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

Diagnosis:  Glaucoma
Treatment:  Surgical Services

The patient is a female with mild stage primary open angle glaucoma for whom coverage of a canaloplasty (66174) is the subject of review.  The provider felt that the patient was not a good candidate for trabeculectomy or a glaucoma drainage device.  An exam documents the patient using Lumigan and Simbrinza drops and having intraocular pressures of 20 mm Hg OD (right eye) and 22 mm Hg OS (left eye) (Tonopen).  Her vision was 20/30-2 OD and 20/50 OS.  Cataracts were reported as visually significant with glare.  Cup/disc ratios were 0.7 OD and 0.6 OS.  Cataract surgery with OMNI MIGS (minimally invasive glaucoma surgery) was recommended.  The health plan denied the canaloplasty as not medically necessary.  The health plan's determination is overturned.

According to Riva, I., et al. (2018), "Several studies have shown that canaloplasty is effective in reducing intraocular pressure and has a low rate of complications, especially compared with trabeculectomy, the gold standard for glaucoma surgery.  Currently, canaloplasty is indicated in patients with open-angle glaucoma, having a mild to moderate disease, and the combination with cataract phacoemulsification may provide further intraocular pressure reduction."

Cagini, C., et al. (2016) states, "Canaloplasty appears to be a valid alternative to conventional glaucoma surgery because of its efficacy and safety profile in selected patients with open-angle glaucoma.  Its advantages over trabeculectomy include absence of subconjunctival bleb, no need for mitomycin C, faster visual rehabilitation, easier follow-up, and fewer postoperative complications. 

The authors concluded that canaloplasty was safe and effective in achieving long-term IOP reductions and reduced dependence on antiglaucoma medications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperkalemia
 
Treatment: Inpatient hospital admission

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

This patient is a woman who had a history of Addison's disease, hyperprolactinemia, pituitary adenoma, anti-phospholipid antibody syndrome with a history of deep vein thrombosis (DVT) and pulmonary embolus, diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease with stent several years ago and depression. She was sent to the Emergency Department (ED) by her Hematologist for a potassium level of 6.2 on laboratory testing; the patient was asymptomatic. Initial vital signs including a blood pressure of 98/69, a heart rate of 77, a temperature 97.4F, a respiratory rate of 18, and an oxygen saturation on room air of 98%. An EKG revealed peaked T waves, but was otherwise unremarkable. Laboratory test results included a white blood cell (WBC) count of 8.0, a hemoglobin of 10.9, a creatinine of 1.2, a glucose of 213, a sodium of 136, a potassium of 6.2, a chloride of 110, a bicarbonate of 16, and a troponin <0.012. She was treated with Kayexalate, intravenous fluids, calcium gluconate, and insulin and had an episode of nausea and vomiting while taking the Kayexalate.  

She was seen by a Hematologist who raised the issue of possible type 4 renal tubular acidosis and by an Endocrinology consultant who felt that medication compliance may have played a role. Psychiatry did not feel that she was actively depressed. She was discharged on stress doses of steroids tapered back to her maintenance doses of Florinef and hydrocortisone over a week, as well as on her other medications, which included aspirin, atorvastatin Linzess, Trulicity, bupropion, Cabergoline, Lexapro, Lantis, Novolog, metformin, metoprolol, Protonix and rivaroxaban.

There is no evidence that this patient required an acute inpatient level of care to evaluate or treat her newly noted potassium level of 6.2, which was asymptomatic, with no evidence for conduction abnormalities or arrhythmias. In addition, she did not have conditions that could contribute to a continued acute rise in potassium levels such as worsening renal function, rhabdomyolysis or significant gastrointestinal bleeding. The healthcare plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The denial of the inpatient hospital admission is upheld because there is no evidence that this patient was at risk for short term adverse cardiovascular events, based on her clinical presentation and results of testing and treatment performed in the Emergency Department.

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: Teeth sensitivity 

Treatment: Nerve treatment on molar tooth, Tooth #'s 2, 11(D3330) and White glass with high gold content crown, Tooth #'s 2, 11 (D2750)

The insurer denied coverage for Nerve treatment on molar tooth, Tooth #'s 2, 11(D3330) and White glass with high gold content crown, Tooth #'s 2, 11 (D2750). The denial upheld.

This patient is a female who presented for dental treatment complaining of sensitivity issues associated with teeth #'s 2 and 11. The provider recommended endodontic therapy and full coverage crowns to address the patient's symptoms.  The insurer has denied these services stating the there is no clinical/ radiographic evidence provided to support the necessity of these services.  The patient is appealing.

