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

Diagnosis: Left temporal epitheliod glioblasroma

Treatment: Proton beam radiation therapy (PBRT)

The insurer is denied coverage for proton beam radiation therapy (PBRT). The denial is overturned. 

The patient is a male who per the consultation note was an ex-heavy smoker with a recent diagnosis of left temporal epithelioid glioblastoma status post left temporal craniotomy for resection of a tumor. The pathology was notable for epithelioid glioblastoma, WHO grade IV, IDH1-R132H wildtype, ATRX equivocal, BRAFV6 180 mutant, MIB1/Ki 67 up to 15%, EGFR amplification negative, MGM T methylation negative, NGS (foundation 1) pending. The post-operative MRI revealed possible residual disease along the superior and anterosuperior margins. The patient was in the office to discuss the role of RT.

The Letter of Medical Necessity indicated the patient had undergone a complete resection of the left temporal lobe epithelioid glioblastoma and required postoperative adjuvant radiation with concurrent Temodar, which provided him with modest, but measurable probability of achieving permanent disease-free survival and was likely to prolong his survival compared to treatment with surgery alone. In order to minimize the short and long-term toxicity of the high-dose radiation the provider believed there was a medical necessity for proton therapy in this patient's treatment regimen. Because of diminished dose to critical normal structures and the expected diminution in acute and long-term consequences of radiation, the provider opined it was medically necessary to utilize protons in the treatment of the young gentleman. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Proton beam radiation therapy (PBRT) is considered medically necessary for this patient.

Adeberg, et al. (2016) performed A dosimetric comparison of intensity modulated proton therapy, volumetric modulated art therapy, and 3-D conformal radio therapy in anaplastic
astrocytoma in glioblastoma. They found significant dose reduction to nearby critical structures including the pituitary gland, brain stem, hippocampus, and whole brain total dose as well as other structures.

More recently, Adeberg, et al. (2018) analyzed doses, comparing proton radiation therapy, volumetric modulated arc therapy, and 3-D conformal radiation based on five intracranial tumor locations. Cleo blastoma patients were included in this analysis. 

In conclusion, proton beam therapy is medically necessary in this case to reduce radiation dose to critical adjacent structures including the optic pathway and normal brain tissue.

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

The carrier's denial of coverage for proton beam radiation therapy (PBRT) is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Total Hip Replacement. 
Treatment:  Inpatient admission.
 
The insurer denied the inpatient admission.  The denial was upheld.

This is a male patient who had post traumatic left hip osteoarthritis.  He was admitted to hospital for an elective left total hip replacement.  He underwent the procedure with spinal anesthesia.  There were no intra operative nor post-surgical complications.  His post-operative pain was controlled with Dilaudid, Tylenol and Oxycodone.  Post operatively he had an episode of dizziness and blood pressure (BP) was 90/59.  He received a bolus of intravenous (IV) fluid and improved.  He was evaluated by physical therapy (PT) and discharged to home. 

The patient had a non-complicated intra-operative and post-surgical course.  He did have the episode of hypotension but responded well to the intravenous (IV) bolus of fluids.  He felt improved and was able to complete his PT.  He was able to walk 300 feet.  He was able to tolerate oral medications.  He did not require additional management, consultation nor diagnostic testing for the event.  He did not report other symptoms or problems. 

The physician record later in day, he was improved and ready for discharge.  No additional treatments were recommended nor provided.  There were no other conditions or factors present to substantiate an inpatient admission.   

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

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

Diagnosis:  Central nervous system/other.  
Treatment:  Inpatient hospital.

The insurer denied the inpatient hospital stay.  The denial is upheld in whole.

The patient is a male with an unremarkable past medical history, who presented to the emergency department with complaints of left-sided arm weakness and near syncope. 

No, the inpatient hospital stay was not medically necessary for this patient at the acute inpatient level of care.

There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at the lower level of care, rather than admission to an inpatient level of care.

This patient presented to the hospital with complaints of numbness and weakness in the left arm and face, as well as some lightheadedness and a near syncopal episode.  Evaluation of the ABCD2 Score for TIA was considered.  This is a risk-stratification tool that estimates the risk of stroke after a suspected transient ischemic attack (TIA).  Based on the calculations, the patient received four points.  This means that further imaging modalities, including MRI and carotid ultrasound, should have been considered, as well as neurology consultation, to help determine whether the patient would benefit from further inpatient evaluation or to expedite outpatient follow-up when appropriate.  This was what was done in this clinical situation.

