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

Diagnosis: Malignant peripheral nerve sheath tumor
Treatment: Ibrance 125mg OR CAPS, pre-service
The insurer denied the Ibrance 125mg OR CAPS, pre-service.
The denial is upheld.

The patient is a man with neurofibromatosis 1, malignant nerve sheath tumor that was resected and treated with nivolumab, but abdominal masses continue to grow. Ibrance was recommended.

No, the health plan should not cover the requested Ibrance.

Cyclin-dependent kinases 4/6 inhibitors (CDK4/6i), namely abemaciclib, palbociclib, and ribociclib, interfere with cell cycle progression, induce cell senescence and might promote cancer cell disruption by a cytotoxic T cells-mediated effect. Phase III randomized clinical trials have proven that CDK4/6i in combination with several endocrine agents improve treatment efficacy over endocrine agents alone for hormone receptor-positive (HR+) HER2 negative (human epidermal growth factor receptor 2) metastatic breast cancer (MBC). Based on such results, these combinations have been approved for clinical use.

While the providers believe that an exception should be made to the usual standard, it remains a fact that beyond preclinical discussions, trials have not been done in peripheral sheath tumors or in similar cancers. As such, the treatment requires clinical trial and cannot be recommended at this time. This treatment is in clinical trials, which establishes it as being Experimental/Investigational.

No, it is not known if Ibrance is more beneficial.

There have not been comparative studies or guidelines to be able to make this determination.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Malignant peripheral nerve sheath tumor
Treatment: Ibrance 125mg OR CAPS, pre-service
The insurer denied the Ibrance 125mg OR CAPS, pre-service.
The denial is upheld.

The patient is a male. He has malignant peripheral nerve sheath tumor (MPNST) and neurofibromatosis type 1 (NF1) with metastatic disease. He was treated with nivolumab with evidence of tumor progression. Ibrance has been recommended based on the presence of CDKN2A (cyclin-dependent kinase inhibitor 2A) mutation in this patient's tumor.

No, the health plan should not cover the requested Ibrance.

No, the requested Ibrance is not more beneficial.

There is no published study showing that palbociclib is safe and effective for treatment of MPNST. This agent is not considered a standard treatment option for MPNST by NCCN (National Comprehensive Cancer Network) guidelines. Given lack of any published clinical evidence supporting use of this agent and also lack of consensus guideline endorsement, it cannot be concluded that this treatment is more beneficial than any available standard treatment.

The appeal letter states that this agent should be approved based on the CDK (cyclin-dependent kinase) mutation in the patient's tumor because this drug targets that mutation. However, as noted above, there is no evidence that this agent is effective in this patient's type of cancer (or for that matter soft tissue sarcoma in general) based on the presence of this mutation. Also, MPNST is a form of soft tissue sarcoma, and this disease is addressed by NCCN, as noted above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine myomas.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who underwent a robotic assisted total hysterectomy for management of her uterine myomas. The patient was admitted the day of surgery for inpatient level of care.

Coverage was denied by the health plan, because the patient had an uncomplicated surgery, her vital signs were stable, she did not require conversion to laparotomy, and after surgery, she was able to ambulate, void, and tolerate an oral diet and oral pain medications. She did not have acute conditions that would have required acute inpatient level of care following an ambulatory level procedure. This denial is being appealed.

No, the Inpatient Hospital Admission was not medically necessary.
The patient had an uncomplicated surgery, her vital signs were stable, she did not require conversion to laparotomy, and after surgery, she was able to ambulate, void, and tolerate an oral diet and oral pain medications. She did not have acute conditions that would have required acute inpatient level of care following an ambulatory level procedure.  Inpatient admission in this case is not supported by peer reviewed data, it is not standard of care and it is not supported by professional organizations.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient had an uncomplicated surgery, her vital signs were stable, she did not require conversion to laparotomy, and after surgery, she was able to ambulate, void, and tolerate an oral diet and oral pain medications. She did not have acute conditions that would have required acute inpatient level of care following an ambulatory level procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is overturned.

