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

Diagnosis: Diabetes Mellitus, Multi infarct dementia, gait ataxia, Hypertension, Macular Edema and Diabetic Retinopathy
Treatment: Increase in Personal Care Services
The insurer denied Personal Care Services. The denial is overturned.

The patient is an elderly female with a history of Diabetes Mellitus, Multi infarct dementia, gait ataxia, Hypertension, Macular Edema and Diabetic Retinopathy. 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 provider indicates that the patient has demonstrated progressive functional decline and worsening cognitive impairment, mobility and ability to perform ADLs, now requiring 1 person assist for major ADLs including toileting, transfers and ambulation. For these reasons, the currently approved plan of Personal Care Services is insufficient to meet the patient's current needs. Hence, the proposed treatment of an increase in Personal Care Services for increased ADL assistance is deemed medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: History of stroke.
Treatment: Formulary exception for Pradaxa (dabigatran).
The insurer denied Formulary exception for Pradaxa (dabigatran). The denial is overturned.

This is an adult male with a history of stroke. The medical documentation provided by the patient's wife, as well as the patient's medical provider indicate that this patient has tried and failed all three formulary alternative anticoagulants, including Warfarin, Eliquis and Xarelto. He has sustained adverse effects with all of these medications, including the development of hematuria, urinary tract infection (UTI) and cellulitis. However, the patient has been stable on regimen of Pradaxa with no adverse effects reported. For these reasons, the health plan should approve a formulary exception for Pradaxa (dabigatran) for treatment of this condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse /addiction/alcohol abuse addiction.
Treatment: Substance abuse Inpatient. 
The insurer denied  the inpatient detoxification stay.
The denial is overturned in whole.

The patient who was self-referred and presented to the emergency department with a request for detoxification treatment prompted by health concerns, psychosocial stress, impairment of functioning and complaints related to alcohol withdrawal. The patient was medically screened and admitted to inpatient level services for monitoring and detoxification and withdrawal management of severe alcohol use disorder.
 The patient in this case presented with a diagnosis of severe alcohol use disorder with symptoms of withdrawal that were moderately severe. The patient  had a history of trauma with co-occurring anxiety and depression that was related to and triggering his alcohol use disorder, as well as intense craving. The patient also has history of hypertension and stroke/CVA adding risk for complications of alcohol withdrawal.
The presenting clinical features and risk for withdrawal seizures and other psychosocial complications of alcohol use disorder did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The patient's admission and continued inpatient stay with detoxification, withdrawal management, through discharge could not have been effectively or safely provided at a lower level of care in this case scenario.
The inpatient treatment of this patient's substance use disorders did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with withdrawal symptoms and co-morbid medical conditions and co-occurring mental disorders as noted in the clinical summary.
Withdrawal symptoms were managed with tapering dosages of benzodiazepine/Librium requiring monitoring, as well as comfort medications and vitamin and nicotine replacement therapy. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care. This answer is consistent with the application of NY State OASAS LOCADTR 3.0 Criteria and Guidelines., and is consistent with prevailing standards of medical practice, published practice guidelines, and American Society of Addiction Medicine (ASAM) Criteria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Oral Candidiasis 
Treatment: Inpatient admission 
The insurer is denied coverage for the inpatient admission.
The denial is overturned.

This is a female patient with a medical history of being immunocompromised and substance abuse. She presented to the Emergency Department (ED) with complaints of malaise, weight loss, and poor oral intake secondary to oral thrush.

Her vital signs on presentation were: temperature of 98.5F, blood pressure of 106/72, pulse of 85, respiratory rate of 16, and an oxygen saturation of 100% on room air. Laboratory results included a white blood cell (WBC) count of 2.16, a hemoglobin of 7.6, a hematocrit of 24.9, a creatinine of 0.75, a glucose of 86, and a potassium of 3.2.

The patient was admitted for oral candidiasis and was started on intravenous fluconazole. Hematology was consulted for chronic anemia. Gastroenterology evaluated the patient for possible gastroesophageal reflux disease (GERD)/gastritis. A bone marrow biopsy was recommended which the patient refused. Due to prolong QT intervals, anti-fungal medication was switched to micafungin. She remained afebrile and hemodynamically stable. The patient signed out against medical advice (AMA).

