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

Diagnosis: Infertility
Treatment: In Vitro Fertilization (IVF)
The insurer denied In Vitro Fertilization (IVF).
The health plan's determination is overturned. 

The patient is a woman who is undergoing infertility treatment. At issue is the medical necessity of in vitro fertilization (IVF) in the absence of prior IUI (intrauterine insemination) cycles in this clinical scenario.

The requested IVF is medically necessary for this patient. With unexplained infertility, Cochrane Reviews found that when comparing "IUI in a stimulated cycle versus TI (timed intercourse) or expectant management in a natural cycle... There was no evidence of a difference in live birth rate between the two treatment groups. The evidence suggested that if the chance of a live birth in TI or expectant management in a natural cycle was assumed to be 24% [percent], the chance of a live birth in IUI in a stimulated cycle would be between 12% and 32%." Thus, making a requirement of IUI prior to IVF is not medically reasonable nor prudent.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Organic oligospermia, Infertility 
Treatment: Flow Cytometry
The insurer denied the request for flow cytometry.
The health plan's determination is overturned.

The patient is a male who is undergoing fertility evaluation with his partner.
At issue is the medical necessity of flow cytometry.

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

The requested health service/treatment of flow cytometry, to determine deoxyribonucleic acid (DNA) fragmentation of the sperm is medically necessary for the patient. Flow cytometry can provide valuable information when deciding whether intrauterine insemination (IUI) is a reasonable option for their treatment of infertility or if they pursue in vitro fertilization (IVF), whether Intracytoplasmic sperm injection (ICSI) is best used as compared to standard insemination.

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

Diagnosis: mononucleosis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld
 
Patient is a teenager with past medical history significant for depression who presented to the emergency department with complaints of neck pain and dehydration.

Vitals on presentation included: Temperature-102.6.3 degrees F (Fahrenheit), Blood Pressure - 95/75, Pulse-111, Respirations -19, oxygen saturation 97% on room air.  Laboratory values were notable for the following: white blood cells (WBC)-9.68, Hemoglobin (Hgb)-14.1, Hematocrit (Hct)-43.8, glucose-95, creatinine-0.7, erythrocyte sedimentation rate (ESR)-21, C reactive protein (CRP)-7.7

Patient was empirically started on intravenous antibiotics and Decadron. She tested positive for rapid Monospot. She was given pain medications which improved her symptoms. She received intravenous hydration, remained afebrile, hemodynamically stable, and clinically improved. She was discharged to outpatient management. 

According to documentation, patient presented with upper respiratory illness-like symptoms. Otherwise, patient was hemodynamically stable with unremarkable laboratory results including a normal WBC. She tested positive for infectious mononucleosis. Patient had no evidence of serious complications of mononucleosis. Based on above findings, patient met criteria of observation level of management. Patient did not meet criteria for acute inpatient admission. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Vertebrogenic Low Back Pain
Treatment: Pain Management Services /Ablation, 3 Units 
(Intracept procedure)
The insurer denied: Pain Management Services /Ablation, 3 Units (Intracept procedure)
The denial is Overturned

The patient is an adult female. Per the appeals letter, the patient has a history of chronic low back pain due to degenerative disc disease that resulted in development of vertebrogenic pain identified by degenerative endplate changes. The patient has pain as well as failed treatment for greater than six months. Prior treatments include epidural steroid injections, medication management and physical therapy. The patient's pain is rated as 7-10/10. Four months ago, the patient was noted to have presented with low back pain that is 7/10. The pain is not radicular in nature. Axial pain is dull and aggravated with prolong standing or sitting. Prior treatments include medication as well as physical therapy. Exam of patient's lumbar spine was positive for facet loading on the right. The health plan's denial of coverage noted that the procedure is investigational. The denial is being appealed.

The health plan should cover the Intracept procedure.

Based on the documentation provided, the requested procedure is considered medically appropriate in this case. The patient has a history of chronic low back pain and despite prior conservative treatments including medication, activity modification, physical therapy and epidural steroid injections, the patient continues to be symptomatic. The patient has reproducible findings on exam, 
as well as on imaging. MRI (magnetic resonance imaging) shows Modic type two changes. The requested procedure is FDA (United States Food and Drug Administration) approved for such findings.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Vertebrogenic Low Back Pain
Treatment: Pain Management Services /Ablation, 3 Units 
(Intracept procedure)
The insurer denied: Pain Management Services /Ablation, 3 Units (Intracept procedure)
The denial is Upheld

The patient is an adult female with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as 
experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections. The patient has failed multiple medications. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury.

