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

Diagnosis: Respiratory System. 
Treatment: continuous positive airway pressure (CPAP). 

The insurer denied continuous positive airway pressure (CPAP). The denial is upheld. 

The patient is a female who complained of snoring for eight years, who occasionally awakenings choking at times, with daytime fatigue and difficulty sleeping. Her body mass index was 44.2 having gained 40 pounds. A home sleep study was negative for obstructive sleep apnea. A follow up polysomnogram yielded a diagnosis of primary snoring. The subject under review is the medical necessity for continuous positive airway pressure therapy (CPAP).

The health plan's determination is upheld.

The requested health service/treatment of Continuous positive airway pressure (CPAP) is not medically necessary for this patient. A home sleep study and a polysomnogram were not consistent with obstructive sleep apnea, therefore CPAP would not be considered appropriate.

Clinically, a primary diagnosis of snoring was made; obstructive sleep apnea was not diagnosed.

According to the American Academy of Sleep Medicine, CPAP is considered the first line of treatment for obstructive sleep apnea that is moderate or severe. As this is not documented in the clinicals provided, with a negative home sleep study and a negative polysomnogram, continuous positive airway pressure therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Contraception
Treatment: Polymerase Chain Reaction Testing (PCR) (87799 x 3)
The insurer denied the Polymerase Chain Reaction Testing (PCR) (87799 x 3).
The denial is upheld.

The patient is a female requesting coverage for polymerase chain reaction testing (87799 x3) that was done. According to the submitted information by the patient, she stated that the doctor noticed some discharge, she took a swab of the discharge and a week later the patient was diagnosed with a yeast infection.  

According to the provider, the patient presented for sexually transmitted disease (STD) testing and was interested in contraception. Her pelvic examination was perfectly normal with no evidence of vaginal discharge.

No, the proposed treatment is not medically necessary.

Diagnosis of vaginitis is based on clinical symptoms, pH (acidity or alkalinity) of the vaginal fluid and microscopic examination of the discharge. Ideally, a diagnosis of bacterial vaginosis (BV) is made if three out of four of "Amsel's criteria" are met: A strong fishy odor on adding alkali to vaginal fluid (positive amine test); Clue cells (vaginal epithelial cells heavily coated with bacilli) on microscopy; Thin, white, homogenous discharge; Vaginal pH greater than 4.5. Microscopic examination may also reveal motile trichomonads or candida hyphae. The presence of Gardnerella vaginalis on culture cannot be used to diagnose bacterial vaginosis, since it is present in approximately 50% of healthy women. Culture of trichomonas and candida may be helpful if clinical symptoms are suggestive and microscopy is negative. Mixed infections are also common, with trichomonas, candida or both coexisting with bacterial vaginosis. Deoxyribonucleic acid (DNA) probes have been developed to directly detect the presence of candida, trichomonas and Gardnerella.

According to the American College of Obstetricians and Gynecologists (ACOG), microscopy is the first line for diagnosing vulvovaginal candidiasis and trichomoniasis. The Centers for Disease Control and Prevention also recommend the gram stain as the gold standard for diagnosis of vaginal infections and recommend use of Amsel's criteria if a gram stain is not available.

The Centers for Disease Control (CDC) states that the DNA probes "have acceptable performance characteristics" compared to the gram stain but make no recommendation for their use. There are no high-grade evidence-based peer reviewed studies published in the medical literature to support the safety and efficacy of the technology which consists of: a. Meta-analyses of randomized trials, or b. Randomized controlled trials.

Based on all of the above, the testing done was not medically necessary and is still considered unproven. Adequate history, physical examination and office microscopy should rule out the presence of these infections.
Appeal type: Medical necessity
Decision: Upheld

Cancer
Radiation Therapy

Diagnosis: metastatic lung cancer.
Treatment: Proton beam radiation therapy (PBRT). 
The insurer denied Proton beam radiation therapy (PBRT). 
The health plan's determination is upheld. 

This is the case of a male patient with metastatic lung cancer to the brain. The patient is being evaluated for Proton beam radiation therapy (PBRT) to the brain and spinal cord.