According to the documentation, the patient presented with progressive weight loss, failure to thrive and an opportunistic infection (candidiasis). Laboratory results revealed pancytopenia and low potassium. Based on these abnormalities in a high-risk patient with advanced immunosuppression, hospital admission was medically necessary for further evaluation and management.

The prior determination of denial of coverage for inpatient hospital services has been reversed. The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Croup
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is overturned.

This is a male patient with a medical history of asthma and one episode of croup which resulted in a hospital admission. The patient was born premature and required a two week stay in the Neonatal Intensive Care Unit (NICU) and continuous positive airway pressure (CPAP) treatment was required for several days. The child was sick with a barky cough and had two episodes of post tussive vomiting. The patient was brought to the Emergency Room (ER) for further treatment. He was noted to have stridor with agitation and with activity and he was treated with Decadron and racemic epinephrine. He continued with stridor at rest and he was treated with a total of 3 doses of racemic epinephrine. 

When the inspiratory stridor persisted at rest despite appropriate treatment and based on the history of prematurity and a previous hospitalization for croup and asthma, the decision was made to admit the child to the hospital for ongoing treatment with a diagnosis of Croup.

The insurer denied the need for admission to the hospital and indicated that the child could have been cared for in the observation setting.

Hospitalization

Indications - Children with moderate/severe croup whose condition worsens or fails to improve as expected after treatment with nebulized epinephrine and corticosteroids should be admitted to the hospital for repeated doses of nebulized epinephrine, observation, and supportive care. Poor response to nebulized epinephrine in conjunction with high fever and toxic appearance should prompt consideration of bacterial tracheitis.

The patient was treated appropriately in the Emergency Room for an acute episode of croup with persistent stridor at rest. The medical record does clearly indicate that despite an improvement following treatment, the stridor recurred and the child needed 3 doses of racemic epinephrine. The history of prematurity with a two week Neonatal Intensive Care Unit (NICU) admission and a previous hospitalization for croup in this child with persistent stridor does support the need for admission to the hospital for continued treatment.

The health plan did not act reasonably or with sound medical judgment or in the best interest of the patient. The acute inpatient admission was medically necessary.

The carrier's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is overturned.

This is a young male patient with a history of asthma and 4 previous hospital admissions for status asthmaticus requiring a pediatric intensive care admission (PICU). He has been maintained on daily inhaled steroids and has required frequent visits to the emergency room (ER). He had been sick for several days with fever of 101, a cough and breathing fast. He received 4 albuterol treatments at home. His symptoms failed to improve after the treatments; the patient's mother brought him to the ER.
In the ER he was noted to have respiratory distress with retractions and increased work of breathing; nasal retractions and wheezing were noted. He received 3 doses of duoneb, prednisone and magnesium with no improvement. A blood test
was significant for a HCO3 of 21 which was low suggesting acidosis. His respiratory symptoms did not improve with treatment in the ER; he was admitted to the hospital with status asthmaticus. The patient was medically stabilized and
discharged home.
The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. When there was ongoing respiratory distress with persistent
wheezing and increased work of breathing, it was appropriate and consistent with the standard of care to admit him to the hospital for ongoing treatment with albuterol
every 3 hours. He had failed outpatient management of his asthma and had a history of frequent previous admissions to the PICU and frequent ER visits for asthma. He was a high risk for respiratory failure and was not stable enough to be sent home.
The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.
The inpatient hospital admission from is considered medically necessary for this patient.

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild dehydration

Treatment: inpatient hospital admission 

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

This patient is a male child with a history of a horseshoe kidney with renal cyst and gastroesophageal reflux who presented with complaints of right sided abdominal pain and about 20 episodes of vomiting. The pain was in the right flank and right lower abdomen. He had received antibiotics prior to arrival for a urinary tract infection. Soon after arrival his nurse notes he was writhing in pain and crying. The pain level was assessed at a 10 out of 10 and he received morphine. White blood cell count (WBC) 14.5 S84% (WBC within normal limits with neutrophil predominance consistent with any kind of stress reaction), with urinalysis negative except high SG 1043 indicating a dehydrated state although BUN was normal. Horseshoe kidney, no hydronephrosis, enlarging renal cyst that had grown to from 6.5 cm from last measurement of 2 cm.  

