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

Diagnosis: Lower back pain

Treatment: Spine surgery (procedure code 27279)

The insurer denied coverage for spine surgery (procedure code 27279)

The denial is overturned

This case involves a patient diagnosed with lower back pain with a mildly antalgic gait, sacroiliac (SI) joint tenderness on the right and left along with static notch tenderness bilaterally. Exam findings noted positive Faber test bilaterally along with positive compression test and positive distraction test bilaterally. She also had diminished sensation in the lumbar (L) 5 distribution on both sides. She previously obtained magnetic resonance imaging (MRI) of the lumbar spine without contrast. The patient had L4- L5 moderate disc bulge and endplate osteophyte encroaching upon the neural foramina bilaterally with the disc appearing to contact the left and right L4 nerve roots. There was no significant central canal stenosis and findings were not significantly changed. At L5- sacral (S) 1, there was endplate osteophyte with disc bulge as well as central disc herniation. There was bilateral foraminal encroachment on the left greater than the right with possible left L5 nerve root impingement. There was no significant central canal stenosis and findings were not appreciably changed. X-rays of the right hip were obtained with no acute findings. They were normal overall. The physician was recommending spine surgery with code 27279, pertaining to SI joint fusion.  

Provided records stated that failed treatment included non-steroidal anti-inflammatory drugs (NSAIDs,) physical therapy, activity modification, and ice/heat application. The report noted that the patient received SI injection with lidocaine and dexamethasone. The patient was seen post injection. She continued to have positive SI joint provocative tests results. She reported over 90 percent (%) improvement of her symptoms following the injections, although pain relief was limited in terms of duration.  

The guidelines note that SI joint fusion is a rapidly growing and evolving therapy with developing evidence to support its safety and efficacy. For patients who do not improve with comprehensive, nonoperative treatment, surgical fusion of the SI joint is an option with overall good, reported outcomes and high patient satisfaction. The information provided for the review noted that the patient attempted conservative treatment measures and had 90% improvement following multiple SI joint injections. Given the patient's response to the injections, proceeding with fusion would be reasonable in this case.  

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

The insurer's denial of coverage for a spine surgery (procedure code 27279) is overturned. 

Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower extremity cellulitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld
 
The patient has a past medical history significant for hypertension, morbid obesity, varicose veins, gastroesophageal reflux disease, and asthma who presented to the emergency room with complaints of left leg pain after injuring it on an exercise bicycle.

Vitals on presentation included: Temperature (T) 37.2 degrees Centigrade (C), Blood Pressure 146/81, Pulse 72, Respiratory Rate 20, oxygen (O2) saturation 100%(percent) on room air. Laboratory results included the following: White Blood Cells (WBC) 8.9, Hemoglobin (Hgb) 13.4, Hematocrit (Hct) 41.3, creatinine 0.73, glucose 87, C reactive protein (CRP) 134.

The patient was started empirically on intravenous antibiotics (cefazolin) for possible lower extremity cellulitis. Infectious Diseases consulted and recommended continuation of antibiotics. Duplex Doppler was negative for deep vein thrombosis (DVT). She remained afebrile, clinically, and hemodynamically stable. Patient was discharged to continue oral antibiotics (Keflex) as an outpatient.
 
According to documentation, patient presented with lower extremity cellulitis. Otherwise, patient remained afebrile, hemodynamically stable. Laboratory results were unremarkable including normal WBC. Cultures remained negative. Patient had no evidence of a disseminated infection or DVT. Based on above findings, patient did meet criteria for observation level of management. She did not fulfill criteria for acute hospital admission. 

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia
Treatment: Repatha
The insurer denied: Repatha
The denial is: Overturned

The patient is a female with a history of hyperlipidemia, dilated ascending aorta and coronary artery calcification. Her coronary artery calcium score was 223, placing her in the 95th percentile for her age, sex and race. On atorvastatin 40 milligrams (mg) daily, her low density lipoprotein (LDL) cholesterol level was 170 milligrams per deciliter (mg/dl). Her atorvastatin dose was increased to 80 mg daily and ezetimibe was started. The atorvastatin was later discontinued due to myalgias. Subsequently her LDL cholesterol level was 243 mg/dl. The medical necessity for Repatha is the subject under review.

Based on the documentation provided Repatha is medically necessary in this instance. This patient has marked hyperlipidemia with an LDL cholesterol level (LDL-C) of 243 mg/dl while on treatment with ezetimibe. On high intensity atorvastatin (40 mg daily, her maximally tolerated dose) her level was 170 mg/dl, which was still well above her recommended goal level of less than 70 mg/dl, given her known coronary atherosclerosis. Based on her LDL cholesterol level she meets criteria for a diagnosis of phenotypic heterozygous familial hypercholesterolemia. 

