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

Diagnosis: Back pain
Treatment: Neurotransmitter, Pre-service
The insurer denied the Neurotransmitter, Pre-service
The denial is overturned.

The patient is a female with chronic low back pain. She has failed multiple modalities including physical therapy, home exercise, kyphoplasty, epidural steroid injections (ESI) and radiofrequency ablation (RFA).

Yes, the Neurotransmitter is medically necessary.

The patient is a female with chronic low back pain. She has failed multiple modalities, including physical therapy, home exercise, kyphoplasty, epidural steroid injections (ESI) and radiofrequency ablation (RFA).

The patient's low back pain is non-surgical.  She has tried adjuvant medications such as Cymbalta.  She has tried and failed most conventional treatments for low back pain. She has had multiple ESIs (epidural steroid injections).  She is trying to avoid surgery, and surgery has not shown to have good results in axial low back pain without instability secondary to spondylolisthesis.  Recent advances in spine cord stimulation (SCS) has shown good results even with axial low back pain. The use of high frequency stimulation has improved results for SCS (spinal cord stimulation) for chronic low back pain.  Surgery is not without risk, opiate medications carry a high risk, and show poor long-term outcomes. Given that the patient has failed all other non-invasive modalities, it is medically necessary to consider a trial of neurostimulation/neuromodulation.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a past medical history of hypertension, dyslipidemia, and coronary artery disease status post prior percutaneous coronary intervention (PCI) with a total of five stents placed.  

The patient presented for evaluation of new onset chest pain, right-sided, non-reproducible, non-exertional with no radiation. The patient was hemodynamically stable. The electrocardiogram (ECG) revealed no acute ischemic changes. Cardiac troponins were negative. The patient was admitted to telemetry to rule out acute coronary syndrome (ACS). No inpatient ischemic work-up was planned. The chest pain subsequently resolved. Repeat troponin was negative as well. The patient was discharged home with a plan for outpatient follow-up.

No, the inpatient admission was not medically necessary.

The patient presented with atypical chest pain. There were no acute electrocardiogram changes or increase in cardiac biomarkers. Acute myocardial infarction was ruled out by cardiac troponins, which were negative. There was no evidence of acute coronary syndrome, acute myocardial infarct (MI), decompensated congestive heart failure (CHF) or hemodynamic instability. The patient was monitored until acute coronary syndrome was ruled out and discharged with no plans for inpatient stress testing or angiography. Therefore, the medical necessity of the inpatient admission is not established and the services could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath and Chest Pain (pulmonary embolism). 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 

The denial is upheld. 

The patient is a male with history of hypertension who presented to emergency room with shortness of breath and chest pain that had stated five days prior to presentation. The patient had been seen by his primary physician (PMD), was noted to have sinus tachycardia on electrocardiogram (EKG), and was sent to emergency room. 

In the emergency room, the patient was found to have pulmonary embolism. The patient was admitted for the management of pulmonary embolism. The patient was treated with subcutaneous (SC) Lovenox as well as empiric antibiotics. The patient did not require supplemental oxygen. The patient did not have right heart strain. The patient was feeling better in 24 hours of admission. 

No, the proposed treatment was not medically necessary. 

The patient was found to have submassive pulmonary embolism with pulmonary infarct. The patient did not require supplemental oxygen. The patient did not have right heart strain. The patient's symptoms improved within 24 hours of hospitalization. The acute inpatient hospital level of care was not medically necessary. The care could have been safely and effectively provided at a lower level of care. 

The acute inpatient hospital level of care was not medically necessary. The care could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Cancer
Radiation Therapy

Diagnosis: Glioblastoma Multiforme
Treatment: Proton beam therapy
The insurer denied proton beam therapy. 
The health plan's determination is upheld. 

This patient is a man with a right temporal brain glioblastoma multiforme status/post subtotal resection. Radiation therapy is recommended to this region to attempt long term control and the proton beam approach is being requested.

