Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Myasthenia Gravis. 
Treatment: Pharmacy/Prescription Drugs (Soliris). 

The health plan denied the requested prescription drug. 
The health plan's determination is upheld. 

An office note from the patient's provider indicated that the patient had been seen 2 weeks previously for myasthenia exacerbations but was not in crisis or intubated. He has complained of ptosis, diplopia, shortness of breath and limb weakness. He was found to have a thymoma that was resected with a malignant pathology. This had been treated with Paclitaxel and Carboplatin, with radiation therapy being on hold. He had an elevated acetylcholine receptor binding and blocking antibodies. He remained on Prednisone 20 mg (milligrams) daily and Mestinon 90 mg three times daily with complaints of ptosis and double vision, dyspnea on exertion and rare dysarthria or dysphagia. Strength was improved but not fully strong. He could not tolerate Azathioprine due to gastrointestinal upset. He complained of worsening symptoms with shortness of breath, orthopnea, weak limbs, head drop, ptosis and diplopia earlier that month was treated with an increase in the steroid dose to 60 mg daily. Examination revealed weakness of neck flexors, left ptosis, double vision and down days with otherwise normal cranial nerves and a normal mental status examination. Diagnoses were myasthenia gravis and malignant thymoma. Use of Soliris was recommended. He was referred for a meningococcal vaccination. 

An appeal request indicated that the patient had a history of myasthenia gravis. He was unable to tolerate Azathioprine. It also been treated with steroids. His MG-ADL (myasthenia gravis- activities of daily living) score was 10/24. The provider indicated that Prednisone should be considered an immunosuppressive agent and believes that he was a candidate for Soliris. He did not indicate why the patient could not utilize intravenous immunoglobulin (IVIG) or Rituximab or other immunosuppressants. 

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

The patient has medically refractory myasthenia, having persistent symptoms despite the use of an oral immunosuppressant, Pyridostigmine (Mestinon) and a steroid-sparing immunosuppressant. Typically, treatment would consist of Rituximab or IVIG. However, there is no evidence in the medical literature that Soliris is more effective with regard to controlling symptoms of myasthenia gravis than other medications for medically refractory myasthenia, including IVIG and Rituximab. While all medications have adverse effects, there is no evidence that the adverse effect profile of formulary medications typically used for medically refractory myasthenia is more than the greater adverse effect profile than Soliris. 

There are alternate medications that can be used for medically refractory myasthenia gravis, including IVIG and rituximab, and no evidence that either available medication is less effective or has greater adverse effects that Soliris.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the hospital emergency department (ED) with right upper abdominal pain of one-day duration. Her past medical history is significant for obesity with a Lap-Band in place. She had had similar abdominal complaints in the past. At the time of presentation, the patient was without a fever and vital signs were normal. She had tenderness in the right upper abdomen. The white blood cell count (WBC) count was 6 thousand (K). The complete metabolic panel identified normal transaminases. An ultrasound showed gallstones, no gallbladder wall thickening, and no pericholecystic fluid.
She was initially treated with intravenous (IV) fluids and IV antibiotics. The patient underwent a cholecystectomy with cholangiogram. The operative dictation describes an uncomplicated cholecystectomy procedure. She was started on a clear liquid diet. The patient was considered to be stable for discharge home.
At issue is the medical necessity of an inpatient stay.

No. An inpatient level of care was not medically necessary.
This patient presented to the hospital with symptomatic cholelithiasis/cholecystitis. The pre-surgical work up was completed with labs, an ultrasound and clinical examination. The indications for cholecystectomy were established. The patient underwent an uncomplicated cholecystectomy procedure. The post-surgical course was uncomplicated. The diet was advanced. The vital signs remained normal. Pain was controlled with oral medication, and the patient was discharged home.
An inpatient stay was not consistent with the referenced Milliman Care Guidelines (MCG) during this time. MCG Cholecystectomy by Laparoscopy state that the goal length of stay is ambulatory, but that inpatient care is needed when there is:
1) Failure to achieve discharge status criteria. 2) Conversion to open surgery. 3) Severe systemic infection. 4) Care for active comorbidities. 5) Complications of the procedure.

