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

Diagnosis: Family history of cancer
Treatment: Guideline Based Hereditary Cancer Panel
The insurer denied Guideline Based Hereditary Cancer Panel.
The health plan's determination is overturned.

The patient is a female who presented to her gynecologist with a significant family history for colon and ovarian cancer. Her family history included colon cancer in her mother, maternal grandfather, maternal uncle, two maternal aunts, and a maternal cousin. She also had two great aunts on her mother's side with ovarian cancer. Guideline Based Hereditary Cancer Panel was ordered and is under review.

There are three questions to be answered when considering if a genetic test is appropriate. First, one must decide if the test is indicated by the family history. For this patient, her family history is dramatic and shows a clear need for genetic investigation. She far exceeds the demands of the customary Amsterdam criteria that address colon cancer. Those criteria recommend testing for just two family members in two different generations - she has six family members. The second question is to assure the testing would change something for the patient's risk of cancer in the future. In this case, the interest would be in germline mutations leading to Lynch syndrome - a condition posing high risk for colon and ovarian cancer. If diagnosed with Lynch syndrome, the patient would be scheduled for much more frequent colonoscopy, and since she is menopausal, likely have both ovaries removed. The testing would clearly change management to have a positive effect on her.

Finally, the clinician must assess if the testing is the best option available. In this case, there is a growing body of evidence that the next generation sequencing technology is far superior to the older directed genetic testing. Therefore, the Guideline Based Hereditary Cancer Panel is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Family history of cancer
Treatment: Guideline Based Hereditary Cancer Panel
The insurer denied Guideline Based Hereditary Cancer Panel.
The health plan's determination is upheld.

The patient is a  female with a family history of colon and ovarian cancer. Her significant (1st or 2nd degree) family history includes a mother with colon cancer, maternal grandfather with colon cancer, a maternal uncle with colon cancer and 2 maternal aunts with colon cancer. The ovarian cancer is a distant relative and not a first or second degree relative. She was tested for the Guideline Cancer panel and this is under review.

The proposed Guideline Based Hereditary Cancer Panel is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has a maternal family history of colon cancer. This test is utilized primarily by a person with a personal history of cancer who have tested negative for a single gene or syndrome, but who's personal or family history remains strongly suggestive of an inherited susceptibility. It can also be utilized for a family history of several different types of cancer that do not seem to fit a particular hereditary cancer syndrome. This patient does not have a personal history of cancer, has not been tested for specific genes regarding her family history of colon cancer and does not have several/various types of cancers in her family. It would be beneficial and standard of care to test her maternal relatives with colon cancer if possible, for specific colon cancer gene mutations first. Therefore, the requested testing is not likely to be more beneficial than standard treatment in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Family history of cancer
Treatment: Guideline Based Hereditary Cancer Panel
The insurer denied Guideline Based Hereditary Cancer Panel.
The health plan's determination is upheld.

The patient is a female with a family history of colon and ovarian cancer who was recommended to undergo hereditary cancer genetic testing using a broad panel. Under review is the use of Guideline Based Hereditary Cancer Panel testing. 

The proposed Guideline Based Hereditary Cancer Panel is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. There is no data to show that the recommended panel testing is superior to standard testing. This testing platform is not supported by peer reviewed literature to be associated with improved health outcomes compared to standard of care testing. There is no data to show that use of this test carries any clinical utility or benefit and there is evidence that this type of testing may actually carry clinical harm.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left distal humerus fracture.
Treatment: Inpatient Stay.
The insurer denied the Inpatient Stay.
The determination is upheld.

The patient was diagnosed with a left distal humerus fracture. The patient presented to the emergency department after a slip and fall resulting in a midshaft humerus fracture five days prior to presentation. The patient had been seen at another emergency department and was placed in a cast and sent home on pain medication. The patient did well until one day prior to presentation when the pain increased. The fracture could not be effectively immobilized in a brace because it was too distal. The documentation indicates that there was displacement of the distal humerus fracture. The patient underwent open reduction internal fixation of the left distal third humeral shaft fracture with application of a long arm splint.
At issue is the medical necessity of an inpatient stay.

