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

Diagnosis: Idiopathic intracranial hypertension.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has a medical history of idiopathic intracranial hypertension and bilateral transverse venous sinus stenosis.  She was admitted for a cerebral angiogram, a venogram with manometry and Venous sinus stenting.  Two overlapping stents were placed in the right transverse/sigmoid venous junction with post stenting resolution of stenosis and improved pressure gradient.  In the postoperative course there were no adverse reactions reported.  The patient was admitted to a step down admission with continued neurovascular checks per protocol.  Postoperative medications, including Dexamethasone 4 milligrams (mg) intravenous (IV) every (Q) 8 hours, were continued.  The patient was monitored overnight for potential complications.  At issue is the medical necessity of an inpatient stay.

The inpatient stay is not medically necessary.  While the patient required an overnight stay post-procedure for monitoring of complications, this could have been accomplished at a lower level of care than an inpatient stay.  Potential major complications following dural venous sinus stenting include intracranial hemorrhage, venous thrombosis with secondary ischemic complications, as well as procedural complications.  Since the first reported case in 2002, venous sinus stenting (VSS) has gained increased acceptance as a minimally invasive surgical option for patients with idiopathic intracranial hypertension (IIH) and significant cerebral venous sinus stenosis (CVSS).  The objective of VSS is to alleviate significant stenosis typically found at the transverse-sigmoid sinus junction, thereby reducing intracranial pressure (ICP) and alleviating the symptoms of IIH.  Idiopathic intracranial hypertension (IIH) is a commonly occurring disease, and the underlying pathophysiology in the recent literature suggests that focal outflow obstruction of the transverse sinus may be the cause.  VVS has shown results, but it is an invasive procedure that requires post procedural monitoring for immediate complications, which, though rare, can occur.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cyanosis; breath holding. 
Treatment:  Inpatient hospital admission. 

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

The patient is a male, who was born at term with an uncomplicated newborn course.  The patient had been having inconsolable crying episodes when sleeping at night for a few weeks.  There have been some episodes of spitting up after feedings.  The patient's mother reported that for the past few nights, the patient had several episodes of straining, as if to have a bowel movement and then turning blue during these crying episodes.  The patient's mother reported that the patient's cyanosis quickly resolved when the baby was picked up.  Because these episodes were recurring for the past few nights, the patient's mother brought the patient to the Emergency Room (ER) for an evaluation.  In the ER, the patient was noted to have normal vital signs and to be crying but consolable.  The patient's physical exam was normal.  The patient had a normal electrocardiogram (EKG) and a normal respiratory viral panel.  In view of the episodes of cyanosis, the decision was made to admit the patient to the Telemetry Unit for observation with a diagnosis of a crying baby. 

Based on the review of the medical record and literature, the patient presented to the hospital with clinical picture of "brief resolved unexplained event (BRUE)".  According to UpToDate, consensus in 2016 indicated the use of BRUE instead of "apparent life-threatening events" (ALTE) whenever the event is transient and remains unexplained after an appropriate medical evaluation.  These events characterized by either cyanosis/pallor, absent/decreased/irregular breathing, marked change in tone (hyper- or hypotonia), or altered level of responsiveness, are often less than 1 minute
in duration (typically <20 to 30 seconds).  Studies have shown that most but not all infants with BRUE are at low risk for recurrence or for having a serious underlying problem.  Infants who have experienced BRUE are considered low risk if they have all of the following:  1) age>60 days, 2) gestational age >=32 weeks and postconceptional age >=45 weeks, 3)  occurrence of only one BRUE (no prior BRUE, and BRUE did not occur in clusters), 4) duration of BRUE <1 minute, no cardiopulmonary resuscitation (CPR) by a trained medical provider was required, 5) no concerning historical features, and 6) no concerning physical examination findings. 

In this case, the patient's young age and the fact that these episodes recurred for several nights are consistent with a high risk for a recurrence of these episodes of cyanosis and breath holding.  Thus, it was appropriate to admit the patient to the hospital for close monitoring and observation.  Thus, inpatient admission was medically necessary for this patient. 

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

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Bronchiectasis, Sarcoidosis.
Treatment:  Cayston (inhaled aztreonam).

The insurer denied coverage for Cayston (inhaled aztreonam).  The denial is overturned.