On further emergency department (ED) assessment his pain was relieved, he was well hydrated but refusing oral intake. The Pediatric Urology consult indicated plan to reassess for cyst drainage an as outpatient. His urinalysis indicated he did not have a urinary tract infection (UTI).

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.
The patient had mild dehydration and would have benefited from observation for a little longer in the ED setting, as his pain was relieved. Mild dehydration can be managed with a single bolus of intravenous (IV) fluid and then encouraging slow increase of oral intake of fluids. The cyst drainage could then have been scheduled as an outpatient.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Human papillomavirus (HPV) prevention; abnormal uterine bleeding 

Treatment: CPT code 90651 (Human Papillomavirus [HPV] vaccine) and CPT code 90471 (Administration of Vaccine) 

The insurer denied coverage for CPT code 90651 (Human Papillomavirus [HPV] vaccine) and CPT code 90471 (Administration of Vaccine). The denial should be reversed. 

The patient is a female who was given the first dose of Gardasil vaccine per physician recommendation to reduce the risk of HPV infection. As per clinical documentation, the patient had a history of HPV. 

According to literature review, the United States Advisory Committee on Immunization Practices (ACIP) recommends the bivalent, quadrivalent, or 9-valent HPV vaccine for females aged 11 to 12 for the prevention of cervical, vaginal, and vulvar cancer and the related precursor lesions caused by the HPV types targeted by these vaccines. The ACIP also recommends the quadrivalent or 9-valent HPV vaccine for the prevention of anal cancer and its precursor lesions, and genital warts in females. These vaccines can be administered to females as young as age nine. Catch-up vaccination is also recommended for females aged 13 to 26 years who have not been previously vaccinated or who have not completed their vaccine series. 

On October 5, 2018 the FDA approved the use of the 9-valent HPV vaccine in women and men aged 27 through 45 years. The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) reviewed the available data at its February 2019 and June 2019 in-person meetings. On June 26, 2019, ACIP voted to recommend shared clinical decision making for persons aged 27 through 45 years when considering the 9-valent HPV vaccine. This recommendation is for women who have not previously received an HPV vaccine series and who are at risk for acquisition of HPV. 

While this patient had tested positive for HPV previously, a history of a prior HPV infection is not a contraindication to HPV immunization. However, immunization is less beneficial for those who have already been infected with one of more of the HPV vaccine types. In summary, and in the absence of any other options, CPT code 90651 (Human Papillomavirus [HPV] vaccine) and CPT code 90471 (Administration of Vaccine), are the best available treatments for this patient 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 CPT code 90651 (Human Papillomavirus [HPV] vaccine) and CPT code 90471 (Administration of Vaccine), should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Human papillomavirus (HPV) prevention; abnormal uterine bleeding 

Treatment: CPT code 90651 (Human Papillomavirus [HPV] vaccine) and CPT code 90471 (Administration of Vaccine) 

The insurer denied coverage for CPT code 90651 (Human Papillomavirus [HPV] vaccine) and CPT code 90471 (Administration of Vaccine). The denial should be upheld. 

This patient is a female with a history of acne and abnormal uterine bleeding.  The human papillomavirus (HPV) is associated with anogenital cancer (including cervical, vaginal, vulvar, penile, and anal), oropharyngeal cancer, and genital warts. Of the more than 150 HPV genotypes, 13 genotypes have been shown to cause cervical cancer. Most cases of HPV-associated cancer are caused by HPV genotypes 16 and 18. 

The U.S. Food and Drug Administration (FDA) have approved three vaccines that are effective at preventing HPV infection. These vaccines cover 2, 4, or 9 HPV serotypes, respectively. The HPV vaccine is recommended for girls and boys aged 11-12 years and can be given to females and males up to age 26 years. The Advisory Committee on Immunization Practices and the College recommend routine HPV vaccination for girls and boys at the target age of 11-12 years (but it may be given from the age of 9 years) as part of the adolescent immunization platform in order to help reduce the incidence of anogenital cancer and genital warts associated with HPV infection. Bivalent, quadrivalent, and 9-valent vaccines are approved for females aged 9-26 years and quadrivalent and 9-valent vaccines are approved for males aged 9-26 years. Recently, the bivalent vaccine has been withdrawn from the U.S. market. The 9-valent vaccine, which covers five additional cancer-related HPV serotypes will soon replace the quadrivalent vaccine. 