The requested Proton Beam Radiation Therapy (PBRT) is not medically necessary for this patient. Medically necessary treatment is defined as those treatments which are generally accepted standard of practice in USA. The generally accepted standard of practice in the USA for this clinical scenario is conventional palliative RT (radiation therapy) to whole brain.
This clinical condition needs conventional palliative radiation therapy (RT). There is no role for Proton beam therapy in this clinical scenario. This treatment has not been proven effective in well conducted randomized controlled trials or well conducted cohort trials from more than one institution. This treatment has not shown to have significant potential as an effective treatment for this specific condition. There are no published studies to support this treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer/Breast Cancer
Treatment: Radiation Therapy
The health plan denied the requested procedure as not medically necessary. The health plan's determination is overturned.

This is a female with history of recurrent left-sided breast cancer. She was previously treated with breast conserving lumpectomy and hypo fractionated whole breast radiotherapy for pT2N0 left breast cancer. She presented with multifocal recurrence of her left breast cancer and was treated with a left mastectomy, lymph node dissection, and implant removal showing 3 out of 10 involved lymph nodes and a close anterior margin. She then received postoperative systemic chemotherapy. She has been recommended to proceed with a course of reirradiation to her left chest wall and regional lymph nodes (including her internal mammary lymph nodes), with curative intent. The request is for approval of proton beam radiotherapy.

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

Yes, the requested proton beam radiotherapy is medically necessary in this patient's case. Proton beam radiotherapy is standard of care and the most appropriate radiation modality in this patient's unique clinical situation requiring reirradiation in close proximity to her heart and left lung. The treating provider performed a proton/photon plan comparison which revealed that the patient cannot be treated safely/effectively with the use of photon-based radiotherapy (including volumetric arc therapy (VMAT) planned intensity modulated radiation therapy (IMRT)) as this resulted in excessive exposure to the patient's heart tissue. Photon-based planning would lead to an unacceptable risk for cardiac morbidity/mortality. The proton radiation therapy plan was able to significantly reduce this exposure to within known safe tolerance limits for the patient's heart. The ASTRO Model Policy for proton radiation therapy supports its use in this patient's unique clinical situation because she cannot be treated safely with photon-based radiotherapy. There are numerous high quality prospective clinical outcomes published in the peer reviewed medical literature that support the use of proton beam radiotherapy for reirradiation of recurrent breast cancer.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Migraine Headaches. 
Treatment: Emgality, Pre-service. 

The insurer denied the Emgality, Pre-service. 
The denial is upheld. 

The patient is a male. The request is for Emgality for treatment of migraine headaches. The patient is currently on Aimovig and Botox but continues to have headaches daily.  He did not tolerate Trokendi XR, propranolol, Cyproheptadine, or amitriptyline.  The request was denied because Emgality is not Food and Drug Administration (FDA) approved for use in patients under the age of 18. The provider notes that Aimovig has been covered for one year, which is the same class as Emgality. 

No, the requested therapy is not likely to be more beneficial for the enrollee than any available standard therapy. 

Emgality is Food and Drug Administration (FDA) approved for treatment of migraine in patients 18 years and older. Its safety and effectiveness in pediatric patients has not been established. Use of Emgality for treatment of migraine headaches in the pediatric population is considered experimental/investigational because it is not Food and Drug Administration (FDA) approved and off label use is not supported by compendia or major peer reviewed medical literature. There is insufficient peer reviewed literature supporting Emgality to be more beneficial for the patient than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Migraine Headaches. 
Treatment: Emgality, Pre-service. 

The insurer denied the Emgality, Pre-service. 
The denial is upheld. 

The patient is a male with chronic migraine headache disorder. He has tried and failed propranolol, cyproheptadine, amitriptyline, and topiramate XR. He is currently treated with Aimovig and Botox. The provider is requesting Emgality. 

No, the requested therapy is not likely to be more beneficial for the enrollee than any available standard therapy. 

There are no high quality clinical trials to support the safety or efficacy of Emgality when used for persons under the age of 18 for the prevention of migraine.  The prevailing opinion among experts is that further studies are required to determine the efficacy of this intervention for adolescent patients with migraine. There are no trials, for any age group, comparing the efficacy of Emgality to standard of care therapy. The clinical trial leading to the Food and Drug Administration (FDA) approval of Emgality for migraine prevention compared efficacy to placebo (Detke et al.).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay.  The denial is upheld.