This is a female patient, who has been diagnosed with sarcoidosis, sickle cell disease, and bronchiectasis.  She utilizes oxygen therapy primarily at night.  This patient has been treated for bronchiectasis exacerbations numerous times with ciprofloxacin and levofloxacin; however, she continues to have symptoms of persistent cough with copious sputum and shortness of breath.  Cultures consistently show moderate Pseudomonas aeruginosa.  The patient has been trialed on inhaled tobramycin but she developed ototoxicity.  Given the inability to utilize the above, with the failure of treatment with ciprofloxacin and levofloxacin, the patient has limited options.  She does not have cystic fibrosis; however, she does have positive cultures; therefore, it was recommended that she utilize the requested Cayston.

Scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.  The indication for the use of this medication is for the treatment of respiratory infections, including those of pseudomonas in cystic fibrosis patients, and is well supported by the available evidence.  The use of this medication for the treatment of respiratory infections with the intent of improving symptoms in non-cystic fibrosis patients with bronchiectasis has been studied and supports efficacy.

The FDA has only approved this medication for the use of respiratory infections in patients with cystic fibrosis.  There is no FDA approved indication for the treatment of respiratory infections in non-cystic fibrosis patients; however, the medication is supported for off-label use based on literature. 

This patient is a good candidate for Cayston.  There is current evidence that this medication improves symptoms in non-cystic fibrosis patients.  She has been unresponsive to other alternative treatment and would be a good candidate for Cayston at this time.  The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for Cayston, inhaled medication, should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Bronchiectasis, Sarcoidosis.

Treatment:  Cayston (inhaled aztreonam).

The insurer denied coverage for Cayston (inhaled aztreonam).  The denial is overturned.

This is a female patient, who is currently diagnosed with sarcoidosis, sickle cell crisis with spleen atrophy, and bronchiectasis.  She had subjective complaints of a chronic cough with copious sputum; she was on oxygen at night.  The infectious disease provider requested Cayston for the treatment of bronchiectasis in this patient; she had Pseudomonas aeruginosa present in her airway cultures.

There is scientific evidence in peer reviewed literature that supports improved health outcomes with Cayston (inhaled aztreonam) for patients with non-cystic fibrosis bronchiectasis (NCFB).  Cayston was shown to improve quality of life in patients with bronchiectasis and high bacterial load in one study.  Another study showed aztreonam improved cough (20%) and sputum production (25%) compared to a placebo.  

Cayston does not have final approval for NCFB.  Cayston has a label to improve respiratory symptoms in cystic fibrosis (CF) patients with pulmonary Pseudomonas aeruginosa infections.  There are currently no FDA approved drugs for NCFB.  

This patient is a good candidate for Cayston.  NCFB is characterized by recurrent lung infection, sputum production, and cough, often requiring long-term antibiotic therapy and hospitalization.  This patient has Pseudomonas on respiratory cultures, chronic and persistent cough, copious sputum, and night-time oxygen requirement despite completing 10 days of systemic antibiotics and steroids.  

In the absence of any approved medications for NCFB specifically and failure of systemic antibiotics and steroids, Cayston appears to be the best available treatment at this time.  Cayston is likely to be more beneficial than standard treatment (none).  There is no current standard treatment for NCFB.  Since the permanent and progressive destruction of the airways leading to poor lung function in NCFB are similar to the process seen in CF, inhaled aztreonam (Cayston) is expected to be more beneficial than standard treatment, since there is none.

The carrier's denial of coverage for Cayston, inhaled medication, should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Chronic Bronchiectasis, Sarcoidosis.
Treatment:  Cayston (inhaled aztreonam).

The insurer denied coverage for Cayston (inhaled aztreonam).  The denial is upheld.

This is a female patient with a past medical history significant for sarcoidosis, sickle cell crisis with splenic atrophy, pulmonary hypertension, Mycobacterium avium complex infection, chronic bronchiectasis and chronic productive cough.  The patient has been treated with ciprofloxacin and prednisone, as well as inhalational aminoglycosides in the past but developed ototoxicity. 

At issue is the medical necessity for inhalational Cayston.  It is indicated to improve respiratory symptoms in cystic fibrosis patients with Pseudomonas aeruginosa (P. aeruginosa).  The active ingredient in Cayston is aztreonam, a monobactam antibacterial.  

Because of the propensity of P. aeruginosa to develop resistance and the limited availability of oral agents, the efficacy of adding inhaled antibiotics, such as tobramycin, to oral antibiotics, such as ciprofloxacin, has been studied, including a multicenter trial with 53 patients with known P. aeruginosa infection, who were having exacerbations of bronchiectasis.  The addition of inhaled tobramycin to oral ciprofloxacin did not improve clinical outcomes compared to ciprofloxacin alone.

