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

Diagnosis: Vomiting
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The health plan's determination is overturned.

The patient is a female with a past medical history (PMH) of duodenal cancer. She was admitted with complaints of (c/o) progressively worsening nausea and vomiting, unable to tolerate even small sips of water without vomiting. Her vital signs were unremarkable. The physical examination was unremarkable. The laboratory studies were unremarkable. The patient was diagnosed with gastric outlet obstruction and was treated with anti-emetics intravenous fluids (IVF), and total parenteral nutrition (TPN). The patient underwent an esophagogastroduodenoscopy (EGD) and laparoscopy that showed a near complete obstruction with a gastric tumor. The patient was discharged in stable condition.

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

The full hospital admission was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o a several day history of nausea and vomiting associated with abdominal pain and inability to keep down even small sips of water. The patient was evaluated and an invasive procedure was performed and the patient was diagnosed with a near complete gastric outlet obstruction from a new gastric mass, for which the patient received a peripherally inserted central catheter (PICC) for TPN and planned surgical intervention in the following week. The patient was not able to tolerate an oral intake for several days, she had intractable vomiting, required invasive procedures, and required parenteral nutrition in anticipation of surgical intervention, and these interventions could not have been safely provided at an alternate level of care.

Regarding the provided criteria, the patient had the following: admission is indicated for 1 or more of the following: complete or partial gastrointestinal (GI) obstruction; inability to maintain oral hydration that persists despite observation care.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: palpitations
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a woman with hypothyroidism and rheumatoid arthritis who presented to the emergency room (ER) with palpitations. He checked his heart rate with his Apple watch, and noted it to be 160 beats per minute (bpm). He went to urgent care, and was sent to the ER. In the ER, heart rate was 130 beats per minute (bpm), sinus tachycardia versus atrial tachycardia on electrocardiogram (EKG). Symptoms resolved and heart rate normalized while in the emergency room. Troponin was elevated at 0.032.

The inpatient hospital admission is not medically necessary. Hospitalization could have been handled at a lower level of care. In this case, the patient had symptomatic sinus tachycardia. However, it resolved spontaneously within the first 24 hours of hospitalization and was not associated with hemodynamic compromise. There was mild troponin elevation, but this was felt due to demand ischemia, and per the consulting cardiologist, did not require inpatient treatment. A lower level of care was appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic abdominal pain

Treatment: pain management service / spinal cord stimulator trial, 01 Unit

The insurer denied coverage for pain management service / spinal cord stimulator trial, 01 Unit

The denial is upheld

This case involves an adult patient seeking a spinal cord stimulator (SCS) trial. The patient was seen with complaints of significant pain throughout the abdomen along with intermittent swelling, pain with pressure/palpation, allodynia, and generalized pressure. The patient was diagnosed with chronic abdominal pain. The provider stated there were concerns for complex regional pain syndrome (CRPS). The treatment plan was for a spinal cord stimulator trial given persistent symptoms despite prior treatment including medications, physical therapy, acupuncture, and medical marijuana.

The patient is noted to have chronic abdominal pain. There is mention of possible CRPS.  Current literature does support spinal cord stimulation for CRPS. The scientific evidence and peer-reviewed literature does support a result of improvement in health outcomes with spinal cord stimulator for CRPS. Spinal cord stimulator does have final approval from the appropriate regulatory body for a diagnosis of CRPS. However, CRPS has not been established based on the submitted documentation. Clinical notes indicate that multiple gastrointestinal (GI) work-ups have been negative. However, no prior GI notes and studies were submitted for review. The most recent clinical note recommended referral to GI for small intestinal bacterial overgrowth (SIBO) or other etiology evaluation. Therefore, other causes of symptoms have not been ruled out. There is also no documentation of psychological clearance. As such, the patient is not a good candidate for a spinal cord stimulator trial at this time. The spinal cord stimulator trial is not the best available treatment for this patient. Adverse risk would be increased over standard treatment/services available at this time. Given the above, the requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of  pain management service/spinal cord stimulator trial, 01 Unit, and coverage for the requested treatment should be upheld.  

