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

Diagnosis: peripheral vascular disease

Treatment: duplex scan of the lower extremities

The insurer is denied coverage for duplex scan of the lower extremities.

The denial is overturned. 

This male patient has a history of hypertension, asthma, and kidney stones.

The physical examination revealed the bilateral feet were slightly discolored purple, and very cool to the touch.  The posterior tibial on the right was present and dorsalis pedis on the right was 1+.  The same was found on the left.  The patient's posterior tibial pulse was slightly diminished bilaterally.  The patient had pain and discoloration in the bilateral feet mostly around the first digit.  The symptoms were likely related to the cold sensitivity, however, the provider opined that the patient would benefit from an arterial Doppler study to assess arterial flow.  The treatment plan included a bilateral lower extremity arterial Doppler study.
The duplex scan of the lower extremities (CPT code 93970) is considered medically necessary for this patient. The patient had clinical signs and symptoms that could be associated with peripheral vascular disease. A duplex arterial ultrasound is the most sensitive non-invasive evaluation for peripheral vascular disease and can guide further management for this patient.

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

The carrier's denial of coverage for duplex scan of the lower extremities is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a history of seizure disorder. She presented after having had two witnessed seizures.

Upon evaluation, the patient reported that pain caused her seizures. She was suspected of having seizure versus psychogenic nonepileptic seizures (PNES).  She was continued on anticonvulsant medications and discharged on the following day. 

No, the Inpatient admission was not medically necessary.
The patient has a pre-existing history of seizure disorder and was already established on anticonvulsant therapy. She did not have any recurrent events after presentation. Her self-reported symptoms, related to uncontrolled pain, suggested PNES (psychogenic non-epileptic seizure) (Shellhaas). The diagnostic studies, monitoring and treatment could have been safely and effectively completed at a lower level of care.

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

Diagnosis: Dental pain. 
Treatment: Braces (Comprehensive orthodontic treatment), Adjustments (periodic orthodontic treatment) and Retainer (orthodontic retention). 

The insurer is denied coverage for comprehensive orthodontic treatment, periodic orthodontic treatment and orthodontic retention. 

The denial is upheld. 

This female patient has a history of dental pain. 

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

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 22 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist and insurer attaining a total of 22 points on the HLD index (5 overjet, 3 overbite, 10 anterior crowding, 4 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. 

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

The carrier's denial of coverage for comprehensive orthodontic treatment, periodic orthodontic treatment and orthodontic retention is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain. 
Treatment: Spine surgery. 

The insurer is denied coverage for spine surgery. 

The denial is upheld. 

This male patient has a history of neck pain and left shoulder pain to the left arm. 

The patient must quit smoking for six weeks prior to surgery and submit to a nicotine test with negative result in order for medical necessity. In this case, there are no red flags to indicate an urgent surgery. If myelopathy were to present itself in a progressive manner, or significant progressive weakness is evident on subsequent exams, smoking criteria can be foregone due to safety reasons in these situations. The requested anterior cervical discectomy and fusion is not medically necessary at this time based on generally accepted practice to prevent complications. 

Chronic cigarette consumption has significant adverse effects on the human spinal column. Multiple mechanisms induced by tobacco use lead to less strong, less healthy, mineral-deficient vertebrae with reduced bone blood supply and fewer and less functional bone-forming cells among chronic smokers. Compared to nonsmokers, chronic smokers develop advanced bony degradation, are more likely to suffer from spinal column degenerative disease and seem more susceptible to traumatic vertebral injury. Spinal fusion procedures in chronic smokers are less often clinically and radiographically successful, compared to similar procedures performed among nonsmokers for definitive biological, physiological, and mechanical reasons. 

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

The carrier's denial of coverage for spine surgery is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Esophageal Cancer
Treatment: Transfer to another facility for end-of-life care
The insurer denied the Transfer to another facility for end-of-life care
The denial is upheld

The patient in this case is a male with metastatic esophageal cancer. He has metastatic disease to the liver and peritoneum and was admitted to the hospital with increasing abdominal distention, found to be due to ascites. He was also diagnosed with spontaneous bacterial peritonitis and was treated with antibiotics and paracentesis. Imaging done during this hospital admission revealed progression of his metastatic disease despite treatment with immunotherapy. He had worsening mental status during this hospital stay. After conversation with his family, he was made DNR/DNI (do not resuscitate/do not intubate), and a request was made for transfer to inpatient hospice. He had continued pain requiring intravenous (IV) pain medication during this hospital stay.