The requested proton beam therapy is not medically necessary for this patient and his subtotal resected glioblastoma multiforme. There is a lack of any significant studies published in peer reviewed journals supporting the benefits and safety of proton radiation for this clinical scenario. This is not a standard treatment option and is under clinical trial to determine its efficacy and safety. Until these trials mature and are published in peer reviewed journals showing the benefits and safety over conventional photon beam radiation, proton beam radiation therapy is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

The patient is a male who was seen for a diagnosis of cervical spinal cord myelomalacia made by neurology then referred to the current provider. The patient's complaints at that time were left index finger numbness and recent right shoulder and arm pain. The patient denied gait instability, imbalance or trouble with fine motor function. His neurological examination at that consultation revealed slight numbness in the radial border of his left index finger and was otherwise unremarkable. A magnetic resonance imaging (MRI) of the cervical spine was reviewed and reportedly showed a large disc herniation at cervical (C)3-4 with significant canal stenosis and spinal cord compression, including signal change within the cord, as well as moderate canal stenosis at the C4-5 level with mild cord compression without signal change. Given the large size of the disc herniation and severe cord compression, even though the patient was relatively asymptomatic from the myelomalacia, the surgeon discussed the potential of sudden irreversible spinal cord damage and recommended an anterior cervical discectomy and fusion (ACDF) C3-4 and C4-5 procedure. This was carried out and no complications were recorded in the operative note. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld.

There is no support in the documentation provided or the medical literature for the medical necessity of an inpatient admission for this patient undergoing an elective ACDF procedure. It is very common to admit ACDF patients to a lower level of care status in order to monitor them overnight, as the complications of respiratory distress from either tissue swelling or a postoperative hematoma usually occur the night of surgery and frequently require emergent attention. In addition, if any intraoperative or postoperative complications occur, then the patient can always be reclassified as an inpatient as needed. In healthy selective patients, not necessarily this patient with significant spinal cord compression and a remote history of a deep vein thrombosis (DVT), this procedure is frequently carried out at a lower level of care setting.
The stay in this case was appropriate for a lower level of care status, an inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension.
Treatment: Edarbyclor 40-12.5 milligrams oral Tablet.

The insurer denied coverage for Edarbyclor 40-12.5 milligrams oral Tablet.  The denial is upheld.

The patient is a male with a history of hypertension. According to statements by the patient's cardiologist, all other formulary angiotensin receptor blockers have been utilized to treat hypertension unsuccessfully, and the patient has been adequately treated effectively with Edarbyclor 14-12.5 milligrams in the past. Review of pharmacy records does not confirm the use of multiple other angiotensin receptor blockers medications for treatment. No blood pressure data regarding the failed therapies were provided.

Review of submitted pharmacy benefit claims reveals that the patient was treated with lisinopril hydrochlorothiazide in addition to amlodipine and bisoprolol. Recently, he was switched to olmesartan, and two months later he was prescribed chlorthalidone. The records show ongoing treatment with no apparent gaps. There are no records that the patient was treated with Edarbyclor recently or any of the six other stated angiotensin receptor blockers.  

Trials of antihypertensive medications that may not be effective may result in adverse reactions, such as poorly controlled hypertension and even hypertensive urgency (Reference 1).  This patient has been treated with multiple angiotensin receptor blockers and is on two other antihypertensive agents. Chlorthalidone is the preferred diuretic treatment for patients with hypertension based on its long half-life and proven trial reduction of cardiovascular disease (Reference 2).  As of the pharmacy records, he was prescribed Edarbi (which is azilsartan medoxomil) and chlorthalidone 25 milligrams. These are the 2 components of Edarbyclor. Aside from the fact that Edarbyclor combined the 2 into a single tablet, there should be no difference in effectiveness regarding blood pressure control by taking 2 separate tablets. Thus, the need for Edarbyclor is not supported.

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

The insurer's denial of coverage for Edarbyclor 40-12.5 milligrams oral Tablet is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who is seeking continuation of growth hormone (GH) treatment for subtle GH resistance. He has been followed in the pediatric endocrinology clinic for over 10 years. His insulin like growth factor-1 (IGF-1) was low and bone age was delayed for which he underwent growth hormone (GH) stimulation testing and his peak GH response was 32.6 and 32.8 nanograms/milliliter (ng/ml) after Arginine and Clonidine respectively. His magnetic resonance imaging (MRI) scan was normal. He also underwent IGF-1 generation test and his baseline IGF-1 was 62 ng/ml which improved to 127 ng/ml after 1 week of GH (0.7 milligrams per kilogram (mg/kg)/week). The health plan's determination is overturned.  He still seems to be growing and his growth velocity was 3.1 cm per year in the last 5 months, which justifies the continuation of growth hormone.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer
Treatment: Surgical Services
The insurer denied the liver transplant. 
The denial is overturned.