No. The inpatient stay was not medically necessary. 

The documentation indicates that the patient was diagnosed with a displaced midshaft humerus fracture but was otherwise in stable condition. The open reduction internal fixation was performed. A clinical note from the next day states that the patient felt lightheaded during morning rounds. The blood pressure was measured at 70/35. A 10 milliliter (mL)/kilogram intravenous (IV) normal saline (NS) bolus was administered, and the blood pressure normalized to 109/65. The patient reported feeling much better afterward. The documentation does not suggest that there was an acute clinical scenario that required the inpatient level of care versus treatment at a lower level of care. Based on the available information, the inpatient stay was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.  

At the time of service the patient was a female who was discharged from the Neonatal Intensive-Care Unit (NICU) 1-2 days prior. She presented to the emergency department (ED) after an episode of choking with apnea. The patient has a history of apnea and difficulty with oral intake while in the NICU. At home, the mother was administering iron and multivitamin (MVI) drops by mouth when the patient had choking, cyanosis, and loss of tone. Mother performed cardiopulmonary resuscitation (CPR) at home. Emergency Medical Services (EMS) was called and transported the patient to the ED.
ED vitals were: temperature (T) 36.8 Celsius (C), heart rate (HR) 160, respiratory rate (RR) 38, oxygen (O2) saturation 98% on room air, weight 5 pounds (lbs.). Exam showed an alert, active infant with good suck reflex and Moro. Respiratory exam was normal, an umbilical hernia and supernumerary digit on the left hand were noted, in addition to a left preauricular pit.
Respiratory syncytial virus (RSV), flu, and coronavirus disease 2019 testing was negative.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

The requested inpatient hospitalization was considered medically necessary. This patient presented to the ED just days after NICU discharge after having a choking episode at home with associated cyanosis and body stiffness. Although baby's condition had returned to baseline upon arrival to the ED, this baby's history and risk factors make inpatient hospitalization medically necessary. According to the American Academy of Pediatrics (AAP) Guidelines for BRUE (brief resolved unexplained episode), this infant fit criteria for higher risk episode given age and former preemie. Thus, given the higher likelihood of underlying medical condition or abnormality, full inpatient hospitalization was necessary for further monitoring and medical evaluation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.
Treatment: Inpatient admission. 
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This patient presented to the hospital complaining of chest pain. He noted that his pain was so severe that he wanted to jump out of a window. There were no associated symptoms accompanying his chest pain. Past medical history was relevant for coronary artery disease, a LAD (left anterior descending) stent, hypertension, atrial fibrillation, EtOH (ethanol alcohol) abuse and seizures. Upon arrival his vital signs were stable (pulse 94bpm (beats per minute), BP (blood pressure) was 130/87mmHg (millimeters of mercury). His physical exam was significant for chest tenderness with palpation of sternum. Serum blood testing demonstrated no elevation in high sensitivity troponin (peak 4.3ng (nanograms)/L (liters), normal range 0-35) an ECG (electrocardiogram) demonstrated normal sinus rhythm with premature atrial beats and no ST (interval on a (electrocardiogram) or T wave (interval on a (electrocardiogram) abnormalities. The patient was admitted to the hospital for monitoring and treatment. Acute coronary syndrome was ruled out and the patient was discharged on medical therapy.

This patient presented with atypical chest pain and no significant past medical history. Her pretest probability of coronary artery disease is high. (Reference 1) Utilizing the HEART (history, ecg, age, risk factors, troponin) score he was considered low risk. (Reference 2) Utilizing the TIMI (thrombolysis in myocardial infarction) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1). (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST (interval on an electrocardiogram) changes on an ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left lower extremity cellulitis.

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission. 

The denial is upheld.

The patient presented to the emergency room with complaints of a left ankle abscess. She had received oral doxycycline on an outpatient basis, reportedly without improvement. The infection began from injuring her ankle from her shoe rubbing against the foot. It had progressed despite the antibiotic and foot soaks at home. On examination, she had a 1 centimeter wound on the lateral aspect of her left ankle, which was non-fluctuant, but there was edema and tenderness, with minimal decrease in range of motion.