Based on the submitted documentation it appears that there is no evidence of any pathology specifically affecting #'s 2 or 11.  There does not appear to be any radiographic evidence of caries.  There is no periapical pathology, and, in fact, metal artifact from the patients earrings completely mask tooth #2 making this area unreadable. Neither the radiographs nor the clinical notes substantiate the requested dental services as enumerated above, nor did the treating doctor indicate a need for treatment in the clinical notes by noting objective findings and therefore they are deemed not medically necessary.

Recommendation: Uphold denial of coverage for nerve treatment on molar tooth, tooth #'s 2, 11 (D3330) and white glass with high gold content crown tooth #'s 2, 11 (D2750) as not medically necessary as the documentation is insufficient to justify or substantiate the treatment.

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

Nerve treatment on molar tooth, tooth #'s 2, 11 (D3330) and white glass with high gold content crown tooth #'s 2, 11 (D2750) are not considered medically necessary for this patient.

Based on the above, the medical necessity for Nerve treatment on molar tooth, Tooth #'s 2, 11(D3330) and White glass with high gold content crown, Tooth #'s 2, 11 (D2750) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance and alcohol use
 
Treatment: inpatient substance abuse services

The insurer denied coverage for inpatient substance abuse services. The denial reversed.

This patient is a male was admitted to inpatient substance detoxification treatment due to substance and alcohol detoxification. He had withdrawal symptoms including tremors, sweats, joint pain, irritable mood, anxiety, light sensitivity, and had a CIWA of 10 and COWS of 11. He was reportedly inhaling 4-5 bags of heroin per day with a more than decade long history of use, drinking 1 pint of alcohol per day with a 2 decades history, and using 20 mg of Xanax per day with several months of use. He reportedly had a positive toxicology for opiates and benzodiazepines. He had past multiple inpatient detoxification treatment and inpatient rehabilitation treatments including a past inpatient substance detoxification and rehabilitation treatment several months prior to admission. He was still using substances and drinking alcohol despite being in a medication assisted treatment program; he was taking 130 mg of Methadone. He had a Librium protocol. He reportedly was discharged to another inpatient facility for rehabilitation treatment.

The insurer denied coverage for inpatient substance detoxification treatment. According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use multiple serious substances in large amounts and also alcohol despite multiple past inpatient substance detoxification and rehabilitation treatments, and he had long term multiple substances of use including using alcohol, heroin, and Xanax, had active withdrawal symptoms,  and was being treated with medication for withdrawal of alcohol and benzodiazepines and heroin including a Librium protocol. He needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms including life threatening, severe, and complicated withdrawal if not in this 24 hour setting then, and he likely would have relapsed again as evidenced by relapsing after past treatments. It also was reported that he reported a past alcohol withdrawal seizure and he was using large amounts of alcohol and benzodiazepines putting him at risk of delirium tremens (DT's).  He continued to use very large amounts of Xanax, large amounts of alcohol and heroin and was at high risk for overdose also. He could not safely and effectively be treated in a less restrictive setting. Also, he required this inpatient substance detoxification prior to inpatient substance rehabilitation treatment.  It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient.

Based on the above, the medical necessity for the inpatient withdrawal and stabilization services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer 
Treatment: Pharmacy/Prescription Drugs 

The patient is a female with neuroblastoma. She was diagnosed with her disease four years ago. Her disease overall has been resistant to chemotherapy and her tumor is inoperable, extending to the neural foramina, invading the brachial plexus, and invading or encasing multiple vessels. She had next generation sequencing on her tumor using a testing platform that identified a BRAF mutation. Due to the BRAF mutation the provider has recommended treatment with Mekinist. The use of Mekinist is under review. 

The health plan's determination is overturned. 

The requested health service / treatment of Mekinist 0.5 mg tabs 30/30 days is medically necessary for this patient. 

This patient has refractory / relapsed neuroblastoma with limited treatment options. Based on the results of next generation sequencing tumor evaluation showed that the patient had a BRAF mutation. The provider has recommended Mekinist as treatment of her disease. Per the literature provided by Tanaka et al., relapsed neuroblastoma may have frequent RAS-ERK pathway mutation, hypothesizing that MEK inhibitors may provide a new molecular-targeted therapy for these conditions. Cell lines were treated with trametinib (Mekinist) and this therapy showed growth inhibition effects on cells with the ERK phosphorylation. Vujic et al. showed trametinib can directly impede the MAPK pathway and can provide a possible treatment option for NRAS mutant cancers such as neuroblastoma. Eleveld et al. showed that there were a high frequency of activating mutations in the RAS-MAPK pathway (61%), showing that this can function as a biomarker for new therapeutic approaches to refractory disease. Takeuchi et al. showed that MAPK pathway inhibition was effective for treating p-ERK-positive neuroblastoma in vivo, and that this is a potentially convenient biomarker for MAPK pathway inhibition in neuroblastoma treatment. 