No, the transfer is not medically necessary.
This patient has advanced metastatic cancer and has pain along with confusion.  It was decided to pursue comfort measures and hospice care.  The facility requested for transfer is an acute care hospital that focuses on end of life care. This patient does not require admission to an acute care hospital.  He would be appropriate for admission to an inpatient hospice facility, but not an acute care hospital.  Records indicate that he is being treated with pain medication and that he might require further treatment with paracentesis, but that could be arranged while he is on hospice care and does not require acute care inpatient hospitalization.  There is no acute poorly controlled symptom that would require admission to an acute palliative care facility. Given the above considerations, acute care inpatient hospitalization is not appropriate. Therefore, the requested transfer is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Multiple Myeloma
Treatment: Velcade 3.5 MG
The insurer denied Velcade 3.5 MG. The health plan's determination is overturned. 

The patient is a female with history of relapsed refractory kappa light chain multiple myeloma. The patient has received multiple lines of therapies including RVD (Velcade + Lenalidomide + Dexamethasone), autologous stem cell transplantation, Lenalidomide maintenance, Daratumuab + Ninlaro, Carfilzomib + Dexamethasone + Daratumuab, Belantamab, Selinexor+ Pomalidomide + Dexamethasone, and most recently regimen of Velcade (Bortezomib), Venetoclax and dexamethasone was recommended.

Velcade 3.5 MG is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Venetoclax is an oral BCL-2 inhibitor with single-agent activity in patients with relapsed or refractory multiple myeloma (RRMM) with t(11;14) translocation. Venetoclax efficacy in RRMM is potentiated through combination with agents including bortezomib. Combination of Venetoclax, dexamethasone and Bortezomib (Velcade) has been shown to improve progression free survival in patient with relapsed refractory multiple myeloma who are treated with multiple regimens. Benefit of this regimen is seen in patients harboring t (11.14) molecular abnormality. Multiple nonrandomized and one randomized clinical trial supports the effectiveness of this regimen in heavy pretreated patients with response rate nearing 50% and PFS of 22 months. Thus, coming Bortezomib with Venetoclax is an important treatment option and proven to be clinically meaningful regimen for patient with refractory multiple myeloma.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Multiple Myeloma
Treatment: Velcade 3.5 MG
The insurer denied Velcade 3.5 MG. The health plan's determination is overturned. 

This is a woman with the diagnosis of multiple myeloma. The request is for the use of bortezomib (Velcade).
The patient presented with kappa light chain disease with anemia. Her cytogenetics demonstrated deletion of chromosome 17p, t(11;14), with R-ISS (Revised International Staging System) stage II. She began RVd ((Revlimid (Lenalidomide), Velcade (Bortezomib) and Dexamethasone)). She had multiple interruptions. She received an autologous stem cell transplant. She then received lenalidomide with elotuzumab. She had disease progression and daratumumab was added. She again had progression and she was changed to ninlaro. She responded initially. but progressed and she was changed to carfilzomib/dex/dara. She again progressed and was started on belantamab, then changed to venetoclax, velcade and dexamethasone. This was held and she was treated with selenixor which she did not tolerate.

Velcade 3.5 MG is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
A prespecified subgroup analyses of the use of venetoclax and velcade suggested improved PFS without a clear decrease in survival among 35 patients with t(11;14). While we await confirmation of efficacy in a prospective trial, some patients with t(11;14) and limited treatment options may reasonably elect a trial of this agent alone or in combination. Under NCCN (National Comprehensive Cancer Network) recommendations, venetoclax alone or in combination with other agents is listed as alternative therapies only for those with t(11;14). This patient would meet criteria for treatment with Velcade.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Multiple Myeloma
Treatment: Velcade 3.5 MG
The insurer denied Velcade 3.5 MG. The health plan's determination is upheld. 