The health plan should not cover the Intracept procedure.

The requested Intracept procedure is not medically appropriate. The patient is an adult female with chronic low back pain in whom an intercept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections. The patient has failed multiple medications. MRI (magnetic resonance imaging) shows Modic changes. Physical 
exam does not reveal any neurological injury. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the 
treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. It has been shown effective in RCT (randomized controlled trials) with 5-year results. However, the patient in this case has not failed or attempted Facet interventions or sacroiliac joint injections, which are common treatments of axial low back pain. The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives sacroiliac injections do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of seizure disorder, hypertension, and diabetes. They presented to the emergency room after suffering two witnessed seizures. The vital signs were remarkable for a pulse of 120 beats per minute (bpm). The patient was in no acute distress and did not appear ill or toxic. The patient was disoriented on neurologic exam.

The laboratory evaluation was notable for a white blood cell (WBC) count of 11,700, a glucose of 382, a creatine phosphokinase (CPK) of 268, a lactate of 8.10, and positive swab for Influenza A. There were no acute intracranial abnormalities on the head computed tomography (CT) scan. The magnetic resonance imaging (MRI) of the brain did not show any acute ischemic infarcts or hemorrhage. The portable chest x-ray showed right mid-lung consolidation, either atelectasis or infiltrate. The electrocardiogram (EKG) showed ST elevations in lead III. The patient was admitted for further treatment and evaluation.

Upon admission to a monitored bed, the patient was treated with intravenous antibiotics, oral medications, and long-acting insulin. The following day, the neurologist evaluated the patient and recommended continuing Keppra. The cardiologist also evaluated the patient, and noted the patient did not have acute coronary syndrome. An electroencephalogram (EEG) was normal. The remainder of the stay was clinically uneventful, and the patient was discharged in stable condition. At issue is the medical necessity of the inpatient stay.

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

The requested health service/treatment of inpatient hospital services was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. 

There was no hemodynamic instability, persistent mental status changes, severe metabolic disarray, or objective evidence of meningitis. There were no further episodes of syncope or seizures, and an acute coronary syndrome was ruled out. The services provided - intravenous antibiotics, oral medications, and insulin - were not at the acute inpatient level of intensity. 

Therefore, based on the standard of care, as well as the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: broken femoral ischemic monomelic neuropathy (IMN)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

According to the documentation submitted, this is the case of a patient with a history of closed fracture of the humerus shaft, restless leg syndrome, and hypertension. The patient presented to the emergency department (ED) with left thigh pain, broken femoral ischemic monomelic neuropathy (IMN). The patient was indicated for operative management. The patient was admitted to Orthopedic services and underwent repair of the left femur nonunion and removal of antibiotic spacer. Physical therapy (PT) services were initiated. 

The medical record shows a complex and unique operation was performed. There were several steps which had to be completed. This person was found to have a nonunion to femur.  The physician removed spacers and placed a bone graft. He harvested the bone graft from the iliac crest (hip area). He harvested bone graft from the left tibia. This consisted of surgical incision at proximal tibia with placement of reamer to harvest graft.  

The surgical sites were thus left femur, left tibia, and left iliac crest. There would be risk of bleeding. There would be anticipated problems with rehabilitation and mobilization. The multiple operations would be expected to be painful and require intravenous (IV) analgesia. This type of operation is not performed in an ambulatory setting or lower level of service. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bilateral hip pain.
Treatment:  12 outpatient physical therapy (PT) visits.

The insurer denied coverage for 12 outpatient physical therapy (PT) visits.  The denial is overturned.

The patient is an adult with bilateral hip pain.  Treatment included hip joint injections, analgesic medications and physical therapy.  The treating physician requested 12 physical therapy sessions, and the insurer approved 8 sessions; the denied 4 physical therapy sessions are under review.