The patient is a male with colorectal adenocarcinoma metastatic to liver, under evaluation for liver transplantation in treatment management. The sigmoid primary was diagnosed with liver metastases only, started chemo with FOLFIRINOX and underwent a left hepatectomy and sigmoid colectomy documenting a stage T4aN1bM1a primary, with negative margins. Recurrent liver-only metastases were detected and determined to be unresectable due to proximity to major vascular structures. The patient was continued on regimen of XELIRI and bevacizumab, and currently on maintenance chemo with capecitabine and bevacizumab. Most recent scans show relatively stable, liver-limited disease, but has developed peripheral neuropathy as side effects from chemotherapy. The subject under review is whether liver transplant is likely to be more beneficial for this patient.

Due to the limited number of eligible patients (which would hinder the progress of a prospective Randomized Controlled Trial [RCT]), the most active group reporting on the utility of liver transplantation for non-resectable colorectal liver metastases focused on improving the selection criteria for improving overall survival (OS) in this setting [1]. Medical options exist for Stage 4 colorectal cancer with recurrent, nonresectable metastases to the liver [2], with 5-year OS rates of 10 to less than (<) 20% [1, 3], which is significantly less than the results obtained for the selected patients in the study.
As the original hepatic metastases did not have any tumors greater than (>) 10 centimeters (cm) (or if > 30 metastatic foci, none > 5 cm), the patient fulfills all other inclusion criteria (and does not have any exclusion criteria) outlined by Dueland, in addition to having a low Fong Clinical Risk Score and Oslo Score [1], which frames the patient as an ideal candidate for the procedure.

If minimal or no post-transplant related complications occur, then the patient's treatment compared to chemotherapy is likely to be more beneficial in terms of a survival advantage, as well as quality of life. Both the OS and the disease-free survival may possibly be less than expected, however, due to the tumor being Kirsten rat sarcoma (KRAS) mutated and the nodal status of the primary tumor [4], and post-transplant chemotherapy needs to be considered. Based on the above discussion, this reviewer is overturning, in whole, the health plan's determination regarding the proposed health treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer
Treatment: Surgical Services
The insurer denied the liver transplant.
The denial is upheld.

The patient is a male type 2 diabetic with left hepatectomy and sigmoid colectomy for poorly differentiated colorectal adenocarcinoma. The patient was treated with chemotherapy with good response, now on maintenance therapy. The Oslo score is 0-1 (favorable outcomes in a thus-far limited patient population).

The subject under review is whether the liver transplant is likely to be more beneficial than any standard treatment.

The proposed treatment, according to surgical literature in a limited number of patients, can be expected to have significantly better long-term survival than standard therapy (chemotherapy).

However, the proposed liver transplant is not the standard-of-care in the United States. Extrahepatic malignancy is specifically excluded from liver allocation rules set out by the Organ Procurement and Transplantation Network (OPTN) bylaws as an accepted indication for deceased-donor liver transplant. The only way such patients can be transplanted is via live-donor liver transplant, or unused/discarded deceased donor organs.

While the result of the "Oslo" protocol are encouraging, this has been done in the United States (US) an estimated fewer than a dozen times and this is practiced in only a very limited number of the nation's transplant centers.

This is an emerging practice. This is not considered the standard of care (yet) in the US. For at least 30 years, metastatic colon cancer has been an absolute contraindication to liver transplantation. Most health plan's appropriately exclude metastatic colon cancer as an indication for liver transplantation, based upon the current literature.

The Oslo group has bravely been pushing the envelope and in carefully selected patients is showing good results. To this reviewer's knowledge very few (less than a dozen in aggregate) cases have been done in the US, including at the University of Rochester, University of Pittsburgh Medical Center (UPMC), and Columbia. Some years from now this may be the standard, but it is not now and certainly is not deemed a standard by the OPTN.
Appeal type: Medical necessity
Decision: Upheld

Dental problems
Dental Procedure

Diagnosis: odontoma
Treatment: Intraoral Osteotomy 
The insurer denied the Intraoral Osteotomy. The health plan's determination is upheld

The patient is a female with an odontoma that is encroaching upon the nasal cavity. There are no radiographs provided. Under review is the medical necessity of an Intraoral Osteotomy.