According to the Centers for Disease Control and Prevention, if health care providers increase HPV vaccination rates in eligible recipients to 80%, it is estimated that an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years. Furthermore, for every year that the vaccination rate does not increase, an additional 4,400 women will develop cervical cancer. The patient received the HPV vaccine at the age of 38. The American College of Obstetrics and Gynecology, in its Committee Opinion, states: "Human papillomavirus vaccines are not currently licensed in the United States for women older than 26 years". Therefore the scientific evidence in the peer-reviewed literature does not support improvement in health outcomes, the service does not have final approval from regulatory bodies for the diagnosis, the patient is not a good candidate for the service and the service is not the best available treatment for the patient. 

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

The carrier's denial of CPT code 90651 (Human Papillomavirus [HPV] vaccine) and CPT code 90471 (Administration of Vaccine), should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Human papillomavirus (HPV) prevention; abnormal uterine bleeding 

Treatment: CPT code 90651 (Human Papillomavirus [HPV] vaccine) and CPT code 90471 (Administration of Vaccine) 

The insurer denied coverage for CPT code 90651 (Human Papillomavirus [HPV] vaccine) and CPT code 90471 (Administration of Vaccine). The denial is reversed. 

This patient is a female with a history of acne and abnormal uterine bleeding. On October 5, 2018, the FDA approved the use of the 9-valent HPV vaccine in women and men aged 27 through 45 years. Obstetrician-gynecologists and other health care providers were encouraged to initiate conversations with women 27-45 years of age about the benefits of HPV vaccination. The vaccine has been shown to be safe and effective in preventing new infections with HPV in women aged 27-45 years. Hence, in patients aged 27 to 45 years old, their decision to be vaccinated should be individually based using shared decision-making and clinical judgement with consideration of those patients' circumstances, preferences, and concern, including the possibility of acquiring a new HPV infection. 

Based on this new regulation, this patient's age is appropriate for this HPV vaccination to prevent HPV infection. The requested services are likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of CPT code 90651 (Human Papillomavirus [HPV] vaccine) and CPT code 90471 (Administration of Vaccine) should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient Hospital

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

The patient is a woman with a history of atrial fib, cerebrovascular accident (CVA), lupus, hypertension, end-stage kidney disease and mechanical valve replacement who initially presented to the emergency department. She presented with a chief complaint of left sided chest pain and left sided flank pain along with shortness of breath for the past few days. In addition, she reported pleuritic chest pain but she denied weakness in her legs and urinary retention. She also reported missing her last session of dialysis. 

The inpatient hospital admission was not medically necessary. The patient primarily received pain management with anti-inflammatory medication to reduce symptoms of presumed costochondritis. There were no acute electrocardiogram (EKG) abnormalities consistent with pericarditis and there was no evidence of acute coronary syndrome, given her negative cardiac enzymes. In addition, there was no evidence of an acute pneumonia or other acute pulmonary condition causing her symptoms. Overall, she could have safely and effectively received care at a lower level.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate Cancer
Treatment: Oncotype DX
The insurer denied the Oncotype DX.
The determination is upheld.

Reviewer 2:

The patient had newly diagnosed prostate cancer. His prostate-specific antigen (PSA) was elevated. No nodule was palpated. Gleason grade group 1 disease was present in 3 of 12 tissue cores, 5, 10, 20% respectively. This correlates to clinical tumor (T) 1c; National Comprehensive Cancer Network (NCCN) very low risk disease. Oncotype DX testing was performed. At issue is whether this testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The health plan's determination is upheld.

This is a patient for whom Gleason grade group 1 disease was present in 3 of 12 tissue cores, 5, 10, 20% respectively. This correlates to very low risk disease. Oncotype DX testing is not proven to be beneficial in this clinical setting. It is not recommended per the guidelines of the National Comprehensive Cancer Network (NCCN) nor the American Urological Association (AUA).
The NCCN guidelines note the test is not indicated for very low risk prostate cancer. Tests of this type have not been subjected to randomized controlled studies, and have been marketed with significant industry support and less than rigorous Food and Drug Administration (FDA) oversight.
The American Urological Association (AUA) states "Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance."
The use of tissue biomarkers has not been established to benefit patients long term in the management of very low risk prostate cancer, as supported by the cited literature references.