Patient is a female with no significant past medical history who presented to the emergency department (ED) with complaints of a sore throat, chest pain, neck pain and a fever for 2 days. She had a low blood pressure (BP), high pulse and respiratory rate, and was febrile (blood pressure of 107/65, pulse of 116, temperature of 101.5 Fahrenheit, respiratory rate 24).   

Appropriately, she was admitted to the intensive care unit (ICU) for a mild hypotensive episode (a blood pressure of 99/45 in the ED which was lower than the 107/65 recorded at triage). A sepsis evaluation was clinically indicated not only because of the low blood pressure, but also because the differential diagnosis of sepsis in adolescents is extensive, especially with chest and neck pain, and includes meningococcemia, urosepsis, toxic shock syndrome, Staphylococcus aureus sepsis, Group A Streptococcus sepsis, Rocky Mountain spotted fever (RMSF), Lemierre's disease, as well as pneumococcus and Capnocytophaga canimorsus if she happens to be asplenic. Several of these infections will not present with characteristic diagnostic signs or tests in the first few days of presentation. 

The treatment plan appropriately included a sepsis evaluation, intravenous fluids, and ceftriaxone. The lab profile was pertinent for leukocytosis and a high creatinine. There was risk of acute kidney injury. The respiratory viral panel (RVP) was positive for rhinovirus, which could be an incidental finding. For the early recognition of sepsis, which now a major national quality measure, a clinician's judgment is a major criterion, and he/she is expected to err on the side of caution. Particular attention should be paid to low BP readings.  

The team correctly performed interventions that qualify for "Inpatient Level of Care", including monitoring the patient in an ICU, in order to prevent adverse outcomes of possible sepsis. The location of admission is a factor in this decision.  Whether to admit to an ICU "varies with the individual presenting characteristics as well as available institutional services and policy". (UpToDate) When in doubt, as in this case, "close observation and a low threshold to admit to the ICU is prudent."

The UpToDate reference cited is for Evaluation and Management of Suspected Sepsis and Septic Shock in Adults, but this applies to adolescents as well, as distinguished from separate protocols for evaluation of fever and sepsis in infants. The Journal of the American Medical Association (JAMA) review highlights our progress in defining sepsis in children in order to save lives.

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 inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Poor Weight Gain With Severe Protein Caloric Malfunction
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female, full term di-di (dichorionic diamniotic) twin who was admitted for failure to thrive with the concern of protein malnutrition. The patient's twin was growing adequately as per pediatrician.

The patient had gained 300 grams over approximately 21 days. This is not appropriate weight gain for an infant. The patient had been followed by their pediatrician with instructions given on formula mixing as well as weight checks in an outpatient setting. As the patient failed outpatient nutritional therapy, as noted by the poor weight gain, the patient was admitted to inpatient medical stay for assessment of social, physiological, and genetic sources for the poor weight gain.

Yes, the Inpatient admission was medically necessary.
The patient had failed outpatient weight therapy, as demonstrated by the 300 gram weight gain in approximately 21 days. Therefore, the patient required close assessment for the cause of the failure to thrive. The patient's twin sibling was gaining weight well. The patient had no change in stool or urine output. There was no inconsolable crying, no excessive spit ups, no other noted symptoms of concern. An inpatient admission is required to assess social, physical and mechanical possibilities of why the patient was not gaining weight. Parental roles as well as physiological causes need to be evaluated closely. As such, and as the outpatient treatment plan failed, an inpatient admission was medically necessary. Especially considering the patient's age, it is medical necessary for the patient to receive an inpatient medical work up to assess their failure to thrive.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient did require an inpatient stay to ensure that they were receiving appropriate nutrition, that was prepared properly, as well as to ensure there is no underlying physiological reason for the poor weight gain.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: D8080 comprehensive orthodontic treatment of the adolescent dentition, D8670 periodic orthodontic treatment visits. 

The insurer denied coverage for D8080 comprehensive orthodontic treatment of the adolescent dentition, D8670 periodic orthodontic treatment visits. 

The denial is overturned. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss (mandibular left canine) in addition to other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of cross bite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index attaining 18 points by internal review when 26 points are required for approval. The orthodontist is appealing on behalf of the patient. 