In this case, the submitted documentation does not support that any of these clinical conditions existed to warrant an inpatient level of care.
A lower level of care would have appropriately provided for pre-surgical assessment, operative treatment and post-surgical care and monitoring including overnight care.
Appeal type: Medical necessity
Decision: Overturned

Digestive System
Inpatient hospital

Diagnosis: Abdominal pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a man with a history of chronic liver disease, gastrointestinal bleed, portal hypertension, esophageal varices, and chronic alcoholism who was admitted to the hospital on July 29, 2020. He was brought to the emergency department with abdominal pain. He had been drinking alcohol that day. He also reported nausea but no vomiting, chest pain, fevers or chills. Vital signs showed temperature 99.8 Fahrenheit, heart rate 115, blood pressure 119/75, and oxygen saturation 99 percent. On exam, he was awake and alert, heart was regular, breath sounds were normal, abdomen was soft and tender. There were no cranial nerve deficits. Labs showed creatinine 0.5, sodium 137, potassium 3.7, calcium 7.4, troponin negative, white blood cell (WBC) 8.4, hemoglobin 7.3, and platelets 112. Alcohol level was 121.6. A computed tomography (CT) of the abdomen demonstrated thickening of the cecum and portions of the colon concerning for colitis. The patient was admitted for suspected infectious colitis. 

The inpatient hospital admission was medically necessary. The patient presented with suspected colitis requiring IV antibiotics and concerns for alcohol withdrawal. He had multiple comorbidities including advanced liver disease, portal hypertension, and prior GI (gastrointestinal) bleeding. There was also concern for bleeding because his initial hemoglobin was 7.3. Given the multiple abnormalities and the patient's elevated baseline risk of having an adverse outcome, it was reasonable to manage him at the inpatient level of care.

The patient presented with evidence of alcohol withdrawal and colitis. Colitis can often be treated as an outpatient, but this particular patient had a more complex presentation due to his extensive history of chronic liver disease, markedly elevated procalcitonin levels, and elevated lactate levels at the time of presentation. He was at increased risk of having an adverse outcome such as development of septic shock or bacteremia. It was therefore appropriate to manage him at the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ears/Nose/Throat-Rhinitis/Nasal inflammation-Sinusitis/Sinus infections
Treatment: Pharmacy/Prescription Drugs-Dupixent
The health plan denied Dupixent as not medically necessary for this patient. 
The reviewer has upheld in whole the health plan determination.

This is a pediatric patient with a history of  chronic eosinophilic rhinosinusitis with polyps who has been following up with an allergy and immunology specialist for the symptoms. Asthma was ruled out and cystic fibrosis(CF) was also ruled out. He had 2 nasal surgeries with polypectomy already. He was on budesonide and saline nasal sinus rinses were done. Patient was placed on oral corticosteroids and antibiotics. The pediatric allergist recommended Dupilumab given the frequency of oral steroids and antibiotics, however, there is no clear documentation submitted for review regarding how many courses of antibiotics were administered.

Dupilumab is a human monoclonal IgG4 antibody that inhibits interleukin-4 (IL-4) and interleukin-13 (IL-13) signaling by specifically binding to the IL-4R subunit shared by the IL-4 and IL-13 receptor complexes. Dupilumab inhibits IL-4 signaling via the Type I receptor and both IL-4 and IL-13 signaling through the Type II receptor. It is used to treat chronic asthma, atopic dermatitis, and Chronic sinusitis with nasal polyp. There is no class 1 level of evidence that Dupilimab is effective in children with rhinosinusitis with polyps in the patient's age group. There is also no clear documentation submitted for review regarding how many courses of antibiotics were administered, or whether an infectious disease (ID) team was consulted.
This patient did not have a workup to rule out immotile cilia syndrome, gastroesophageal reflux disease (GERD), or immunodeficiencies, etc. which could be causing the rhinosinusitis. There is no documentation whether there was an adenoidectomy done to treat the sinusitis and control the inflammation. Additionally, there is no documentation whether there were computed tomography (CT) scan findings of any other systemic disease such as Wegener's granulomatosis or sarcoidosis. In a patient with chronic rhinosinusitis, where there is uncontrolled inflammation, provider's need to determine the possible source(s) of the uncontrolled inflammation. Hence, these conditions are part of the standard work up the majority of the specialists would perform for a patient with this condition.
For these reasons, Dupixent is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Respiratory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient admission. 
The denial is overturned in part.  

The patient is a female with oxygen dependent chronic obstructive pulmonary disease (COPD), prior cerebrovascular accident (CVA), substance and alcohol use who presented to the hospital for abdominal pain. She has been admitted multiple times previously for similar symptoms. The patient described generalized abdominal pain, worsened with meals. She had been seen by gastroenterology and had a fairly comprehensive work-up in the past and carries the diagnosis of cannabinoid hyperemesis syndrome. She  had two recent upper endoscopies. She has a history of (H/O) fundoplication for reflux.

On exam, vitals were stable, but she appeared uncomfortable due to pain and was frequently vomiting. Abdomen was tender in the epigastrium without guarding or rebound. Imaging identified a right lower lobe (RLL) infiltrate thought to be from aspiration. Computed tomography (CT) of abdomen otherwise normal. In the emergency room (ER) after morphine, Zofran, Haldol and proton pump inhibitor (PPI) the patient appeared in no apparent distress (NAD). She was started on antibiotics for pneumonia. On the second hospital day the patient denied further nausea or vomiting. She continued to have epigastric tenderness to deep palpation. She had no events and no specific complaints.
The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is overturned in part. 