This patient has well documented bilateral hip pain that has been modestly relieved by joint injections and analgesic medications.  He is not yet a candidate for hip replacement, and his treating orthopedic surgeon wishes to delay any surgical intervention.  A note documents the patient's improvement as a result of the physical therapy.  In addition, the provision of 12 physical therapy sessions for the conservative treatment of this patient's condition is reasonable, clinically appropriate and medically necessary.  If no further progress is noted after the 12 visits; subsequent physical therapy would not be indicated.  The patient should also be independent with a home exercise program by that time.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 12 outpatient physical therapy (PT) visits is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status Post (s/p) Brain Injury
Treatment: Continued Rehabilitation Facility admission
The insurer denied Continued Rehabilitation Facility admission.
The denial is upheld.

The patient is a young adult male with history of motor vehicle accident 4 months ago, where he sustained traumatic brain injury (TBI) with intraparenchymal hemorrhage, interventricular hemorrhage and sub-arachnoid hemorrhage. The patient was admitted into the ICU (intensive care unit) and had tracheostomy and also ventilator. He was extubated 3 months ago. The patient's admission was associated with disability, decreased balance and memory issues. The memory issues were concerning for his safety at home. The patient was transferred to the acute inpatient rehabilitation 3 months ago and discharged 12 days later. Prior to admission, the patient was independent, employed, and living with his parents in a primary home with two steps to enter.
As the date of discharge, the patient was independent with most ADLs (activities of daily living), able to ambulate 150 feet independently without assistive device, able to navigate 12 steps without rails and mild balance deficits, etc. He had no ongoing clinical issues.
The health plan denied coverage for the last 2 days of admission, when he was discharged, as not medically necessary. The denial is being appealed.

The Continued Rehabilitation Facility admission was not medically necessary.

The continued stay in an acute inpatient rehabilitation facility was not medically necessary according to InterQual 2022 criteria for Acute inpatient rehabilitation. As of the dates in question, the patient was independent with most ADLs (activities of daily living), able to ambulate 150 feet independently without assistive device, able to navigate 12 steps without rails and mild balance deficits, etc. He had no ongoing clinical issues. There was no clinical or rehabilitation need basis as of the dates in question for continued stay in an acute inpatient rehabilitation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered mental status, human immunodeficiency virus (HIV), high blood pressure, hyperlipidemia, diabetes mellitus, bowel and bladder incontinence
Treatment: Room and Board in Skilled Nursing Facility
The insurer denied: Room and Board in Skilled Nursing Facility
The denial is upheld

The member is an adult female with history of general debility with altered mental state. She was admitted to a skilled nursing facility (SNF). Relevant past medical history includes human immunodeficiency virus (HIV), hypertension, hypersensitivity lung disease, diabetes mellitus, bladder/bowel incontinence, depression, and temporal lobe epilepsy.  The member is clinically stable. Prior to admission, the member was living with her son-in-law in a two- bedroom apartment on the second floor of a building without elevator access with two (2) steps into the building and twenty (20) steps up to the apartment. She is able to receive personal care worker (PCW) services five (5) hours a day, seven (7) days a week. The member was admitted to the skilled nursing facility (SNF) 6 weeks earlier and is now ambulating 150 feet using a rolling walker; she required supervision with transfer, stand-by assistance for toileting and contact-guard assistance with stairs. She will continue to receive personal care worker (PCW) services five (5) hours a day, seven (7) days a week as previously noted.
The denial of a continued skilled nursing facility (SNF) stay was based on the member not meeting medical necessity for a continued stay.

The proposed skilled nursing facility (SNF) stay is not medically necessary.

The proposed stay in a skilled nursing facility (SNF) is not medically necessary due to the member's current state of activity. The member is ambulating 150 feet using a rolling walker; she requires supervision with transfer, stand-by assistance for toileting and contact-guard assistance with stairs. She will continue to receive personal care worker (PCW) services five (5) hours a day, seven (7) days a week.
The reason for request for a continued stay is her lack of independent ability to navigate 20 steps up into her apartment, but she is able to do this with contact-guard assistance. Therefore, she would be able to do this with family members present or the health aide when present. For this reason, a continued stay in a skilled nursing facility (SNF) is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Narcolepsy
Treatment: Xywav
The insurer denied coverage for Xywav
The denial is upheld

The patient is a teenager who was diagnosed with narcolepsy and cataplexy. The patient's other past medical history includes anxiety, depression, mononucleosis, and difficulty sleeping. The patient also complains of headaches, snoring, frequent awakenings along with sleep paralysis and insomnia.