She was admitted with a diagnosis of left lower extremity cellulitis, and received intravenous (IV) cefazolin with Tylenol as needed for pain. She was non-toxic and hemodynamically stable. She was discharged home on oral cephalexin as the culture yielded Staph. aureus.

The reviewer agrees with the insurer that she could have been safely treated at an observational level. There was no evidence of an abscess on sonogram. A brief period of observation on IV antibiotics was all that was necessary to ensure there was no progression of the infection. Moreover, there is no documented Medical Decision Making to justify an inpatient level of care. The evidence for management at this level of medical care is described in the review and in the guideline below.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures and depression. 
Treatment: Long term care placement in a nursing home. 

The insurer denied coverage for long term care placement in a nursing home. 

The denial is upheld. 
 
This is a female with history of seizures and depression. She was admitted to a nursing home following a hospitalization. Under review is the medical necessity for long term care placement in a nursing home. 

The patient is medically stable, and care is primarily custodial. Long term care placement is not medically necessary, as services can be provided at a lower level of care (example: home with custodial home health aide services). According to the therapy notes, the patient is primarily at the supervision to stand by assistance level for routine activities of daily living. She is otherwise medically stable and does not have complicated nursing issues that require inpatient physician monitoring or skilled nursing services, respectively. She is able to ambulate with a walker. The patient was eventually discharged home. 

From a physical medicine and rehabilitation perspective, long term care placement in a nursing home, was not medically necessary. 

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

The insurer's denial of coverage for long term care placement in a nursing home is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genetic Diseases. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied L-Methylfolate Calcium 7.5 milligrams (MG) Tablet. 
The denial is upheld. 

The patient is a female with a past medical history of generalized anxiety disorder and post traumatic disorder who was prescribed levomefolate calcium (L-methylfolate) 7.5 milligrams (mg) daily. The insurer sent initial adverse determination denial notice stating coverage for L-methylfolate 7.5 mg as not medically necessary. The insurer sent final adverse determination denial notice denying request to approve coverage of L-methylfolate 7.5 mg daily stating the medication was nonformulary and the patient must try and fail two formulary alternatives; Elfolate or Folic acid. The insurer sent final adverse determination denial notice continuing to deny coverage of L-methylfolate. The patient appealed the denial decision. The patient's provided appeal of denial decision with comment from the provider that patient required L-methylfolate due to having a heterozygous polymorphism in the methylenetetrahydrofolate reductase (MTHFR) mutation at C6TTT gene, which causes reduced ability to convert folic acid to L-methylfolate a precursor to endogenous production of serotonin, dopamine, and norepinephrine.
At issue is the medical necessity of L-Methylfolate Calcium 7.5 milligrams (MG) Tablet.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of L-Methylfolate Calcium 7.5 MG Tablet is not medically necessary for this patient.
The health plan denied coverage of L-methylfolate as the patient had not tried preferred generic alternatives of elfolate and folic acid. Folic acid may not be as effective as L-methylfolate but there is no documentation that the patient tried and failed Folic acid. Elfolate is a brand of L-methylfolate and there is the same dose of 7.5 MG available. There is no documentation that the patient has tried and failed or had intolerance to Elfolate which is an equivalent to L-methylfolate and is used to treat mental health conditions in those with MTHFR gene mutations.
Therefore, the requested health service/treatment of L-Methylfolate Calcium 7.5 MG Tablet is not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Constipation.
Treatment:  Motegrity.

The insurer denied coverage for Motegrity.  The denial is overturned.

The patient is reported to have severe constipation. The letter from the physician's office states that she has already tried and failed Linzess, Trulance, and Amitiza. She was given samples of Motegrity and had a good response. Her physician is now requesting approval for Motegrity. 