This male patient presented to the emergency department (ED) via Emergency Medical Services (EMS) with a chief complaint of palpitations and left-sided chest pain. His medical history was remarkable for paroxysmal atrial fibrillation, hypertension and morbid obesity. Per EMS his initial blood pressure was 64/46 millimeters of mercury (mmHg) with a heart rate of 154 beats/minute. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. The patient's heart rate slowed after a dose of diltiazem. Upon arrival in the ED the patient reported an improvement in his symptoms. His blood pressure was 127/85 mmHg with a heart rate of 107 beats/minute. His respiratory rate was 19/minute with a room air oxygen saturation of 98%. His physical exam was remarkable for obesity and a rapid, irregular heart rate. An electrocardiogram showed atrial fibrillation with T wave inversions in the lateral limb leads. The patient's brain natriuretic peptide (BNP) level was normal. His initial troponin level was .02 nanograms/milliliter (ng/ml) and rose to .08 ng/ml. Chest X-ray showed no acute pathology. The patient was treated with metoprolol without slowing of his heart rate. He then received a dose of intravenous diltiazem which was effective in controlling his rate. He was admitted to the hospital and started on oral diltiazem.  The patient's rhythm spontaneously converted to sinus. An echocardiogram showed normal left ventricular systolic function with mild left ventricular hypertrophy and grade I diastolic dysfunction. The patient was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

This patient presented with acute atrial fibrillation (AF). He was hemodynamically stable, he was not in decompensated heart failure, had no evidence of structural heart disease and was not at high short-term risk for thromboembolism. While his second troponin level was mildly elevated, this is common in patients with atrial fibrillation, even in the absence of coronary artery disease. The patient's rhythm spontaneously converted to sinus on the morning after presentation. For stable patients presenting with acute AF, the safety of management at a lower level of care has been well demonstrated. Based on the information provided, this hemodynamically stable patient did not require an inpatient level of care. The patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis. 
Treatment: Taltz. 
 
The insurer denied Taltz. 
The denial is upheld. 

The patient is a male with psoriasis, 50% body surface area (BSA), treated with topical therapies and phototherapy. The provider is requesting treatment with Taltz. The subject under review is the medical necessity for the requested service. 

No, the Taltz is not medically necessary. According to the documentation, the patient must have tried and failed topical therapies, and have a history of a trial and failure to at least 3 months of methotrexate and have tried at least 2 of the following biologics (Humira, Stelara, Tremfya, Cimzia or Skyrizi). Stelara is the only other biologic approved for use in children. Methotrexate is still commonly used in pediatric psoriasis and the patient has no documented contraindications to its use. Stelara would also be an appropriate choice for this patient. Stelara should be used with caution if there is a risk of malignancy, which would be low in a child. The exact malignancies in the family history should be reviewed.

Therefore, the health plan acted reasonably and the requested Taltz is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left hip intertrochanteric fracture. 
Treatment: Four Physical Therapy Home Care Visits, Preservice. 

The insurer denied the Four Physical Therapy Home Care Visits, Preservice. 

The denial is upheld. 

The patient is a female status post fall with left hip intertrochanteric fracture and status post open reduction with internal fixation (ORIF) intertrochanteric fixation left hip. 

The patient completed 11 home physical therapy (PT) sessions. Her pain was well controlled, she was walking more than 100 feet using a rolling walker with standby assist, she was able to navigate the stairs with contact guard and using cane, was able to transfer sit-to-stand with stand-to-sit independent while using the walker, and the home rehabilitation team recommended her to continue an independent home exercise program. 

Further documents were reviewed that did not provide any additional information on her status as of the last physical therapy. 

No, the proposed four physical therapy home care visits are not medically necessary. 

The requested continue home physical therapy is no longer needed because the patient's pain was well controlled, she was walking more than 100 feet using a rolling walker with standby assist, was able to navigate the stairs with contact guard and using cane, was able to transfer sit-to-stand with stand-to-sit independent while using the walker, and the home rehabilitation team recommended her to continue independent home exercise program. 

Therefore there was no medical necessity for a continue supervised home physical therapy as she can continue with her independent home exercise program as advised by the rehabilitation team that provided the home physical therapy. 

The patient's pain was well controlled, she was walking more than 100 feet using a rolling walker with standby assist, was able to navigate the stairs with contact guard and using cane, was able to transfer sit-to-stand with stand-to-sit independent while using the walker, and the home rehabilitation team recommended her to continue independent home exercise program. 

As the rehabilitation team has recommended home exercise program, the patient does not need four more in-home physical therapy visits.  The patient no longer needs the supervision and instruction from an in-home rehabilitation team; the additional physical therapy is not needed based on her current condition.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Arrhythmia/Irregular Heart Rhythm
Treatment: Pharmacy/Prescription Drugs
The  health plan denied the requested prescription drug, Pradaxa. 
The health plan's determination is overturned.