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

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 D8080 comprehensive orthodontic treatment of the adolescent dentition, D8670 periodic orthodontic treatment visits is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diverticulitis

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission 

The denial is overturned

This case involves a male with a past medical history significant for anxiety, type 2 diabetes mellitus, thyroid disease, and gastric sleeve surgery, who presented to the emergency department complaining of vomiting, diarrhea, and abdominal pain. He reported that his pain was a 5/10 (on a pain scale of 0-10) in the epigastric region around the umbilical area, was non-radiating, and associated with nausea and vomiting. He claimed to be unable to tolerate anything by mouth and reported soft/watery non-bloody diarrhea with flatus. He was sent to the emergency department by his surgeon and received treatment with ciprofloxacin, Zofran, oxycodone, and intravenous fluids. Imaging indicated the patient had diverticulitis whereupon he was admitted to the surgical unit for further management. He was seen by gastroenterology, who recommended nothing by mouth and empiric treatment with antibiotics. Laboratory testing noted low hematocrit at 37.2, A CT (computed tomography) scan of the abdomen/pelvis revealed diverticulitis, and possible colitis. He was evaluated by General Surgery who determined that the patient required inpatient management for Acute Diverticulitis requiring IV (intravenous) antibiotics and IV hydration. The patient was started on ciprofloxacin and Flagyl in the emergency department with endoscopy and colonoscopy both advised. His diet was slowly advanced as tolerated with bariatric clear liquid. He was able to ambulate, urinate, and maintain pain control. Laboratory testing noted abnormal hemoglobin, hematocrit, and an abnormal red blood cell count. He had elevated urine nitrates and an increased urine specific gravity. With no other acute complaints, he was discharged with oral antibiotics and instructions to follow-up with bariatric surgery.  

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. A full hospital admission was considered medically necessary for this patient.

Based on the record, the patient was NPO (nothing to be given orally status) and required intravenous (IV) antibiotics. Such patients with acute diverticulitis are managed as an inpatient. 

Based upon the provided information, it was determined that the patient received appropriate care given that there was a chance that operative intervention would be required. He needed treatment that was not appropriate to be performed at a lower level of care.  

The insurer's denial of coverage for a full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Diabetes, heart disease, heart failure, hypertension, hyperlipidemia, osteoarthritis, benign prostatic hypertrophy (BPH), and glaucoma
Treatment: Consumer Direct Personal Aide Service (CDPAS) 7 days x 12 hours x 2 shifts 
The insurer denied coverage for CDPAS 7 days x 12 hours x 2 shifts
The denial is overturned in part

The patient is of advanced age and has chronic medical problems including diabetes, heart disease and glaucoma. He lives alone in a private residence. The caregiver is his grandson. Under review is the requested increase CDPAS 7 days x 12 hours x 2 shifts. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is described as "minimally impaired." He refuses to use his Personal Emergency Response System (PERS). However, he is "able to call his daughter in case of emergency." The patient requires extensive assistance for bathing/dressing and limited assistance for personal hygiene. He is independent for toilet transfers and limited assistance for toilet use. He is frequently incontinent of bladder and infrequent of bowel. The patient is independent with bed mobility and transfers. He is able to ambulate with a cane. His gait is unsteady, and he has fallen several times. He was hospitalized after a recent fall. He currently has CDPAS 53 hours/week. The combination of the patient's modest cognitive deficits, and modified independence with functional mobility do not support the medical necessity of the requested CDPAS increase 7 days x 12 hours x 2 shifts. However, his recent functional status decline and multiple falls which included Emergency Room visits and hospitalization, support an increase CDPAS to 84 hours (12 hours/day, 7 days/week); allowing the patient the ability to continue living safely at home. 

The healthcare plan acted reasonably in part. From a physical medicine and rehabilitation perspective, the requested CDPAS 7 days x 12 hours X 2 shifts, is not medically necessary. However, a CDPAS increase to 84 hours (12 hours/day, 7 days/week) is medically necessary. 

The insurer's denial of coverage for Consumer Direct Personal Aide Service (CDPAS) 7 days x 12 hours x 2 shifts is modified. Medical Necessity is not substantiated for 12-hour split shift/7 days a week. However, 12 hours/day 7 days a week is medically necessary.

