denied the Trastuzumab, Pre-service.  The denial is upheld.

The patient in this case is a man diagnosed with gall bladder adenocarcinoma. His cancer was initially stage 3, but he subsequently was diagnosed with metastatic cancer.  He was treated with cisplatin and gemcitabine, but has had worsening cancer. Caris testing was done, and IHC (immunohistochemistry) was done that revealed 2+ staining for HER2 (human epidermal growth factor receptor 2).  This was listed as "equivocal" in the report.

No, the treatment with Trastuzumab is not medically necessary.

Trastuzumab is not a standard treatment for gall bladder cancer.  This patient was found to have 2+ staining by IHC (immunohistochemistry).  This is not a clearly positive result in breast cancer or gastric cancer, the two types of cancers for which there are validated criteria for assessing HER2 (human epidermal growth factor receptor 2) test results.  There is no clear evidence that this patient has HER2 (human epidermal growth factor receptor 2) positive cancer.  Furthermore, trastuzumab is not currently considered a standard treatment, proven to be effective, for gall bladder cancer.  Therefore, it is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative colitis, spinal stenosis, anxiety, gastroesophageal reflux disease, insomnia and arthritis
Treatment: Consumer directed personal assistance services 63 hours per week
The insurer denied the Consumer directed personal assistance services 63 hours per week.
The denial is upheld.

This patient is a male with medical conditions including ulcerative colitis, spinal stenosis, anxiety, gastroesophageal reflux disease (GERD), insomnia and arthritis.  He is appealing denial of consumer directed personal assistance services (CDPAS) at 63 hours per week after the provider's request for additional hours.  The patient has been approved for 42 hours per week for approximately five months.  

The request for additional hours is because the patient feels weaker and may fall.  The Uniform Assessment System (UAS) evaluation performed shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, and shopping; extensive assistance with managing medications, stairs, transportation, bathing, lower body dressing, walking, locomotion, and toilet use; limited assistance with managing finances, phone use, personal hygiene, upper body dressing, and toilet transfer; and independent with bed mobility and eating.  He ambulates with a cane, rollator and wheelchair.  He is infrequently incontinent.

No, the proposed treatment is not medically necessary.
Medically necessary services are those which are:
1) safe 
2) effective
3) generally accepted national standard of medical practice 
4) not provided primarily for convenience of the patient or the practitioner 
5) 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.

This patient has been approved for 42 consumer directed personal assistance service (CDPAS) hours per week.  He is appealing the denial of 63 hours per week.  Uniform Assessment System (UAS) evaluation performed shows the patient is independent with bed mobility and eating; requires assistance with other activities of daily living (ADLs) and personal care that include limited assistance with managing finances, phone use, personal hygiene, upper body dressing, and toilet transfer.  He uses assistive devices for ambulation.  The patient has not fallen in the past 90 days.  There is no appeal letter from the doctor or other information supporting a change in the patient's condition since the approval for 42 hours per week.  Consumer directed personal assistance services (CDPAS) are not indicated when there are no tasks being performed.  Based on all available information, an increase in consumer directed personal assistance service (CDPAS) hours is not medically necessary.  The proposed increase in consumer directed personal assistance services (CDPAS) to a total 63 hours per week is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied the Intracept Procedure.
The determination is upheld.

The patient has complaints of low back pain. He has axial low back pain. The patient has had physical therapy, home exercises, nonsteroidal anti-inflammatory drugs (NSAIDs), as well as opioids. Magnetic resonance imaging (MRI) of the lumbar spine demonstrates Modic changes. The pain affects the patient's activities of daily living (ADL). There is a request for the Intracept Procedure (Intraosseous Ablation of the Basivertebral Nerve) and this is under review.
There is insufficient support in the literature verifying the proposed health service or treatment Intracept Procedure (Intraosseous Ablation of the Basivertebral Nerve[BVN]) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Per Fischgrund, et al "In the present study, using a 10-point Oswestry Disability Index (ODI) improvement as a threshold, 75.6% of treatment arm patients as opposed to 55.3% of sham arm patients were characterized as responders. In addition, the treatment group reported statistically significant improved outcomes compared to the sham group. Comparison of the difference in outcome score between the sham and treatment groups does not represent the clinical utility of the Intracept Procedure because a sham treatment is not a clinically acceptable treatment for chronic low back pain (CLBP), nor is a sham response likely to occur in an open label setting. The overall therapeutic value of the procedure should be viewed through its safety profile and observed improvements from patient baseline, which are the same filters applied to other more invasive procedures which have not been compared to sham treatment. The results of this study support BVN ablation as a minimally invasive treatment for relief of chronic low back pain. This is one study and there are no trials. There are insufficient large-scale, randomized, controlled studies showing the efficacy of this procedure. It is not in accordance with standards of good medical practice lacking large case studies and long-term follow up.