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

Digestive System/Gastrointestinal

Diagnosis: Constipation
Treatment: Biofeedback services
The insurer denied Biofeedback services. The health plan's determination is overturned. 

The patient is a female with a medical history of constipation and migraine headaches. She was seen for constipation since childhood, abdominal pain before bowel movements, prior hematochezia, and painful hemorrhoids. She had failed medical management (including MiraLAX, stool softener, fiber, magnesium, probiotics), diet changes (including lactulose and gluten-free diet, and increased fluid intake), and increased physical activity. She presented with persistent symptoms. A Colonoscopy was unremarkable. Anorectal manometry showed type for dyssynergic defecation, inability to expel a balloon in less than a minute. She was treated with biofeedback therapy.

The Biofeedback Services were medically necessary for this patient.

Current medical literature supports the medical necessity of biofeedback therapy in this case. The patient had symptoms and testing consistent with constipation due to dyssynergic defecation. Some of these are due to structural anatomical issues, but others are functional issues with normal anatomy. In such cases, biofeedback therapy can be effective. The American College of Gastroenterology guidelines for the management of benign anorectal disorders recommend anorectal manometry to determine whether a functional disorder is present, and a physical functional performance test, such as a balloon expulsion test, is also warranted when evacuation or outlet disorder is suspected - these have been performed, and dyssynergic defecation was diagnosed. Additionally, the patient has failed multiple medical therapies. For these reasons, the request for biofeedback therapy is supported as medically necessary for the patient's constipation with dyssynergic defecation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal.  
Treatment: Inpatient Hospital. 

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

The patient is a female who presented with anal pain due to thrombosed external hemorrhoid. The pain was reported as 9/10 with difficulty sitting for long periods of time. She did have some bleeding. She was noted to have an external hemorrhoid. She was offered bedside incision and drainage but due to her anxiety she refused this and requested treatment in the operating room. She went to the operating room for drainage of thrombosed hemorrhoid and hemorrhoidectomy. The patient was kept overnight after surgery and discharged the next day.
The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld in whole.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient had a clear need for a surgical procedure but did not have a need for inpatient level of care from the hospital. There is no physician documentation of the need for an inpatient level of monitoring, complex diagnostics, or treatments other than the surgery. There is no evidence of patient specific problems that would require an inpatient level of care to meet medical needs or to assure patient safety. There is no evidence of a complicating event that occurred before, during, or after the patient's care that would require inpatient level of care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pneumonia.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is overturned. 

This is a male child with a history of bronchiolitis, who had been sick for 5 days with fever to 104 and a worsening cough.  The patient went to the Emergency Room (ER) with difficulty breathing for two days.  The patient was described by his mother as being sleepier and not drinking adequate fluids.  The patient's pulse oximeter was 91% on room air.  On physical exam, the patient appeared tired with tachypnea with a respiratory rate of 40 and suprasternal retractions.  The patient's eyes appeared sunken and there was a history of a decrease in urine output.  The patient's chest X-ray demonstrated an interval worsening of a right middle lobe and left lower lobe pneumonia. 

The patient's blood testing demonstrated an elevated C-reactive protein (CRP) of 4.6 and erythrocyte sedimentation rate (ESR) of 22 with low bicarbonate of 19.  Testing for influenza and strep were negative.  The patient was treated with an intravenous (IV) bolus of normal saline and antibiotics.  The decision was made to admit the patient with a diagnosis of dehydration and pneumonia, which had failed outpatient management.

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient.  The patient was treated appropriately in the ER for pneumonia, which demonstrated an interval worsening despite oral antibiotics.  In addition, there was clinical evidence that the patient was dehydrated with low serum bicarb of 19, a decrease in urine output and sunken eyes on physical examination.  The decision to admit to the hospital was consistent with the standard of care for treatment of a prolonged febrile illness with worsening respiratory symptoms and radiologic evidence of interval increase in pneumonia in a pediatric patient, who did not respond to oral antibiotics.