However, in this clinical case, the patient had mildly decreased muscle strength in the left arm and leg, but these changes were transient and resolved very quickly.  The imaging studies did not reveal any clinically significant abnormalities that were acute and necessitated admission at the inpatient hospital level of care.  During the entire hospital stay, the patient remained afebrile and hemodynamically stable and had no evidence of arrhythmias of immediate concern.  The neurologic symptoms improved and never recurred during the entire hospitalization.

Taking into consideration all these facts, there was no evidence that either the severity of the patient's condition or the complexity of the services provided rose to the level of acute inpatient care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient was treated overnight for possible appendicitis. The patient initially presented to an outside emergency room (ER) where a computed tomography (CT) scan was performed which revealed appendicoliths and a question of acute appendicitis. The patient was then transferred to the treating hospital where the CT scan was re-read and the decision was made to "observe" the patient, per the treating physician, provide supportive care. By the next morning, the patient's symptoms had resolved and she was discharged. At issue is the medical necessity of an inpatient stay.

The inpatient level of care was not medically necessary. The patient did not meet criteria for an inpatient stay. Specifically this patient did not have a fever, she had no signs of sepsis or ongoing infection (e.g. a normal WBC), and no evidence of complicated or perforated appendicitis on CT scan, or any of the other criteria listed by InterQual/MGS as requiring inpatient stay. (1) The administration of pain medication or antibiotics does not meet the threshold for an inpatient level of care. Ongoing short term treatment, assessment, and reassessment could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute and chronic respiratory failure, asthma; acute kidney failure; atrial fibrillation

Treatment: Personal Care Assistance (PCA) services 24 hours a day, 7 days per week (live in or split shift), for a total of 168 hours per week

The insurer is denied coverage for  Personal Care Assistance (PCA) services 24 hours a day, 7 days per week (live in or split shift), for a total of 168 hours per week. The denial is upheld.

This is a male has an extensive medical history and has been residing in a rehab/nursing home facility following hospitalization. There are very limited medical records provided for review, including a few rehab progress notes and the UAS. It was noted in the insurer's denial letter that the patient was found unresponsive at home. The rehab notes indicate primary diagnosis was acute respiratory failure. No other details are available regarding hospitalization.

The UAS diagnosis list includes myotonic muscular dystrophy, chronic obstructive pulmonary disease (COPD), heart failure, respiratory failure. An appeal letter noted that the patient used oxygen at home (not clear if it was always used or prn). Prior to the hospital admission, the patient was living at home with the assistance of a personal care aide (PCA) 70 hours per week. According to the patient's brother, the patient was able to engage in social activities at home and outside the home. He used a scooter for mobility. His cognitive status appears to be in normal range with MMSE [mini mental status exam] score 28/30 noted in the insurer's denial letter, and no memory impairment noted in the UAS.

At this time, there is insufficient clinical information about the patient's current functional status for ADLs, which is needed to determine medical necessity for 24 hour PCA services. There is insufficient information to determine whether the patient needs one or two caregivers for safe transfers; and there is insufficient information to confirm 24 hour availability of one or more informal caregivers who will assist the PCA with a two person transfer, if the patient still needs two people for safe transfers.

Personal care services cannot be approved at this time. It is understood that the patient wants to return home and hopefully that is still possible if his medical condition is stable for discharge and a safe discharge plan can be developed for home care, which include a plan for safe transfers.

The health plan acted reasonably with sound medical judgment in the best interest of the patient. The need Personal Care Assistance services 24 hours per day, 7 days per week (live-in or split shift) is not substantiated to be medically necessary at this time.

Based on the above, Personal Care Assistance (PCA) services 24 hours a day, 7 days per week (live in or split shift), for a total of 168 hours per week is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral non-displaced mandibular fractures along with multiple lacerations

Treatment: Inpatient hospital services

The insurer is denied coverage for inpatient hospital services. The denial is upheld.

The patient is a male (M), ASA 1, who presented to the Emergency Department (ED) with bilateral non-displaced mandibular fractures (per imaging) as well as multiple lacerations. The patient was then evaluated and sent home. He was seen back for a post-operative visit was subsequently admitted to the facility and then scheduled for Open Reduction Internal Fixation (ORIF) of the fractures. During the admission, Operating Room (OR) time was not available, resulting in the discharge of the patient and re-scheduling of the patient at an outside facility.