An Intraoral Osteotomy is not medically necessary for this patient.
Although treatment is needed for this patient, it cannot be determined that an intraoral osteotomy is the indicated procedure. Odontomas represent the most common type of odontogenic jaw tumors among patients younger than 20 years of age. Clinically, they are often associated with eruption failure of adjacent permanent teeth. Radiographic examination is essential to verify the presence of the tumor and early removal prevents tooth eruption failure and disturbances in a majority of the cases. In this case, no radiographs were provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Back Pain
Treatment: Pain Management
The health plan denied the requested pain injections as not medically necessary. 
The health plan's determination is upheld.

This is a female patient. The patient is noted to have a history of low back pain.
In a progress note , the patient appeared to have reports of low back pain and leg pain in the joints rated at 3/10. It was noted the patient has had nerve conduction studies. The patient complained of neuropathic pain with burning, numbness and shooting. Pain is located in the low back, tailbone, radiating to the right buttock and left buttock and ankles as well as the bilateral knees. Prior treatment has included anticonvulsants with Gabapentin and Lyrica, nonsteroidal anti-inflammatory drugs including Celebrex, acupuncture was not effective, physical therapy/home exercise were not effective, and aquatic therapy and transcutaneous electrical nerve stimulation (TENS) unit were not effective. She reports she cannot get any relief. She reports functional limitations in ability to work, aerobic activity, hobbies, housework and normal sleep pattern. Lumbar examination revealed tenderness to palpation at the bilateral paraspinals, restricted painful extension. Motor strength was 5/5 in the bilateral lower extremities. There was positive facet challenge. There was numbness in the legs. Assessment included low back pain, neuropathic pain in the legs, and spondylosis of lumbar joint. The provider states that her magnetic resonance imaging (MRI) is positive for facet arthropathy at (lumbar)  L2-L3, L3 - L4 and L4 - L5 and therefore they are requesting diagnostic lumbar facet blocks, given she has failed many conservative treatments.
At issue is the medical necessity of the requested pain injections.

I uphold, in whole the health plan's determination of medical necessity.

No, the requested health service/treatment of pain injections is not medically necessary for this patient. According to evidence-based Official Disability Guidelines (ODG), facet injections/medial branch blocks can be considered when there are objective examination findings consistent with facet mediated pain, no evidence of radiculopathy, as well as failure of at least 3 months of conservative treatment including physical therapy or chiropractic treatment, home exercise, and medications such as nonsteroidal anti-inflammatory drugs. One (single) set of diagnostic medial branch nerve blocks (MBBs) is required, with documented pain reduction greater than or equal to   70%, lasting approximately 2 hours (Lidocaine); confirmatory (repeat) blocks are not recommended prior to neurotomy if diagnostic criteria are confirmed. No more than 2 intervertebral disc/facet joint levels bilaterally should be injected during any one session; the number of medial branch nerves injected will vary according to joint level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease with unstable angina

Treatment: Inpatient admission

The insurer has denied coverage for inpatient admission.

The denial is upheld. 

This male patient has a history of diabetes mellitus, hypertension, hyperlipidemia and coronary artery disease (CAD) with 6 stents that had prior revisions with the last revision being one month prior to arrival. He is on Plavix and aspirin. He presented to the Emergency Department (ED) with complaints of chest pain of three days duration and shortness of breath at rest. An electrocardiogram (EKG) showed normal sinus rhythm with peaked T waves (the deflections in an EKG that represent the electrical activity produced by ventricular repolarization) and no ST segment (the isoelectric period when the ventricles are in between depolarization and repolarization) changes. His HEART (History, EKG, Age, Risk Factors, and Initial Troponin) score was 5. He was given nitroglycerine and aspirin, and then admitted to the telemetry unit for cardiac work up of CAD with unstable angina. The initial plan was for cardiac catheterization; however, the patient's Cardiologist noted a recent outpatient work up. The patient was cleared for discharge.

The patients' pretest probability of coronary artery disease is intermediate. (1) Utilizing the HEART score, he was considered intermediate risk (5 points). (2) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati, et al. (3) Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, and ischemia work up prior to discharge.

The patient is followed closely by his cardiologist and underwent balloon angioplasty of a previously placed stent approximately one month prior to presentation. Serum troponin and EKG tracings were within normal limits. Numerous studies have demonstrated that such work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. (4,5) They found no significant difference in outcome at 30 days between the two groups. Fernanda Bellolio, et al noted that patients presenting with chest pain that were managed in an observation unit had similar 30-day myocardial infarction rates as those admitted to the hospital. (5)

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 the inpatient hospital admission is upheld. The medical necessity is not substantiated.