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 the inpatient hospital admission should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Disruptive mood dysregulation disorder, oppositional defiant disorder, and attention deficit disorder.
Treatment: Latuda 60mg Tablet.
The insurer denied the Latuda 60mg Tablet. The denial is overturned. 

This male has diagnosis of disruptive mood dysregulation disorder, oppositional defiant disorder, and attention deficit disorder. He has been prescribed Latuda 60 milligrams (MG) daily. Use of this medication has not been authorized by the insurer since the patient's diagnoses do not include one of the usual indications for Latuda such as bipolar disorder, major depression, or schizophrenia. 

However, the facility notes that the patient has a very strong family history of bipolar disorder.  The facility reports, "The patient becomes physically aggressive when agitated. He is a morbidly obese boy and when he is agitated and aggressive family members' safety is at risk. This is not only a medical concern, but physically he can hurt someone seriously. There is a strong family history of bipolar disorder. He has suffered severe irritability for some time and that has led to his being physically aggressive toward others."

Yes, the proposed medical treatment with Latuda is medically necessary.

The treatment staff are explicit regarding this patient's history of aggression and ongoing potential for physical danger to others. They also note extreme irritability. Extreme irritability in a young adult with a strong family history of bipolar disorder is an indication that this patient is in fact likely exhibiting early signs of bipolar disorder which has not yet fully manifested itself. The treatment is appropriate, in the best interest of the patient, and indicates sound medical judgment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease, Diabetes Mellitus, Hypertension, Dizziness and Gait Ataxia
Treatment: Home Care/Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 minutes increase to 24 hour(s) per day (Split-Shift)
The insurer denied the Home Care/Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 minutes increase to 24 hour(s) per day (Split-Shift).
The denial is overturned. 

The patient is a female with a history of Coronary Artery Disease, Diabetes Mellitus, Hypertension, Dizziness and Gait Ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 24 hours per day/split shift Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the Home Care/Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 minutes increase to 24 hour(s) per day (Split-Shift) is deemed medically necessary. 

This is a female with a history of Coronary Artery Disease, Diabetes Mellitus, Hypertension, Dizziness and Gait Ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's physician indicates that due to progressively worsening dementia, the patient has been experiencing a rapid decline in cognitive and motor function including recurrent falls and gait ataxia. She is now fully dependent for assistance completing ADLs (activities of daily living). Hence, the currently approved plan of Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 24 hours/week split shift Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/orthodontic procedure. 
The insurer denied nerve treatment on bicuspid tooth, tooth 4, 5 and 28. 
The denial is upheld in whole.

The patient is a female who presented to the office her dental provider for evaluation and treatment of teeth # 4, 5, and 28. Included for review are previous letters of appeal and denial, full mouth radiographic images, three pages of American Dental Association (ADA) claim forms, and health plan documents. In question is the medical necessity of the planned treatment of root canal therapy for teeth #4, 5, and 28.
Previous denials have been on the basis that root canal therapy is not a covered benefit for teeth involved or planned to be involved with a removable partial denture. From the provided documentation, there is no indication that there has been any evaluation of the teeth in question, diagnosis for the teeth in question nor rationale for the requested therapy. From the radiographic documentation provided, there is no evidence of decay, fracture, or other damage to the tooth that would necessitate the requested therapy for the teeth in question.

The health plan's determination is upheld.

The requested health service/treatment of nerve treatment on bicuspid tooth #4, 5, and 28 is not medically necessary. As there is no evidence of any pulpal diagnosis, any clinical examination, nor any other rationale provided, no therapy is necessary for the teeth in question. From the radiographic evidence provided these teeth do not present with any decay nor peri-apical infection to necessitate root canal therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Nutropin AQ. 
The denial is overturned in whole. 