This patient is a female with relapsed kappa light chain multiple myeloma. The patient has previously undergone induction with RVD (Revlimid (Lenalidomide), Velcade (Bortezomib) and Dexamethasone), and a stem cell transplant. She has also received lenolidomide+elotuzumab, ninlaro+daratumumab, carfilzomib+dexamethasone+daratumumab, Blenrep, selenexor, and now venetoclax.

Velcade has been recommended as a component of therapy; and this is under review.

Velcade 3.5 MG (milligrams) 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 regimen requested has been demonstrated to effective but with significant potential for toxicity. A phase 3, placebo controlled trial (BELLINI) evaluated the addition of venetoclax to bortezomib plus dexamethasone in patients with relapsed or refractory multiple myeloma (MM). While venetoclax deepened responses and improved median progression free survival (PFS), the trial was stopped early because of an increased risk of death with venetoclax, including eight treatment-emergent fatal infections, which resulted in inferior overall survival.

The use of the combination is the question posed in this review. Given the potential toxicity of the triplet and the fact that this patient has failed multiple prior regimens including a proteasome inhibitor, it is not clear that the addition of bortezomib would include outcomes. Due to the potential for toxicity, the addition of bortezomib to venetoclax+dexamethasone is not recommended by the National Comprehensive Cancer Network (NCCN).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gynecological. 
Treatment: Lab Work/Blood Tests. 
The insurer denied microarray diagnostic testing. 
The denial is overturned. 

The patient is a female under consideration for medical necessity for genetic testing as performed for the indication of a calcification at the tip of the liver in the newborn. There was a concern for risk for infection and toxoplasmosis, rubella cytomegalovirus, herpes simplex, and human immunodeficiency virus (TORCH) titers were drawn. As part of this testing, the patient also underwent Current Procedural Terminology (CPT) 81229 for genetic testing. The patient was noted to undergo a targeted anatomic scan and noted normal growth and an elevated maternal serum alpha-fetoprotein screening (msAFP) as the indication for the ultrasound. During the scan, the anatomy was noted to be normal with a solitary calcification noted at the tip of the liver adjacent to the fetal stomach and below the diaphragm. The patient was counseled on an increased risk for infection, cystic fibrosis and or chromosomal abnormalities. For this reason, she underwent fetal genetic testing. The subject under review is the medical necessity for the microarray testing.

The health plan's determination is overturned.

In this case, the performance of the microarray (CPT 81229) would be medically necessary as based upon the abnormal finding on the fetal liver at the time of ultrasound. At the time of the initial review, the ultrasound was not present, and this is now reviewed in concert with the request. Given an ultrasound anatomic abnormality, the performance of a microarray is indicated to exclude any genetic contribution to the presentation in this case.

Thus, in this case, where there is a fetal liver abnormality, the patient would be "recommended to have chromosomal microarray analysis" under the ACOG recommendations. Thus, ACOG would both support the use for array in this patient and given the 2012 NEJM publication (2) and prior publications (3) of this technology which ACOG uses to base its recommendation (1) and would consider this technology. Thus, the requested genetic diagnostic testing would be medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: allergic contact dermatitis

Treatment: Dupixent

The insurer is denied coverage for Dupixent

The denial is upheld. 

This male patient has a history of hyperlipidemia and neoplasm of the parotid gland.

The requested medication, Dupixent, is not medically necessary for this patient's condition. There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Dupixent for this patient's condition as an accepted standard of practice in the U.S. compared to alternative therapies.  

The requested medication Dupixent is not medically necessary based on the standard of care, and there are no unique clinical circumstances to this particular individual in the documentation provided that would make it medically necessary. It is noted that the patient has a diagnosis of atopic dermatitis, but documentation to show true contraindications to conventional medications commonly used in the treatment of atopic dermatitis is not provided in the submitted documentation. It is noted that cyclosporine is mentioned in the office visit note plan for the patient, but no follow up is given as to whether the patient used the medication. The submitted documentation shows that the patient has only tried and failed topical steroids. However, the patient has no true long-term contraindications to the conventional medications commonly used for atopic dermatitis.  

The conventional medications, such as methotrexate, should be tried and failed prior to initiating Dupixent. Dupixent is not medically necessary for this patient according to the standard of care.