Based on current data, inhaled aerosols of antibiotics are generally not recommended alone or in combination with oral antibiotics for acute exacerbations in bronchiectasis.  The role of inhaled antibiotics in non-cystic fibrosis bronchiectasis continues to evolve.  Society guidelines and systematic reviews suggest a therapeutic trial of inhaled antibiotics in patients with three or more exacerbations per year or significant morbidity from fewer exacerbations and P. aeruginosa in their sputum.  Inhaled antibiotics, including aztreonam, have been investigated primarily in patients with cystic fibrosis when P. aeruginosa is present in the respiratory secretions.  Benefits in cystic fibrosis patients have been demonstrated.  Inhaled antibiotics may play a role in the future in the management of some patients with non-cystic fibrosis bronchiectasis and Pseudomonas infection/colonization, but currently no agent is approved for this purpose by the US Food and Drug Administration (FDA).

Based on these findings, Cayston (inhaled aztreonam) is not likely to be more beneficial than any other standard treatment.

The carrier's denial of coverage for Cayston, inhaled medication, should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted teeth
Treatment: D7240 - Removal of impacted tooth-completely bony Tooth 17, 32;
D9239 - Intravenous moderate (conscious) sedation/analgesia first 15 minutes;
D9243 - Intravenous moderate (Conscious) sedation/analgesia each subsequent 15 minute 
increment x 3
The insurer denied the D7240 - Removal of impacted tooth-completely bony Tooth 17, 32;
D9239 - Intravenous moderate (conscious) sedation/analgesia first 15 minutes;
D9243 - Intravenous moderate (Conscious) sedation/analgesia each subsequent 15 minute 
increment x 3
The denial is overturned. 

The patient is a male. He was denied removal of his lower impacted wisdom teeth, as the roots are not completely formed.

Yes, the proposed treatment is medically necessary.

The panorex shows inadequate space for the wisdom teeth to erupt. The American Association of Oral and Maxillofacial Surgeons (AAOMS) Parameters of Care states that an impacted third molar that is so positioned that it will probably not erupt by the middle of the third decade constitutes pathology with dental and medical consequences. To limit known risks and complications associated with surgery, it is medically appropriate and surgically prudent to remove impacted third molars before the middle of the third decade and prior to complete root development. An impacted tooth with completed root formation that is totally covered by bone in a patient beyond the third decade that does not meet the following indications for removal should be monitored for change in position and/or development of pathology, which may then indicate its removal. The patient meets these criteria, as the patient has impacted wisdom teeth that are so positioned that they will probably not erupt by the middle of the third decade. 

The plan acted according to its guidelines, but these are not the standard of care in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: CT Scan of Abdomen and pelvis (Pre-Service).
The insurer denied the CT Scan of Abdomen and pelvis (Pre-Service).
The denial is upheld. 

The patient is a male with increased LFTs (live function tests). He underwent US (ultrasound), which revealed hepatosplenomegaly and gallstones. Labs revealed elevated IBD (inflammatory bowel disease) markers. A CT scan of the abdomen and pelvis with IV contrast revealed a normal liver and bowel. His MD is requesting CT scan to r/o (rule out) liver mass, cirrhosis and IBD.

No, the CT Scan of Abdomen and pelvis is not medically necessary.

The patient has increased LFTs, and an US with hepatosplenomegaly. While cirrhosis is a possibility, a CT is not the best test to r/o cirrhosis. Lab testing with Fibrosure, imaging with ultrasound elastography, or a nuclear medicine liver spleen scan are the best tests to evaluate for the possibility of cirrhosis and are the standard of care. 
The patient also has elevated serum markers that could signify IBD. CT scan is not a good test to r/o IBD. If IBD is suspected, standard of care is colonoscopy, and/or small bowel evaluation with small bowel series or capsule endoscopy.

Finally, in the absence of cirrhosis, the patient is not at increased risk for liver mass. Even if the patient were found to have cirrhosis, screening for liver cancer in patients with cirrhosis consists of a yearly US of the liver and AFP (alpha-fetoprotein). If US reveals an abnormality, or if AFP is elevated, then an MRI of the liver would be standard of care to rule out a liver mass. As the standard of care tests to look for liver mass, cirrhosis or IBD in this patient are a serum AFP, a Fibrosure or ultrasound elastography, and a colonoscopy and small bowel series or capsule, the requested CT scan of the abdomen and pelvis is not clinically appropriate or accepted standard of medical care at this time, and is not medically necessary. The health plan therefore acted reasonably, with sound medical judgment and in the best interest of the patient, by denying it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Paranoid schizophrenia, diabetes. 
Treatment: Consumer Directed Personal Assistance Services. 