UpToDate has an article titled "Management of chronic constipation in adults." The article discusses pharmacological therapy. It states that prucalopride is an SHT (receptor agonist) prokinetic agent that has been shown to be superior to a placebo and well tolerated for the treatment of constipation. The improvement in quality-of-life scores was maintained up to 18 months. It has FDA (Food and Drug Administration) approval for the treatment of chronic idiopathic constipation in adults.

There are several approved drugs for the management of chronic idiopathic constipation. These include linaclotide, plecanatide, Jubiprostone, and prucalopride. However, the physician's letter states that the patient has already failed Linzess, Trulance, and Amitiza. The formulary agents have already been tried and failed. Although there was no adverse reaction reported with the formulary agents, they were not successful in improving the constipation. The prucalopride has been reported to be more effective than her previous medications. Giving this patient Motegrity is appropriate.

The insurer's denial of coverage for Formulary Exception for Motegrity is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke 

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld 

This case involves a female who presented to the hospital with complaints of double vision and left eye droop. She had a history of hyperlipidemia and hypertension. The evaluation of the patient noted a left medial gaze palsy, horizontal diplopia, and left ptosis. The patient was admitted to the stroke unit for posterior ischemic stroke versus cranial nerve III palsy versus intracranial pathology. 
Per the MCG (Milliman Care Guideline), admission is recommended for transient ischemic attack when there are findings of hemodynamic instability, focal neurological signs recur, findings on brain imaging that require inpatient care, altered mental status, cardiac arrhythmias of immediate concern, when a clinically significant cardiac or vascular disorder is identified that requires inpatient care, severe hypertension, prolonged cardiac telemetry monitoring is needed, suspected vasculitis, and with pregnancy. In this case, the patient presented to the hospital with complaints of double vision and left eye drooping. The evaluation noted left medial gaze palsy, horizontal diplopia, and left ptosis. The patient was admitted to the stroke unit for posterior ischemic stroke versus cranial nerve III palsy versus intracranial pathology. It was argued that full hospital admission was medically necessary for the patient. It was noted that the patient had acute onset double vision and left eye droop. There were concerns for vascular risk factors including age, postmenopausal state, hypertension, hyperlipidemia, and former smoker status. The neurology impression was partial left cranial nerve III palsy versus ocular myasthenia gravis. It was stated the neuro-checks were required more frequently than every 4 hours. However, the documentation did not reveal findings on brain imaging that required inpatient care, worsening focal neurological signs, altered mental status, cardiac arrhythmias of immediate concern, inpatient care to address significant cardiac or vascular disorder, severe hypertension that had not resolved, or suspected vasculitis. The patient's neurological status could have been monitored at a lower level of care. Thus, the denial of coverage for the full hospital admission was appropriate and is upheld.

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness Of Breath.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with diabetes, chronic respiratory failure due to severe pulmonary hypertension on supplemental oxygen, and diastolic heart failure. She presented to ER (emergency room) with dizziness.

The patient was admitted to acute in hospital level of care.  The patient was seen by cardiology, pulmonology and neurology for dizziness in the setting of severe pulmonary hypertension. The patient was discharged home with pulmonary hypertension medication optimization and supplemental oxygen.

This admission is denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

Yes, the Inpatient Admission was medically necessary.
This patient with severe pulmonary hypertension on multiple medications with worsening lightheadness and dizziness was admitted to acute in hospital level of care. The patient was seen by cardiology, pulmonary and neurology. Patient's lightheadedness was thought to be due to hypoxia and PAH (pulmonary arterial hypertension) medications. The acute inpatient level of care was medically necessary, since the patient had severe pulmonary hypertension as well as other chronic medical conditions that put patient at high risk for adverse outcomes if not evaluated and treated aggressively. The current standard of clinical practice is to admit the patient to the hospital rather than evaluate and treat at a lower level of care.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

Given the patient's signs and symptoms, it would not have been reasonable to expect significant improvement within 24 hours, as is what happened with the patient. The patient's treatment course would have been expected to require treatments or interventions that could not have been provided at a lower level of care. The treatment provided was reasonably expected to be provided at an intensity that required an acute inpatient level of care.