The insurer's denial of coverage for Consumer Direct Personal Aide Service (CDPAS) 7 days x 12 hours x 2 shifts is modified as noted above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, ventral hernia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) at the request of her doctor for hernia surgery. Her complaint was that of abdominal pain and vomiting of one-week's duration. The records document that she had chronic comorbid diseases of diabetes, hyperlipidemia, and hypertension. She also had a history of prior gastric bypass surgery. At the time of ED presentation, the patient had normal vital signs. The white blood cell count was normal. She was found to have a periumbilical ventral hernia on the computed tomography (CT) scan that had been performed. The patient had normal vital signs.
She underwent a surgical procedure that included a laparoscopic ventral hernia repair with mesh and laparoscopic closure of a Petersen space defect (due to her gastric bypass anatomy). The surgical procedure was completed without complication. She was tolerating liquids and her vital signs were normal following surgery. The diet was advanced and the patient was discharged from the hospital.
At issue is the medical necessity of an inpatient stay.
An inpatient stay was not medically necessary as supported by the submitted medical records.  The patient presented to the hospital emergency department (ED) with the known diagnosis of a ventral hernia based on CT imaging that had been performed. She underwent surgery and the initial recovery was without complication. The care and treatment provided during this period of time could have reasonably been provided with a lower level of care than inpatient status.
The records document that this patient was clinically stable at the time of her ED presentation and remained stable during the period of monitoring. Surgery was performed without complication and her diet was advanced following surgery. Pain management was with oral medications. She was discharged home.
A lower level of care would have satisfied the clinical needs of this patient during this time. She was clinically stable at the time of presentation, had an uncomplicated surgical procedure and had an uncomplicated initial recovery. Additionally, her chronic pre-existing medical conditions (diabetes, hyperlipidemia, and hypertension) did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Broken crown. 
Treatment: D2750 White Glass with High Gold Content Crown, Tooth #3. 

The insurer denied the D2750 White Glass with High Gold Content Crown, Tooth #3. 
The denial is upheld. 

The patient is a female. She had an existing crown on tooth #3. She stated it had fallen out and was "temporarily" cemented back in place, but that it has fallen out again. The patient states the inside of the crown is "damaged" and cuts her tongue. 

The health plan denied coverage of a crown, because no decay was seen on the x-ray of the tooth. This denial is being appealed. 

No, the D2750 white glass with high gold content crown, tooth #3, is not medically necessary. 
The x-ray shows the crown on tooth #3, which is not evidenced to have recurrent decay under it. 

Based upon the one x-ray presented, no recurrent decay is seen in the tooth under the existing crown. The standard of care would be to re-cement with "permanent" cement, not temporarily as it was in this patient's case. With no decay showing, there is no medical necessity for a new crown. 

In regards to the crown being "damaged" and cutting the patient's tongue and jaw, there is no photo evidence of this showing anything wrong with the original crown, and it can not be seen on the x-ray presented. A photo showing the damage would help to ascertain if a new crown is needed, but that was not presented. There is no medical necessity for a new crown based upon documentation provided. 

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

Diagnosis: GERD
Treatment: LINX Procedure
The insurer denied the LINX Procedure.
The determination is upheld.

The patient has a body mass index (BMI) of 31 kilograms per square meter (kg/m2) with long-standing gastroesophageal reflux disease (GERD) refractory to medication. A 24 hour potential hydrogen (pH) study revealed an elevated DeMeester score consistent with GERD. An upper gastrointestinal (UGI) series revealed a small hiatal hernia, reflux to the level of the clavicles and findings of gastroparesis. An esophagogastroduodenoscopy (EGD) revealed no evidence of Barrett's esophagus. Esophageal manometry was normal. The patient has not had gastric surgery but did have a median arcuate ligament repair. A recommendation was made for a gastric emptying study.
At issue is whether the LINX procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Although this patient has history of GERD and diagnostic findings consistent with GERD, this patient is also reported to have findings consistent with gastroparesis. A recommendation was made for a gastric emptying study, however, the report has not been provided for review. Gastroparesis, alone, can promote GERD. The severity of gastroparesis should be evaluated before consideration can be made regarding the appropriateness of LINX treatment, which has not been formally studied in this setting.