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic abdominal pain

Treatment: pain management service / spinal cord stimulator trial, 01 Unit

The insurer denied coverage for pain management service / spinal cord stimulator trial, 01 Unit

The denial is overturned

The patient has a history of chronic severe pain radiating over the left flank and abdomen. She has failed conservative treatment with pain medications, physical therapy, home exercise program, and acupuncture. Her pain is impacting her ability to work and her activities of daily living (ADLs). She was seen and examined and diagnosed with complex regional pain syndrome (CRPS) I (1) and a spinal cord stimulator (SCS) trial was recommended. Physical exam findings at that time included hyperalgesia and decreased left sided core range of motion (ROM) and core strength. She then had follow-up video visits with another doctor who also diagnosed the patient with CRPS I and also recommended a SCS trial for this patient.

Based on the review of the medical record, the patient has failed conservative treatment of CRPS I and current literature supports the use of a spinal cord stimulator trial for treatment of her pain. If the patient receives at least a 50 percent (%) benefit, a permanent placement of a spinal cord stimulator should be considered. Current literature supports that the spinal cord stimulation would be a safe and effective treatment option that could be easily reversed if needed, to treat this patient's medical condition. Thus, the spinal cord stimulator is considered likely to be effective to treat this patient's severe, intractable back and flank pain.

According to UpToDate, overall complications of SCS range from 5.3 to 40 percent and are most commonly due to hardware-related issues. The majority of complications are not life-threatening, such as lead migration, but they do often require lead revision or explantation. Spinal epidural hematoma (SEH) is a rare, potentially catastrophic complication of SCS.

The requested service should be approved as it is likely to be more beneficial than continuing failed treatments or narcotics for this patient.

In summary, the denial of  pain management service / spinal cord stimulator trial, 01 Unit, and coverage for the requested treatment should be reversed.  

This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

 
Diagnosis: Chronic abdominal pain

Treatment: pain management service / spinal cord stimulator trial, 01 Unit 

The insurer denied coverage for pain management service / spinal cord stimulator trial, 01 Unit 

The denial is upheld

This patient has chronic abdominal pain. She has tried physical therapy, a home exercise program, and chiropractic and acupuncture treatments without significant pain relief. Her medication trials have included non steroidal anti inflammatory drugs (NSAIDs), opioids, Gabapentin, Lyrica and Tizanidine. Her magnetic resonance imaging (MRI) is notable for a thoracic (T)11 disc bulge. The progress note suggesting Complex Regional Pain Syndrome (CRPS) states: "The patient displays ongoing chronic abdominal pain (3+ years) disproportionate to any inciting event; patient reports abdominal hyperesthesias, intermittent abdominal edema (left greater than right (L>R)), and decreased abdominal/core range of motion (ROM) and strength since initial pain presentation; positive hyperalgesia (T9-T11 on the left) to pinprick, and reduced abdominal range of motion (ROM)/strength; No other diagnosis to explain the patient's diagnosis."

While, the scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes and it has final approval from the appropriate regulatory bodies for this diagnosis; the patient has not had any sympathetic nerve blocks or any intra-thecal medication trials. There is no psychological clearance documented in the notes. Therefore, it can not be said that the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of pain management service / spinal cord stimulator trial, 01 Unit, and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pressure, Dizziness and Fatigue, status post Heart Procedure.
Treatment: Inpatient Stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a male who has a history of hypertension. He was having chest pain. His ejection fraction (EF) was normal. He presented for an elective cardiac catheterization. His vital signs were essentially normal. The creatinine level was normal. He underwent a successful and uncomplicated catheterization and left anterior descending artery percutaneous intervention. He remained stable and was discharged.

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

The inpatient stay was not medically necessary. The patient underwent a successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There was no renal failure, acute coronary syndrome, vascular complications, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, need for urgent revascularization, need for prolonged intravenous medications or oxygen support and there was no need for the introduction of high-risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization, compared to an outpatient level of care, has not been established as the standard of care towards percutaneous catheterization or overall cardiac outcomes.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lung Cancer
Treatment: FoundationOne CDx test
The insurer denied FoundationOne CDx test.
The determination is upheld.

This is a male patient diagnosed with stage IV adenocarcinoma of the left lung with pleural effusion and epidermal growth factor receptor (EGFR) positive about 8 months ago. Tagrisso was initiated. The FoundationOneCDX assay was ordered around the time of diagnosis and at issue is whether the FoundationOneCDX assay is likely to be more beneficial than any standard treatment for the insured's life threatening or disabling condition.