The insurer denied the Consumer Directed Personal Assistance Services. The denial is upheld. 

The patient is a female with a history of paranoid schizophrenia, hypertension and diabetes mellitus. 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 40 hours per week Personal Assistance Services to offer increased ADL support. 

No, the proposed treatment of 40 hours per week Personal Assistance Services is not deemed medically necessary. 

This is a with a history of paranoid schizophrenia, hypertension and diabetes mellitus. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). However, an in-home assessment of the patient's functionality and ability to perform ADLs was completed and revealed that her currently approved plan of Personal Assistance Services is sufficient to meet the patient's current needs. There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment of 40 hours per week Personal Assistance Services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Neurocognitive decline.
Treatment:  Modafinil.
The insurer denied Modafinil.  The determination is upheld.

The patient has a diagnosis of a non-seminomatous germ cell tumor.  He was seen because of a concern for neurocognitive decline, attributed to multiagent chemotherapy for the treatment of germinoma.  He was found to have a mixed germ cell tumor with 80% embryonal carcinoma, 20% yolk sac tumor with angiolymphatic invasion by embryonal carcinoma.  He describes having difficulty focusing and concentrating for more than 1 to 2 hours at a time.  He had no problems with attention before developing the cancer.  Brain magnetic resonance imaging (MRI) was significant only for a capillary telangiectasia.  He had a normal mental status and neurological examination.  A trial of Modafinil was recommended.  At issue is the medical necessity of Modafinil.

Modafinil is not medically necessary.  The patient has a diagnosis of a non-seminomatous germ cell tumor.  He was seen because of a concern for neurocognitive decline, attributed to multiagent chemotherapy for the treatment of germinoma.  A review of current medical literature, including all of the references provided [2-6], fails to reveal any evidence that Modafinil is effective in restoring cognitive function were attention in patients with post-chemotherapy cognitive complaints.  The clinical trials, including one provided by Dr. Kurz, have been negative.  There is, therefore, no evidence of efficacy for the requested service of modafinil in the peer-reviewed medical literature to support its use.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional
Treatment: Pharmacy/Prescription Drugs
The insurer denied: Eligard
The denial is: Upheld in whole

The patient is a female diagnosed with precocious puberty. This request is for Eligard. As reported; she underwent extensive pubertal advancement over the past 6 months and her bone age is 2-3 years ahead of her chronological age (CA). She has height prediction of approximately 58-59 inches. The subject under review is the medical necessity for Eligard.

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

The definition of precocious puberty is children who have the onset of secondary sexual characteristics younger than age 8 in girls and younger than age 9.5 in boys.[1-3] Central precocious puberty (CPP) is diagnosed using a basal luteinizing hormone (LH) of greater than (>) 0.3 or stimulation testing with a gonadotropin-releasing hormone (GnRH) analog such as leuprolide showing a pubertal response defined as an LH >5 and estradiol greater than 40. [4] CPP is treated with GnRH agonists[5-10] such as Lupron[11] and Supprelin.[12] The Food and Drug Administration (FDA) indication for GnRH agonists is for use in central precocious puberty (CPP). In addition, when used for CPP the FDA recommends discontinuation of GnRH agonists before age 11 for females and before age 12 for males.[11] This is consistent with accepted recommendations for discontinuation of GnRH agonist therapy. 

The patient's current age is beyond the age when treatment is normally discontinued for central precocious puberty. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Coronary Artery Disease
Treatment: Personal Care Services

Summary:
The proposed treatment of an increase in Personal Care Services to 24 hours a day, 7 days a week (Split Shift for a total of 168 hours per week) is deemed medically necessary. 

This is a male with a history of stroke, coronary artery disease, atrial fibrillation, dementia, insomnia, urinary incontinence and chronic gait ataxia. Due to impairments related to these conditions, he requires assistance with completion of the majority of his activities of daily living (ADLs). Documentation from the patient's Attending Physician indicates that the patient's overall medical condition has significantly deteriorated with worsening dementia/cognitive impairment, mobility/strength and insomnia. For these reasons, the currently approved plan of Personal Care Services is insufficient to meet the member's needs. Hence, the proposed treatment of an increase in Personal Care Services to 24 hours a day, 7 days a week (Split Shift for a total of 168 hours per week) is deemed medically necessary for improved assistance with completion of the patient's ADLs.