Given the nature of the fractures (open, bilateral) administering antibiotics, due to increased risk of infection, and airway management are vital, especially in the pediatric population. High skilled nursing is required in order to properly care for patients in the acute fracture setting, especially in the event of an airway emergency. Severe bleeding, gross trismus, being unable to tolerate secretions, or a direct airway injury may increase risk for such an emergency. Lastly, providing adequate hydration while maintaining nothing by mouth (NPO) status are vital for the preoperative nourishment of a pediatric patient (www.uptodate.com/contents/mandibular-jawfractures-in-children).

After review of the chart and noting the patient was seen in the hospital on two different occasions without any acute needs and stable enough for discharge on both occasions, the medical necessity of this hospital admission is not substantiated. Per the provided documents representing admission the patient maintained stable vitals, was tolerating a soft/liquid diet, taking medications as directed, was not complaining of breakthrough pain, nor was there any described airway issue or worry for future airway events. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital services is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is upheld.

The patient is an elderly female with a past medical history significant for HTN (hypertension), diabetes, dyslipidemia, CAD (coronary artery disease). She presented for evaluation of dizziness. The patient was hypotensive in her doctor's office and was referred to the ED. 

In the ED, the patient's blood pressure was normal. The ECG (electrocardiogram) revealed no ischemic changes. Cardiac troponin was negative. The patient's urinalysis was consistent with UTI (urinary tract infection), and the patient was treated with antibiotics and IV hydration. She was seen in consultation by neurology, and no acute interventions were needed. She was discharged home.

This patient presented for evaluation of dizziness. Her blood pressure was low in the doctor's office, but was normal in the ED. She was treated with IV fluids for suspected dehydration and antibiotic for suspected UTI. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. There was no evidence of acute bleeding, seizure or CVA (cerebrovascular accident). Her presentation did not include any high risk features and was not suggestive of an acute cardiac or neurologic pathology. She had no focal neurologic signs to suggest a cerebro-vascular event or a TIA (transient ischemic attack). The patient remained stable throughout her stay. 

Although it was prudent to observe the patient and rule out cardiac pathology prior to discharge, there was no evidence of an acute cardiac or neurological condition requiring an inpatient admission. The clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Rheumatoid arthritis
Treatment:H.P. Acthar gel
Decision: Denied

Summary:
The patient is a  female with seronegative rheumatoid arthritis (RA). She has failed treatment with prednisone, methotrexate and Plaquenil.  At her office visit , she was taking prednisone 10 mg daily, Plaquenil 200 mg twice daily and methotrexate 17.5 mg weekly.  The AP (attending physician) planned to start treatment with H.P. Acthar gel, as well as Humira.  There is no specific documentation regarding treatment failure of Humira.  Appeal is for H.P. Acthar gel for the treatment of RA.

This patient with seronegative RA failed treatment with prednisone, methotrexate, and Plaquenil.  Humira and H.P. Acthar gel were both prescribed.  It is unclear whether she responded to Humira.  Per 2015 published guidelines for the treatment of RA, if disease activity remains high despite DMARD and TNF inhibitor therapy, the use of a non-TNF inhibitor biologic therapy is recommended.  There are several non-TNF biologic therapies that could be used to treat this patient, any of which could be considered standard of care in the rheumatology community.  The use of an alternate TNF inhibitor could also be considered for this patient.  The use of H.P. Acthar gel for the treatment of RA in this patient would not be clinically appropriate or in accordance with standard of care in the rheumatology community.  Therefore, the proposed H.P. Acthar gel for the treatment of RA in this patient is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cyclic vomiting and diabetic ketoacidosis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.
The Acute Inpatient Admission was medically necessary.

This patient is a male with hypertension, type-1 diabetes, and history of cyclic vomiting, who presented with multiple episodes of vomiting, diarrhea, and abdominal pain after heavy marijuana use. 

The patient's blood pressure was 204/91, heart rate 64, temp 97.9, pH 7.31. He was unable to tolerate oral intake in the emergency room. He was treated with intravenous fluids and insulin, potassium, Procardia, Zofran, and Pepcid. 

This patient was admitted with cyclical vomiting and diabetic ketoacidosis. This patient was medically unstable due to ongoing vomiting and diabetic ketoacidosis, which required an inpatient stay. This patient had ongoing vomiting until the day before discharge and was unable to tolerate oral intake. In addition, he had ongoing acidosis with a CO2 level of 17. Therefore, the inpatient stay was medically necessary due to ongoing vomiting and diabetic ketoacidosis. If the patient had been discharged earlier, he would have been at high risk of readmission for worsening diabetic ketoacidosis in the setting of ongoing acidosis. Therefore, yes, the proposed inpatient stay was medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: H3K27 mutated diffuse intrinsic pontine glioma
Treatment: Tagrisso SGM

The plan should not cover the proposed Tagrisso; this treatment is not indicated.  