The patient is a male diagnosed with idiopathic short stature (ISS). His growth hormone (GH) stimulation test (agent not mentioned) peaked at 11. His height velocity is reported to be 3.6 centimeters per year (cm/yr.) His insulin-like growth factor 1 (IGF1) was 189 (49-487); Z-score was 0; insulin-like growth factor binding protein 3 (IGFBP3) was 4350 (2134-6598). His IGF1 was 139 (37-459); Z-score was -0.4 standard deviation (SD); IGFBP3 was 3890 (1828-6592). No Tanner was mentioned. 

His mother's height 152.40 centimeter (cm) and father's height is 167.64 cm and mid parental height is 166.52 cm (-1.44 standard deviation score [SDS]). This subject under review is for the medical necessity of Nutropin. 

Nutropin AQ is medically necessary for this patient. The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below: 

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4, 5, 6, 7, 8, 9]. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means." 

The patient had a pretreatment height less than or equal to -2.25 SD. The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Diagnostic Testing. 
The insurer denied facility based sleep study. 
The denial is upheld in whole.

The patient is a male who was referred to the sleep lab to have a sleep study. The patient has been complaining of symptoms of sleep apnea including sleepiness, snoring, and memory impairment. The patient reports also insomnia and difficulty falling asleep. The patient had a home sleep study that showed mild sleep apnea with an apnea hypopnea index (AHI) of 5.3 events per hour. The subject under review is the medical necessity for the facility based sleep study.

The health plan's determination is upheld. 

This is a patient who is well known to have sleep apnea. There documentation does not support the medical necessity for an in-lab (facility based) sleep study. The home sleep study is as adequate as the in lab sleep study to establish the diagnosis of sleep apnea.
According to Rosen et al., a home sleep apnea test (HSAT) is an alternative to polysomnography for the diagnosis of obstructive sleep apnea (OSA) in uncomplicated adults presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA.
Based on the Canadian Sleep Society, when used appropriately under the supervision of a physician with training in sleep medicine, and in conjunction with a comprehensive sleep evaluation, portable monitoring (PM) may expedite treatment when there is a high clinical suspicion of OSA.
Laratta et al. considered polysomnography as the gold standard for diagnosis of sleep apnea. However, home sleep apnea testing may be used to confirm the diagnosis in symptomatic patients with a high pretest probability of OSA and without clinically important cardiopulmonary comorbidity.
According to the American Academy of Sleep medicine (Collop et al.) portable or home polysomnogram (PSG) is a viable option for evaluating adults with high clinical suspicion for obstructive sleep apnea if it is performed and evaluated by a comprehensive sleep medicine program.
Kapur et al. gives a "strong" recommendation for polysomnography, or home sleep apnea testing with a technically adequate device, to be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA.
Review of the submitted medical information shows that the patient suffers from sleepiness, snoring and memory decline. However, the patient does not have any medical (chronic obstructive pulmonary disease [COPD], congestive heart failure [CHF], neuromuscular disorder) or sleep (narcolepsy, central apnea) comorbidities that can degrade the accuracy of a home/portable study. There is no evidence the patient failed home sleep testing or has any contraindication to portable home sleep study. The home sleep study is as adequate as an in-laboratory sleep study to evaluate this patient for possible sleep apnea. Therefore, the in-laboratory sleep study is not medically necessary. The patient was already diagnosed with sleep apnea with an AHI of 5.3. The in lab sleep study is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Infusion Therapy. 
The insurer denied Prolastin-C for medical necessity. 
The denial was upheld. 