The proposed health service, FoundationOneCDX assay is not likely to be more beneficial than any standard treatment for the insured's life threatening or disabling condition.

The National Comprehensive Cancer Network (NCCN) guidelines recommend the following molecular markers to assist in the selection of medical therapies for advanced cases of non-small cell lung cancer: epidermal growth factor receptor (EGFR), C-ros Oncogene 1 (ROS1), mesenchymal epithelial transition factor (MET), rearranged during transfection (RET), Programmed death-ligand 1 (PDL-1), proto-oncogene B-Raf (BRAF), Kirsten rat sarcoma (KRAS), anaplastic lymphoma kinase (ALK), Erb-B2 Receptor Tyrosine Kinase 2 (ERBB2) and neurotrophic receptor tyrosine kinase (NTRK).

Any additional markers are not recommended by the NCCN and there is no evidence in randomized, controlled clinical trials that show a survival benefit when other markers are used to select targeted agents versus standard of care markers as outlined by NCCN guidelines.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lung Cancer
Treatment: FoundationOne CDx test
The insurer denied FoundationOne CDx test.
The determination is overturned.

This is a male patient with newly metastatic adenocarcinoma of the lung. The FoundationOne assay was obtained at the diagnosis of metastatic disease and is under review. At issue is whether the FoundationOne CDx test is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The service under review is is a laboratory study. The use of next generation sequencing gene panels to guide the treatment of patients with metastatic non-small cell lung cancer is recommended by the National Comprehensive Cancer Network (NCCN) Guidelines, which state "... is recommended at this time that when feasible, testing be performed via a broad, panel-based approach, most typically performed by next generation sequencing (NGS)..." The assay in question is Food and Drug Administration (FDA) approved and evaluates the cancer for the recommended biomarkers - epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), C-ros Oncogene 1 (ROS1), mesenchymal epithelial transition factor (MET), rearranged during transfection (RET), human epidermal growth factor receptor 2 (HER2), proto-oncogene B-Raf (BRAF), Kirsten rat sarcoma (KRAS), and tropomyosin receptor kinase (TRK).

The authors of UpToDate state "Next generation sequencing (NGS) overcomes many of the shortcomings of direct sequencing and allele-specific testing... It retains sensitivity even in specimens with low tumor cellularity, which is an improvement over direct sequencing, and can identify new abnormalities, which would not be detected by allele-specific testing. Moreover, NGS can often detect abnormalities that would historically be tested by fluorescence in situ hybridization (FISH)..." The service under review is not the subject of ongoing investigation for these purposes.

For these reasons, the use of this assay in this scenario is considered a standard of care for evaluating biomarker status of metastatic non-small cell lung cancer patients.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lung Cancer
Treatment: FoundationOne CDx test
The insurer denied FoundationOne CDx test.
The determination is overturned.

This is a patient with metastatic lung cancer, stage IV, tumor (T) 4 nodes (N) 0 metastasis (M) 1, adenocarcinoma morphology. Next generation sequencing (NGS), FoundationOne testing was ordered by the treating physician. NGS showed microsatellite (MSI) stable, tumor mutation burden 0 mutations per megabase (muts/mb), epidermal growth factor receptor (EGFR) exon 19 deletion, phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha (PIK3CA) mutation. Due to the presence of EGFR mutation detected by this NGS testing, treatment with Osimertinib was initiated. At issue is whether the FoundationOne CDx test is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

NGS testing (such as FoundationOne) is now a standard practice in management of newly diagnosed lung cancer. The National Comprehensive Cancer Network (NCCN) and European Society for Medical Oncology (ESMO) recommend routine testing of molecular profiling (NGS-FoundationOne is one such commercially available test) at the time of diagnosis. NGS testing allows identification of molecular alteration for targeted therapies. NGS also provides prognostic tools and many patients are able to enroll in clinical trials based on the discovery of molecular targets if standard Food and Drug Administration (FDA) approved therapies are not available. Obtaining information of the mutations status of following genes is a crucial step in formulating treatment plans for first line and subsequent line setting in lung cancer: EGFR, anaplastic lymphoma kinase (ALK), C-ros Ongogene (ROS), proto-oncogene B-Raf (BRAF), neurotrophic receptor tyrosine kinase (NRTK), Erb-B2 Receptor Tyrosine Kinase 2 (ERBB2), Kirsten rat sarcoma (KRAS) (G12C), mesenchymal epithelial transition factor (MET), rearranged during transfection (RET) and tumor mutation burden (TMB) status and Micro-satellite instability (MSI) status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer/Other/Vulvar Cancer. 
Treatment: Radiation Therapy. 