This patient has already failed all standard forms of treatment of her neuroblastoma and now requires a more specialized approach, focusing on known targets within her tumor tissue. The use of Mekinist is supported by the current peer-reviewed literature for the treatment of this disease when the BRAF mutation is present. Therefore, based on the clinical information provided for review, the current peer-reviewed literature and standards of care in the field, the use of Mekinist is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: skin disorders.
Treatment: Pharmacy /prescription drugs.
The insurer denied Pepcid-20MG. 
The denial is upheld in whole.

This is a  patient with the request for Pepcid-20 milligrams (MG) for Idiopathic urticaria. The patient has tried levocetirizine 2 times (x) per day and Allegra.
No. There are no head to head studies which have shown that cyproheptadine syrup/tablet; desloratadine odt will be ineffective or less effective than Pepcid for the treatment of hives.
Current guidelines for Chronic Urticaria states that for initial therapy, administer a second-generation antihistamine at standard therapeutic dose.  If step 1 does not control symptoms adequately within one to two weeks, therapy may be increased by Advancing the dose of the second-generation antihistamine, Adding a different second-Generation antihistamine, Adding an H2 antihistamine or Adding a leukotriene-receptor antagonist or Adding a first-generation H1 antihistamine at bedtime. If the measures in step 2 do not result in adequate control of symptoms, the dose of the first-generation H1 antihistamine may be advanced gradually in step 3.  Patients whose symptoms are not controlled by step 3 therapies or who are intolerant of dose advancement of first-generation H1 antihistamines are considered to have refractory chronic urticaria (CU) and can be considered for biologics.
In this case, the patient has tried Allegra and levocetirizine. The alternatives, cyproheptadine syrup/tablet, desloratadine odt are suitable for trial for urticaria as they also have antihistaminic mechanisms.
Appeal type: Medical necessity
Decision: Upheld

Issue: medical necessity of Immunoglobulin
Diagnosis: Central Nervous System/ Neuromuscular Disorder
Treatment:  Drug Immunoglobulin
The health plan denied Drug Immunoglobulin
The health plan's determination is upheld in whole. 

The treatment with Immunoglobulin is not medically necessary for this patient.

The patient has a listed diagnosis of myasthenia gravis with acute exacerbation. An acute exacerbation is not supported by the documentation submitted for review. The diagnosis is based on LRP4 antibodies; nerve conduction studies and electromyography are reported as normal.
It is stated that the patient is currently on Mestinon only, without any other standard of care immunosuppressants. The patient complains of generalized weakness and fatigue, but no current difficulties swallowing or breathing. There is reported subjective shortness of breath, but pulmonary function tests have been normal. There is no diplopia. The standard of care in the treatment of myasthenia gravis has not been met. The patient has not failed any of the first line treatment options for myasthenia gravis. There are no documented, proper trials of prednisone, azathioprine, mycophenolate, eculizumab or any other immune suppressive agents. There is also no documented contraindications to all such agents.
There is insufficient evidence from high quality peer reviewed literature, large, well designed, blinded, randomized trials to support long term safety and efficacy of the requested drug for this patient's condition as described, and even less evidence of its superiority.
The very limited evidence available for IVIG in the treatment of myasthenia gravis relates to acute exacerbations, multi drug resistant patients, and as a temporary control measure while slower acting agents such as azathioprine work. There is also insufficient evidence to support IVIG as a first line agent for the immune suppressive treatment of patients with myasthenia gravis not currently undergoing an acute crisis.
The submitted documentation does not support the presence of an acute exacerbation, multi drug failure or ongoing treatment with a slower acting pharmacological agent.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital

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

The patient is a female with a past medical history of myocardial infarction who presented to the emergency department (ED) with complaints of chest pain with radiation to the left jaw since the night prior to presentation. It comes and goes every two minutes. (By different note, there was no radiation and the quality of pain was achy). Her pain was intermittent and sharp.

The Inpatient Hospital Admission was not medically necessary for this patient. The patient presented with atypical chest pain. She reported history of MI, however, that was not confirmed. The patient had normal vitals, physical examination, labs and electrocardiogram (ECG). She was stable, but the plan was to observe her overnight. The patient refused to stay. Her condition upon presentation was stable and she did not meet criteria for inpatient admission. She should have been managed at a lower level of care. Even if the patient stayed overnight, the likelihood of her qualifying for inpatient stay would be very low.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a morbidly obese female patient with a history of heart failure with preserved ejection fraction (HFpEF), paroxysmal atrial fibrillation (AF), restrictive lung disease and diabetes mellitus. She had a transesophageal echocardiogram (TEE) that revealed severe mitral regurgitation (MR) and end systolic diameter of 4.3cm and a left ventricular ejection fraction (LVEF) of 60%. There was moderate tricuspid valve regurgitation and moderate pulmonary hypertension was also noted. The cardiology team consulting over the patient assessment was performed; her Society of Thoracic Surgery (STS) score for surgical mortality was 3.2%. 