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

The carrier's denial of coverage for Dupixent is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and monthly visit x 12
The insurer denied braces and monthly visit x 12.
The determination is overturned.

The patient has an anterior crossbite on teeth 7 and 10. He presented with a skeletal Class II malocclusion with minor crowding in the maxilla and mandible. He is treatment planned for 36 months of orthodontics to address the crowding and crossbite. At issue is the medical necessity of braces and monthly visit x 12.

The requested treatment is medically necessary.
This patient presents with an anterior crossbite on teeth 7 and 10, as well as significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3)
If left untreated the damage that will likely occur to the patients teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, the treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male who presented to the emergency department  complaining of palpitations and generalized weakness. His medical history was remarkable for diabetes, hypertension, hyperlipidemia, opioid dependency, and morbid obesity. His blood pressure was 151/135 millimeters of mercury (mmHg) with a heart rate of 164 beats/minute. His room air oxygen saturation was 94% (percent). His physical exam was remarkable for obesity, diminished basilar breath sounds and a rapid, irregular heart rate. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. Chest X-ray showed mild pulmonary vascular congestion. His serum troponin level was normal. The patient was treated with aspirin, enoxaparin and an intravenous diltiazem bolus followed by a continuous infusion. He was then transferred to another institution for hospital admission for management of atrial fibrillation. Oral diltiazem was prescribed, and the intravenous infusion was titrated off. At some point the patient's rhythm converted to sinus. He remained in sinus rhythm with no complaints. An echocardiogram showed normal left ventricular size and function. There was mild mitral and tricuspid regurgitation. The patient was discharged. Medical necessity for an inpatient stay is the subject under review.

The health plan's determination is upheld.

An inpatient stay was not medically necessary. This patient presented with acute atrial fibrillation (AF) with a rapid ventricular rate. There was no evidence of ischemia or decompensated heart failure, he had no evidence of structural heart disease and was not at high risk for thromboembolism. For patients presenting with acute AF, the safety of observation level care or discharge to home with close follow-up has been well demonstrated. As stated by Lin et al., "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization. Likewise, Conti et al., based on an observational study of 3475 patients concluded, "In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations." Finally, given documentation that this patient converted to sinus rhythm inpatient hospitalization cannot be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied hospital admission. The denial is upheld. 

The patient is a female who presented to the emergency department with concerns of shortness of breath and cough with associated chest wall pain. Pertinent history included asthma and hypothyroidism. 

The patient was admitted with an impression of pneumonia, acute hypoxic respiratory failure, sepsis, mediastinal lymphadenopathy, pleuritic chest pain, and influenza A. Treatment plan included cultures, arterial blood gas (ABG), Tamiflu, bronchodilators, empiric antibiotics, and consultations. Infectious disease consultation was obtained who had an impression of Influenza pneumonia. Recommendations were to continue Tamifu, empiric antibiotics, and follow-up with pending laboratory testing. Pulmonary consultation was obtained who noted no acute respiratory distress. The impression was influenza with pneumonia. Recommendations were to continue Tamiflu, empiric antibiotics, and nebulizers.  Shortness of breath was improving and overall felt better. Vitals noted the patient to be afebrile, hemodynamically stable, and without hypoxia. Treatment plan was essentially unchanged. She was able to ambulate to the bathroom. Shortness of breath continued to improve. Procalcitonin was 0.05 and white blood count (WBC) normalized. Sputum culture was unremarkable. Pulmonary noted breathing well on room air, not in acute asthma exacerbation, and recommended outpatient follow-up. Infectious disease recommended likely transition to oral antibiotics in the morning. The patient was deemed medically stable and discharged. 

The hospital admission was not medically necessary for this patient. 

Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. 

The patient had a history of asthma and presented with shortness of breath. Initial evaluation was pertinent for a low-grade fever, leukocytosis, multifocal pulmonary infiltrates, and a positive influenza A test. No hypoxia or hypoxemia was documented. Pulmonary noted the patient was not in an acute exacerbation of asthma. Treatment plan included nebulizers, Tamiflu, and empiric antibiotics. Following observation care, the patient afebrile, hemodynamically stable, breathing comfortably on room air, and with normalized or near normal laboratory abnormalities. No other acute issues or complications were documented.