The health plan denied: Radiation Therapy for Vulva Cancer Phase 1: 25 fractions (treatment sessions) of Proton beam therapy. Phase 2: 7 fractions (treatment sessions) of Proton beam therapy. 

The determination is overturned. 

This is a female with a history of congenital human immunodeficiency virus (HIV) and was recently diagnosed with FIGO Stage IIIA (cT2N2M0) invasive squamous cell carcinoma of her vulva. She has been recommended to proceed with definitive chemoradiotherapy with curative intent. 

At issue is the medical necessity for the requested Radiation Therapy for Vulva Cancer Phase 1: 25 fractions (treatment sessions) of Proton beam therapy. Phase 2: 7 fractions (treatment sessions) of Proton beam therapy. 

I overturn the health plan's determination of medical necessity, in whole. 

Yes, the requested proton beam radiation therapy is medically necessary in the patient's situation. 

The treating provider supplied a proton/photon plan comparison which revealed that the photon-based intensity modulated radiation therapy (IMRT) plan would result in an unacceptable risk for infertility secondary to the ovary/uterus exposure that was generated with this plan. The proton radiation plan was able to significantly minimize the exposure to the patient's reproductive organs, in addition to other surrounding critical tissues. Proton radiation is expected to minimize the patient's risk for radiation-induced secondary malignancies, worsening in blood counts (which can complicate her HIV), and risk for chronic bowel/bladder dysfunction. It is critical to minimize the patient's risk for serious late toxicity since she has a very good prognosis for long term survival. Proton radiation is supported by high quality prospective clinical outcomes reported in the peer reviewed medical literature. It is supported by the ASTRO Model Policy in the patient's situation.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Ulcerative colitis
Treatment: Uceris 2 milligram (mg) rectal foam
The insurer denied coverage for Uceris 2 milligram (mg) rectal foam
The denial is upheld

The patient has a history of severe ulcerative colitis that required a total colectomy and ileostomy. She subsequently had peristomal pyoderma. She underwent a J-Pouch ileoanal anastomosis along with a diverting loop ileostomy. She subsequently refused surgery for reversal of the ileostomy. She had small bowel obstructions. More recently she was diagnosed with pouchitis but has had difficulty holding steroid suppositories and enemas. Her anal leakage has increased. She has a diagnosis of ileal pouchitis. Her physician writes in the progress notes to consider a course of budesonide as well as to give Uceris foam. Note that Uceris is a form of Budesonide.

UpToDate has an article titled "Management of acute and chronic pouchitis." Initial therapy for chronic pouchitis who failed antibiotics is to give mesalamine. The article lists 3 choices for subsequent therapy for patients who do not improve after mesalamine. These treatment choices include topical hydrocortisone, topical budesonide, and oral budesonide. 

The insurance company has denied the Uceris foam since the patient has not tried and failed the formulary alternatives. Budesonide is a formulary alternative. It is a recommended treatment according to UpToDate for chronic pouchitis. Giving budesonide is not likely to cause an adverse reaction. It has not been shown to be ineffective. It is not known whether Uceris foam would be more effective than budesonide since these medications have not been used in this patient to treat the pouchitis. Since there is a formulary alternative of budesonide, the denial is upheld.

The formulary drugs are not expected to cause adverse effects.

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non- formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Uceris 2 milligram (mg) rectal foam to treat pouchitis is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder (malocclusion). 
Treatment: Braces and Monthly Visits. 
The insurer denied Braces and Monthly Visits. 
The determination is upheld. 

This is a female patient with a Class I malocclusion, severe maxillary crowding and moderate mandibular crowding, moderate overjet and mild open bite, maxillary midline deviated to the left. At issue is whether the requested health service/treatment of braces and monthly visits are medically necessary. 

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 14 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, deeping impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 millimeters (mm) or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment for braces and monthly visits are not medically necessary.