Transcatheter mitral valve replacement (TMVR) has FDA approval for degenerative (primary) mitral regurgitation (MR).  In the EVEREST II trial patients with primary MR were randomized to TMVR or surgery.  The study found that the mitral valve surgery was superior to TMVR for correcting mitral regurgitation; though there was a reduction in the rate of major adverse events associated with percutaneous closure: 15% TMVR vs. 38% in the Surgical group.(4)

Current AHA/ACC Guidelines support transcatheter mitral valve repair in patients with severe chronic primary mitral regurgitation, New York Heart Association (NYHA) class III functional status and prohibitive surgical risk (IIB level of evidence B).(3) The patient is morbidly obese with a BMI of 50, and has a STS score of 3.2% making surgical treatment for mitral valve in the low risk category.(1) This patient's STS score did not meet the criteria for prohibitive surgical risk. 

The requested service (TMVR) is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for transcatheter mitral valve replacement (TMVR) is upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a female patient with a history of aortic aneurysm, morbid obesity, sleep apnea on continuous positive airway pressure (CPAP), diabetes mellitus, coronary artery disease, restrictive lung disease, and hypertension. It was reported that the patient was found to have severe, symptomatic mitral valve regurgitation and was a moderate to high risk for surgical mitral valve repair/replacement. She had an ejection fraction of 60% with eccentric mild/moderate mitral regurgitation, with flail leaflet of A2.  The patient's surgical risk for mitral valve repair was 3.6% and that for surgical valve replacement was 7.5%. 
 
The MitraClip is FDA approved for repair of severe mitral regurgitation (both primary and secondary mitral regurgitation) in patients who are deemed non-operative candidates. This patient was preoperatively determined to be at moderate to high risk, depending on the type of procedure performed.  For mitral valve repair, which the MitraClip accomplishes, the patient is not considered a high-risk, but rather an intermediate risk candidate.  While it may be true that minimally invasive procedures may result in the need for a bail-out or salvage mitral valve replacement at the time of surgery (carrying with it open surgical procedure), this complication also applies the MitraClip, percutaneous approach to the procedure. 

The MitraClip, requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for transcatheter mitral valve replacement (TMVR) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bipolar Disorder 

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was upheld.   

This is a patient with a history of Bipolar Disorder-Depressed and abuse. The patient reported having a recent episode of mania where she experienced racing thoughts, agitation and poor sleeping where she was hospitalized for her symptoms and was treated with Latuda and Cymbalta. The patient was admitted to a psychiatric facility due to complaints of depressed mood anhedonia, and decreased energy; loss of interest, negative thinking, decreased eating, and poor functionality (i.e. neglecting activities of daily living) and social isolation. On examination it was reported that the patient's thought process were goal directed with limited judgment insight. She was started on Zoloft and her Latuda was adjusted; increasing her current dose. She participated in group, individual, and milieu therapy. It was reported that the patient's symptoms and affect improved. She denied any thoughts of suicidal and homicidal ideations. She was 

The APA Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with aggression, homicidal or suicidal intent, plan, or behavior, manic episodes, psychotic symptoms, or severe agitation are candidates for inpatient hospitalization. In this case this patient did not have reports of suicidal or homicidal ideation, severe agitation, manic episodes, psychotic symptoms, aggression, and had no reports of acute medical instability. The patient had no past reported suicide attempts, and there were no reports of acute substance use issues. 

From admission through discharge, the patient did not have reports of manic episodes, aggression, disruptive behavior, paranoid delusions, hallucinations, disorganized speech or thought process, suicidal or homicidal ideation, plan, or intent, or severe agitation. There were no reports of acute medical instability or severe withdrawal requiring hospital treatment. The patient was recommended to partial hospital program (PHP) treatment and care coordination. However, there were no reports that the patient recently failed or attended PHP treatment prior to this hospitalization. There were no reports of specific identifiable or quantifiable treatment objectives that could have only been achieved in a 24-hour acute inpatient hospital setting or that could not have been achieved in a less restrictive level of care. Thus, acute inpatient mental health treatment was not medically necessary to treat this patient's medical condition. 

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

The carrier denial of coverage for the inpatient hospital services at the acute inpatient level of care is upheld. The medical necessity is not substantiated.