The patient is a female child with high grade diffuse intrinsic pontine glioma (DIPG) with H3 K27M mutation who has a non-resectable tumor, has failed whole brain cranial radiotherapy (XRT), and ONC 201. The patient currently has progressive disease and is receiving Decadron and continued ONC 201.

The treatment has no likelihood of benefiting this child.  It is not approved for this tumor.  It has not been studied in pediatric patient so there is no safety data.  

Note: there are clinical trials that the child may be eligible for that can be found at www.clinicaltrials.gov.

The requested Tagrisso is not likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: H3K27 mutated diffuse intrinsic pontine glioma
Treatment: Tagrisso SGM

The health plan should not cover the proposed Tagrisso SGM.

The patient is a female child with a review for Tagrisso. The patient has a diagnosis of glioblastoma multiform E and molecular profiling demonstrates an epidermal growth factor receptor (EGFR) mutation. The patient has a biopsy confirmed H3K27 mutated fuse intrinsic pontine glioma; she is status post endoscopic third ventriculostomy, cranial radiation and enrolled on expanded access orally active, small molecule DRD2 antagonist (ONC 201). Her most recent magnetic resonance imaging (MRI) results shows progressive disease. She has been started on steroids.

The requested Tagrisso is not likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.

There is no evidence at this time to support the use of Tagirsso as therapy for glioblastoma multiforme (GBM).  There is no evidence in the adult literature to support the use of Tagrisso as therapy for GBM; the adult guidelines for GBM do not recognize the use of Tagrisso as therapy for the treatment of this disease state.  There is also no evidence in the pediatric literature to support the use of Tagrisso as therapy for GBM.  At this time, only case reports are available, and case reports are not considered acceptable evidence of efficacy.  At this time there is no clinical rational to support the requested use of Tagrisso to treat GBM.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: H3K27 mutated diffuse intrinsic pontine glioma
Treatment: Tagrisso SGM

The health plan should not cover the proposed Tagrisso SGM.

The patient is a female child with a history of biopsy-confirmed H3K27 mutated diffuse intrinsic pontine glioma (DIPG) who relapsed after radiation therapy.  She was treated on an experimental protocol with a small molecule DRD2 antagonist (ONC 201). She was restarted on Decadron. The attending physician is recommending treatment with Tagrisso.

Glioblastoma (GBM) has a poor prognosis in children despite the use of surgical resection and radiation therapy. While use of molecularly targeted therapies is commonplace in other solid tumors, development of these agents in GBM has been challenging. Obstacles include marked intratumoral heterogeneity, redundancy of signaling pathways driving tumor cell proliferation and a dearth of drugs that penetrate the blood-brain barrier. The epidermal growth factor receptor (EGFR) gene is among the most commonly deranged genes in GBM, with over half of GBM specimens containing a mutation, rearrangement, splicing alteration and/or amplification of EGFR [6]. Despite extensive characterization of EGFR alterations and intense efforts toward clinical development of EGFR-targeted agents in GBM, no therapies against EGFR have gained regulatory approval in this disease. 

Tagrisso is an oral, third-generation tyrosine kinase inhibitor (TKI) that irreversibly inhibits EGFR and was developed specifically to target the EGFR T790M-resistant mutation in EGFR-mutated non-small-cell lung cancer (NSCLC). Osimertinib has significant brain penetration and has demonstrated remarkable efficacy against EGFR-mutant NSCLC brain metastases. There are currently no published trials which demonstrate the efficacy of this drug in the treatment of DIPG and its use in this patient would not be considered medically indicated. 

There is no data that the requested health service would be more beneficial than other treatments for the patient's condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental problems
Secondary: Teeth spacing problem
Treatment: Dental/Orthodontic procedure

This patient has a Class III malocclusion. Mild maxillary crowding and mild mandibular crowding. Anterior crossbite with moderate anterior open bite. The proposed treatment is braces. The health plan's determination of medical necessity is upheld, in whole. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 17 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, severe traumatic deviation, impacted permanent anteriors where extraction is not indicated, deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9mm or greater and underbite 3.5mm 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, braces are not medically necessary for this case.