This is a female with severe emphysema who is being prescribed Prolastin-C. She continued to smoke 2 cigarettes per day. She has had a computed tomography (CT) scan showing severe emphysema. Her pulmonary function test (PFT) has also showed very severe airway obstruction with forced expiratory volume in 1 second (FEV1) of 0.34L, 15% predicted. Her alpha-1 phenotype was MZ(one M gene and one Z gene) and her absolute alpha 1-antitrypsin level was 95 milligrams per deciliter (mg/dL).
She has a history of spontaneous pneumothorax and multiple hospital admissions for chronic obstructive pulmonary disease (COPD) exacerbations, including an intubation for respiratory failure. She currently takes Trelegy and albuterol as needed, but has been on Symbicort, Incruse, and Spiriva. She requires supplemental oxygen at 2 liters (L) nasal cannula continuously.
Prolastin-C is at issue for medical necessity.

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

The requested health service/treatment of Prolastin-C is not medically necessary for this patient.
The patient has severe emphysema, but it is not from alpha-1 antitrypsin deficiency. She has the MZ phenotype, with one normal M allele which makes the chance of developing emphysema from an alpha-1 antitrypsin deficiency extremely rare. Additionally, when her level was checked, the alpha-1 level was 95 mg/dL, which is adequate to protect her from developing emphysema from low levels. A level greater than 57 mg/dL is protective against developing emphysema. It is noted that alpha-1 antitrypsin is an acute phase protein. That is true, however if someone has a phenotype and is unable to produce alpha-a antitrypsin, then the level would be low in all circumstances. As such, Prolastin-C is not indicated for this patient.
Therefore, the requested treatment of Prolastin-C is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal Muscular Atrophy
Treatment: Evrysdi SGM
The health plan denied the requested prescription drug. 
The health plan's determination is upheld.

A review of the prior authorization request indicated a diagnosis of spinal muscular atrophy type 2. The patient was not dependent on any invasive ventilation or noninvasive ventilation (though other notes indicate that he was using bi-level positive airway pressure (BiPAP)). The medication was prescribed by or in consultation with a physician specializing in the treatment of spinal muscular atrophy. The patient is not currently undergoing treatment with Evrysdi. The diagnosis of spinal muscular atrophy was confirmed with genetic testing. The patient has three copies of (genetic proteins= survival motor neuron (SMN) SMN2 and 0 copies of SMN1.
The patient did not undergo a Hammersmith Infant Neurological Exam, Part 2, Hammersmith Functional Motor Scale Expanded (HFMSE), Children's Hospital of Philadelphia infant test of neuromuscular disorders or Motor Function Measure - 32 items (MFM-32). The patient's age and initiation of the request is not documented.
An office note indicates that the patient did have BiPAP dependence. He is using BiPAP at night with classicist daily. He was undergoing a home physical and occupational therapy. He required a G-tube (gastrostomy tube) for feeding. He was receiving Spinraza. It was noted that the patient had spinal muscular atrophy type 2 and had a stable motor assessment despite complaints of weakness in the arm that was attributed to a delay in Spinraza dosing. A change to Evrysdi was planned.
The reason for denial on prior review as per communications from CVS Caremark is that the patient did not undergo a Hammersmith infant neurologic exam, part two (HIN2), Hammersmith functional motor scale expanded, Children's Hospital of Philadelphia infant test of neuromuscular disorders (CHOP-INTEND or MFM32).
A letter of medical necessity dated indicated that he had been treated with Spinraza but had a decline in function. His physician recommended Evrysdi. He indicated that the HIN2 and CHOP-INTEND would not be appropriate, that HFMSC could not be performed, and that the MFM 32 was not routinely used in clinical practice.

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

No. Evrysdi SGM is an oral medication used to treat spinal muscular atrophy type I. Evrysdi is not medically necessary. In order to determine whether accuracy is effective for the patient, there must be a reproducible documentation of examination findings. It is possible that the physician may not see the patient at every visit. The HFMSC and MFM 32 would be appropriate for these patients. The risk of physical injury with the HFMSC is low. There is no rationale why the physician cannot perform these simple tests or derive a score from his existing examination. The patient would be most properly monitored with the use of these of one of the scales, and, in its absence, response or lack of response cannot be monitored and the requested medication would therefore not be considered medically necessary.