The inpatient hospital admission was medically necessary, in part. Based on the record, the patient required one day of inpatient care. The specific indication for inpatient admission is that the patient had a new pulmonary infiltrate in the setting of advanced COPD. The patient had an elevated white blood cell (WBC) count and lactate level. In addition, for the first 24 hours the patient was unable to take by mouth (PO). By the second hospital day the patient had made significant improvement with less abdominal pain and no progression of pulmonary symptoms.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Class I malocclusion and anterior crossbite 
Treatment: Braces/monthly visits
The insurer denied the Braces/monthly visits. The health plan's determination is overturned. 

The patient in question is a male with a Class I malocclusion and anterior crossbite of tooth # (number) 10. He is treatment planned for 24-30 months of orthodontics to correct the malocclusion. Under review is the medical necessity of Braces and Monthly Visit (x12).

Braces and Monthly Visit (x12) are medically necessary. The patient has significant anterior crowding with tooth #10 in crossbite. This tooth has a high risk for restorative problems in the future due to its traumatic occlusion with the mandibular teeth. Tooth #23 is already displaced labially and due to the crossbite with tooth #10 will move more labial with time. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons, the requested Braces and Monthly Visit (x12) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congenital HSV (herpes simplex virus)
Treatment: Acyclovir 5% Cream
The insurer denied the Acyclovir 5% Cream.
The denial is upheld. 

The patient is a female whose request for 5% acyclovir cream is under review. Per the health plan denial, the treatment is requested for congenital HSV (herpes simplex virus) infection and HSV (herpes simplex virus) vesicular dermatitis. There are no provider notes to support why acyclovir cream is requested.

No, the Acyclovir 5% Cream is not medically necessary.

The health plan denied the Acyclovir and requested more information which was not provided. Thus, the health plan acted responsibly. Acyclovir is used for non-life-threatening herpes infections of the skin and around the mouth.  However, there are no provider notes to support why acyclovir is requested in this patient.  Therefore, the requested Acyclovir 5% Cream is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colon Cancer. 
Treatment: Pharmacy/Prescription Drugs (Retevmo). 

The health plan denied the requested prescription drug. 
The health plan's determination is upheld. 

This is a female with metastatic colon cancer. The patient received adjuvant FOLFOX chemotherapy. At recurrence, she was started on FOLFOX+Avastin followed by resection, debunking, and hyperthermic intraperitoneal chemotherapy (HIPEC). Following progression, the patient received FOLFOXIRI+Bevacizumab. She has also progressed on Cetuximab and was intolerant of Regorafenib. A next generation sequencing panel was obtained that demonstrated the cancer to have a RET (genetic protein) fusion mutation. Retevmo (Selpercatinib) has been prescribed and is under review. 

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

No. The use of Selpercatinib in the treatment of metastatic colon cancer is unproven and has not been recommended by the peer-reviewed literature, the authors of UpToDate, nor in the National Comprehensive Cancer Network (NCCN) Guidelines. The use of this agent in this setting remains the subject of ongoing investigation in multiple trials including NCT03157128 and NCT03906331. For these reasons, criteria for medical necessity for the use of Selpercatinib in this clinical scenario have not been satisfied.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Central Nervous System/neuromuscular disorder. Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Radicava. 
The health plan's determination is overturned in whole.

The patient is a female with a diagnosis of sporadic amyotrophic lateral sclerosis (ALS). The most recently office visit indicates that the patient is taking riluzole 50 milligrams (mg) twice daily. Treatment with Radicava is the subject of this review.

The health plan's determination is overturned in whole.

Documentation indicates that the patient is treated with riluzole. Riluzole is not a cure for ALS. Riluzole slows the progression of ALS. There are no head to head comparisons between riluzole and Radicava. As such, it is impossible to determine if riluzole would not be as effective as the non-formulary drug Radicava.
There are no papers regarding head to head comparisons. The drugs will never be head to head compared. A person does not use either or. It is common practice for patients with ALS to use both riluzole and Radicava. Edaravone (Radicava) received U.S. Food and Drug Administration (FDA) approval for all people with ALS in May 2017 to treat patients with ALS in the United States. While the evidence for the benefit of edaravone is clearest in patients with early ALS, as defined in the pivotal trial, there is no reason to believe that the population evaluated in that trial is biologically distinct from the greater ALS population. In patients treated with edaravone, there was a smaller decline in function, measured by the Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) as compared to patients not treated with edaravone.
Appeal type: Medical necessity
Decision: Upheld

Trauma
Nursing Services (including Private Duty Nursing)

Diagnosis: Traumatic Brain Injury
Treatment: Continuous Consumer Directed Personal Assistance Services 
The insurer denied the Continuous Consumer Directed Personal Assistance Services (24 Hours per Day, 7 Days per Week).
The health plan's determination is upheld. 