This case involves a patient with a history of atrial fibrillation rapid ventricular response, chronic systolic heart failure due to alcoholic cardiomyopathy, hyperlipidemia, diabetes mellitus, cirrhosis with portal hypertension. The patient requires full anticoagulation to reduce his risk of stroke. Given the patient's high risk of bleeding secondary to end-stage liver disease, the patient has been prescribed Pradaxa for stroke risk reduction, given a favorable bleeding risk profile compared to alternative formulary agents. The patient's health plan has denied an exception request for Pradaxa due to failure to meet plan's exception criteria.

I recommend that the health plan determination be overturned, in whole, and coverage be granted for Pradaxa as a formulary exception.

Based on the patient's medical history of significant liver disease with associated increased bleeding risk, the formulary medications would likely have significant adverse effects and associated increased risk of bleeding for this patient. Therefore, coverage for Pradaxa should be granted for stroke risk reduction and its favorable bleeding risk profile in this patient with end-stage liver disease compared to the alternative formulary agents [1,2].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder/Other/Sickle Cell Anemia.
Treatment: Inpatient Hospital.
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female who initially presented to the emergency department with generalized body pain and nausea. Pertinent history included sickle cell disease complicated by avascular necrosis of the right hip, asthma, and depression. Initial vital signs revealed a temperature of 97.7F(Fahrenheit), a heart rate (HR) of 122 beats per minute (bpm), a blood pressure (BP) of 112/60 millimeters of mercury (mmHg), a respiratory rate (RR) of 16/minute, and a peripheral capillary oxygen saturation (SpO2) of 100% on room air. An electrocardiogram (EKG) revealed sinus tachycardia without acute ischemic changes. Initial serology revealed a hemoglobin of 8.8, platelets of 446, a sodium of 134, a potassium of 4.1, a blood urea nitrogen (BUN) of 7, and a creatinine of 0.6. A chest radiograph was unremarkable. The patient was placed in the hospital thereafter with an impression of sickle cell anemia with pain crisis and without signs of infection or acute chest syndrome. The treatment plan included intravenous fluids, analgesia, and anti-emetics. The pain was noted to be improved and no chest pain or shortness of breath was present. A general diet was provided. No change in treatment plan was noted.  The patient was noted to be under the cover and not wanting to be bothered. It was documented that the patient refused all other medications except for Morphine. The patient left against medical advice.
At issue is the medical necessity of the inpatient stay.

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

No. Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care, such as observation, with transition to outpatient services.

In this particular situation, clinical indications for admission to inpatient care were not met. The patient did not have signs or symptoms of central nervous system acute injury, acute chest syndrome, hypoxemia, emergent surgery needed, splenic or hepatic sequestration, acute ischemia, acute renal failure, aplastic crisis, priapism or other vascular complications, traumatic hyphema, infection requiring inpatient treatment (e.g., bacteremia), altered mental status, need for exchange transfusion, inability to maintain oral hydration despite observation care treatment, or pain insufficiently responsive to observation care treatment that requires treatment in an inpatient setting.[3]
Appeal type: Medical necessity
Decision: Upheld

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

The patient presented to the hospital with a history of progressively worsening abdominal pain, nausea, and vomiting of 1-day duration. His evaluation included a physical exam and labs. He was without a fever at the time of presentation. Lab data identified an elevated white blood cell count (WBC) count of 15.9 thousand (K). His evaluation yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was requested.
The patient underwent a laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. He was provided IV fluid and perioperative antibiotics. His vital signs remained normal throughout the hospitalization without a fever. Diet was advanced and pain management was converted to oral medications. He was discharged home.
At issue is the medical necessity of an inpatient stay.
Inpatient stay was not medically necessary for this patient. The care and treatment provided could have appropriately been rendered with a lower level of care.
This patient presented with abdominal pain. The evaluation with examination, lab data, suggested the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and an appendectomy performed. The early post-surgical course was uncomplicated and the patient was clinically stable for discharge from the hospital on the first post-surgical day.
The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient presented with abdominal pain and underwent uncomplicated appendectomy. A lower level of care would have satisfactorily allowed for the care provided and would have been consistent with the accepted standard of medical care. This lower level of care would have also allowed for overnight monitoring. 
Generally accepted medical standards indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, the procedure of appendectomy may be performed with a lower level of care. In this case, the patient tolerated oral hydration, diet and medication and the pain was well controlled. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.