The patient had an evaluation during which she had an overnight polysomnogram (PSG) followed by a multiple sleep latency test (MSLT).

As per the results of the MSLT
There were 5 naps. (SLT = sleep latency test )
1st Nap   SLT  10min (minutes) 12sec (seconds)
2nd Nap  SLT    8 min18sec
3rd Nap   SLT    8min 06 sec
4th Nap   SLT 14min 48 sec
5th Nap   SLT   8min 36 sec

None of the individual tests showed a sleep latency of 8 minutes or less. The average MSLT was 10 min.

Based on the above results the diagnosis of narcolepsy is not established. Hence Xywav is not considered to be medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Xywav is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis 
Treatment: Avsola 100 milligrams (mg) vial every 4 weeks
The insurer denied coverage for Avsola 100 mg vial every 4 weeks.
The denial is overturned.

The patient has severe ulcerative colitis. The patient had been on infliximab (Avsola) every 8 weeks, but continued to have symptoms. lnfliximab levels were low and the antibody level was low. The infliximab dose was increased to every 4 weeks. The patient has improved on this dose, but the insurance company is now refusing to approve continuing the dose at every 4 weeks intervals. 

The American Journal of Gastroenterology has an article titled "Clinical utility of measuring infliximab and human anti-chimeric concentrations in patients with inflammatory bowel disease." The conclusion was that measuring infliximab concentrations and antibody levels is clinically useful. Increasing the drug dose may be a good strategy if infliximab levels are subtherapeutic.

Clinical Gastroenterology and Hepatology has an article titled "Appropriate Therapeutic Monitoring of Biologic Agents for Patients with Inflammatory Bowel Disease." The conclusion states that consensus was achieved towards the utility of therapeutic drug monitoring of biologics in irritable bowel disease, particularly anti-TNF (Tumor necrosis factor) therapy. For anti-TNF therapies, proactive therapeutic drug monitoring was found to be appropriate after induction and at least once during maintenance therapy. 

This patient has active ulcerative colitis and low infliximab levels. Obtaining therapeutic drug monitoring along with dose escalation for anti-TNF agents is supported in the peer reviewed medical literature. In view of the presence of active disease on the longer interval and the low therapeutic drug levels, it is appropriate to shorten the dose interval of Avsola to every 4 weeks for this patient. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for Avsola 100 milligrams (mg) vial every 4 weeks is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lung Cancer.
Treatment:  Chemotherapy Regimen - Tecentriq with etoposide and carboplatin (AR2597020- New Century Health Regimen).
The insurer denied Chemotherapy Regimen - Tecentriq with etoposide and carboplatin (AR2597020- New Century Health Regimen).  
The denial is upheld.

The patient is an adult female. She was diagnosed with non-small cell lung cancer. She was found to have a large right lower lobe mass extending to the right hilum. Biopsy was done and revealed small cell lung cancer. She had a pleural effusion with evidence of hyper metabolic uptake. Treatment with carboplatin, etoposide and Tecentriq was recommended. She started this treatment 4 months ago. Cycle 4 of this regimen was given last month. She was supposed to have imaging done before her next visit, but that was not done. She was seen 2 weeks ago, and treatment with carboplatin, etoposide and Tecentriq was continued. Records note that symptomatically she had improved. She was treated with cycle 5 of carboplatin, etoposide and Tecentriq 2 weeks ago and was planned for one additional cycle. Cycles 5 and 6 are in question.

The requested health service is not medically necessary.

The combination of carboplatin, etoposide and Tecentriq is a standard combination of drugs for treatment of extensive small cell lung cancer. However, it is only standard to give this combination for 4 cycles. Following that, both published clinical trial evidence and NCCN (National Comprehensive Cancer Network) guidelines support changing treatment to Tecentriq alone. There is no evidence showing that continuing carboplatin and etoposide along with Tecentriq for two additional cycles can improve health outcomes. NCCN (National Comprehensive Cancer Network) guidelines do not endorse this as a standard form of treatment. Continued treatment with two more cycles of carboplatin, etoposide and Tecentriq is not medically necessary.