The patient is female with a previous traumatic brain injury. She suffers from physical and cognitive disabilities. This review is for the medical necessity of continuous consumer directed personal assistant services 24 hours a day 7 days a week. The services were denied based a medical necessity. The patient was approved for 24.5 hours per week of services.

The Continuous Consumer Directed Personal Assistance Services (24 Hours per Day, 7 Days per Week) are not medically necessary for this patient.
The time allowed for services provided are adequate to meet the patient's medical needs. Additional services are not medically necessary. The patient suffers from previous traumatic brain injury. She suffers from physical and cognitive disabilities. It is difficult to ascertain from the notes provided what exactly are the patient's specific physical disabilities and cognitive disabilities.
The patient requested continuous consumer directed personal assistant services 24 hours a day 7 days a week for help with housework, personal care and supervision for safety. An assessment states that the patient's medical condition has not changed since prior evaluation. Supervision services can be provided by other available services such as the traumatic brain injury waver which the patient does qualify for. The patient currently lives with her aunt and boyfriend.
It is noted that the patient has no informal helper and the informal helper is unwilling to assist with her care; however, the patient does live with her boyfriend. Her boyfriend is also listed as 1 of the caretakers to provide services which is inconsistent. Her mother is also listed as 1 of the caretakers.
There is a notation stating that the patient is ambulatory but then there is also a statement that the patient is not ambulatory during one of her "episodes". It is difficult to ascertain exactly what the episode actually is, from a medical standpoint.
After review, it is reasonable say that the patient's medical needs including activities of daily living (ADL) and Instrumental activities of daily living (IADL) can be met with a lot of the time already being provided. Additional services would be considered for safety and supervision which are not typically medically necessary. There was no provided information that would necessitate ongoing care that cannot be provided during the time allowed by the health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervicalgia, Other spondylosis with radiculopathy cervical, Radiculopathy cervical, Fusion of spine cervical and spinal stenosis cervical.

Treatment: Spinal surgery (codes 22614, 22842, 22600, and 63001) and the associated inpatient stay.

The insurer denied coverage for spinal surgery (codes 22614, 22842, 22600, and 63001) and the associated inpatient stay.

The denial is upheld. 

This is a female patient who presented to an orthopedic surgeon for evaluation of neck pain radiating to the left upper extremity in the C5-6 distribution. The patient underwent an anterior cervical discectomy and fusion (ACDF) at C5-6 after a motor vehicle accident with years of benefit. The patient then underwent C4-5 and C6-7 disc replacement surgery without significant improvement. The patient's diagnoses are cervicalgia, other spondylosis with radiculopathy cervical, radiculopathy cervical, fusion of spine cervical and spinal stenosis cervical. The request is for a C3-T1 posterior spinal fusion with instrumentation with Mazor Robotic guidance, possible left C3-4 foraminotomy and allograft/autograft. 
  
Based on the review of the medical record and literature, the requested procedure is not medically necessary for this patient. The patient has failed conservative treatment.  However, there are two surgeon's opinions and exams that are inconsistent with each other. It appears that the patient has some radiculopathy consistent with her other surgeries that have been ongoing. The patient has a C5-6 radiculopathy by one surgeon and C7-8 radiculopathy by the opining surgeon. There is a question of instability at C7-T1 but, this is not seen on any image report. The patient has a moderate foraminal stenosis on the left at C3-4. Given that her exams are not consistent with the C3-4 level, that there is a question of left shoulder pathology as she had a left shoulder magnetic resonance imaging (MRI) with pathology, and no X-ray that shows instability at the C7-T1 level; there is no indication for a C3-T1 instrumented fusion with possible decompression at C3-4. Shoulder pathology should be ruled out. The request does not meet the eviCore national policy for posterior cervical fusion. 

UpToDate notes the limitations of surgery for cervical radiculopathy. They note the need for assessment of the stability of the cervical spine and also propose criteria for surgery which include "Evidence of cervical nerve root compression by magnetic resonance imaging (MRI) or computed tomography (CT) myelography at the appropriate side and level(s) to explain the clinical symptoms and signs and progressive motor weakness." 

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

The carrier's denial of the requested spinal surgery (codes 22614, 22842, 22600, and 63001) and the associated inpatient stay should be upheld. The medical necessity is not substantiated.