In addition to this patient's phenotypic heterozygous familial hypercholesterolemia, her coronary artery calcium score is indicative of significant coronary artery atherosclerosis. Per a panel of experts convened by the American Society for Preventive Cardiology "Clinical atherosclerotic cardiovascular disease (ASCVD) includes acute coronary syndromes, history of myocardial infarction (MI), stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack (TIA), or peripheral arterial disease presumed to be of atherosclerotic origin, as well as other forms of atherosclerotic vascular disease including significant atherosclerosis of the coronary, carotid, iliofemoral circulations, and the aorta." This patient meets this definition. Current guidelines endorse the use of Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors for patients with clinical ASCVD whose LDL cholesterol levels remain above goal despite maximally tolerated statin therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Proton Beam Therapy
The insurer denied Proton Beam Therapy.
The determination is upheld.

This is a patient with a history of recurrent left breast cancer (status/post (s/p) mastectomy for ductal carcinoma in situ (DCIS) with positive margin). She now presents with node positive disease. She has been recommended to proceed with a course of postoperative radiotherapy following surgical resection. At issue is whether proton beam radiation therapy is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The proposed proton radiation is not likely to be more beneficial than standard treatment (photon-based radiation) for the insured's breast cancer.
Proton radiation is not proven to yield superior clinical outcomes in this patient's situation. The treating provider did not supply a proton/photon plan comparison to show that photon-based radiation (3 dimensional (D) conformal radiation therapy (CRT) or intensity modulated radiation therapy (IMRT) with a deep inspiration breath hold) is unable to provide adequate safety/precision. The patient has not received prior thoracic radiation, nor does she have a genetic/comorbid condition that would increase her risk of normal tissue toxicity. The American Society for Radiation Oncology (ASTRO) Model Policy for proton radiation does not support its use in the member's setting outside the context of a clinical trial. Therefore, the proposed proton radiation is not likely to be more beneficial than standard treatment for the insured's breast cancer.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Proton Beam Therapy
The insurer denied Proton Beam Therapy.
The determination is upheld.

This is a patient with a history of left (L) breast cancer. The patient presented with recurrent disease. She was treated with neoadjuvant chemotherapy followed by surgery. Radiation therapy (RT) was recommended using the proton beam therapy. At issue is whether proton beam radiation therapy is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health treatment proton beam radiation therapy is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Proton beam therapy is an emerging technology which has been used in the past few years to treat several clinical conditions. However, there is no clinical published data to support its superior clinical outcome compared to other routine 3 dimensional (D) conformal radiation therapy (CRT) or intensity modulated radiation therapy (IMRT) techniques. Most published studies are small studies from single institutions which do not provide long term outcome of proton compared to conventional established photon radiation therapy (RT). These studies suggest improved dosimetric coverage with less side effects. However, there is no clinical published study comparing proton versus photon to conclude any advantage of proton over established RT techniques. Thus, it is not possible to draw any conclusion of any advantage of proton over photon beam RT in breast cancer.

Although proton beam radiation therapy has been shown to be safe and effective for certain tumors that are adjacent to critical structures, there is insufficient clinical peer-reviewed literature to support its use for the treatment of breast carcinoma. There are other established alternative available such as conventional conformal or IMRT photon therapy that have been shown to be safe and effective for the adjuvant treatment of breast cancers. There are several phase I and II clinical trials still evaluating the role of proton therapy for breast cancer. The National Comprehensive Cancer Network (NCCN) guidelines do not suggest the use of proton beam for breast cancer. The report of American Society for Radiation Oncology (ASTRO's) emerging technology committee also does not include proton therapy for breast cancer. Proton beam radiation therapy, therefore, is not an appropriate treatment due to insufficient clinical data in the medical literature supporting its routine use.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Proton Beam Therapy
The insurer denied Proton Beam Therapy.
The determination is upheld.

This is a patient with a history of a ductal carcinoma in situ involving the left breast. She had a mastectomy and reconstruction with implant. She did have positive margins on pathology but did not receive radiation therapy at that time. She now has multifocal left chest wall recurrence and positive axillary lymph node metastases. She had neoadjuvant chemotherapy with good response. She went on to have a revision mastectomy and reconstruction again with axillary nodal dissection. She had two lesions on the chest wall and axillary node metastases. She is recommended to have left chest wall and nodal region radiation therapy to decrease her risk of recurrence and the proton beam approach is requested. At issue is whether proton beam radiation therapy is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed treatment of proton beam radiation therapy is not likely to be more beneficial than standard treatments for the insured's life threatening or disabling condition or disease. There are lack of any significant clinical trials published in peer reviewed journals comparing standard of care photon beam intensity modulated radiation therapy (IMRT) and proton beam radiation that support the benefits and safety of proton beam radiation therapy post mastectomy. There are ongoing clinical trials accruing patients that need to mature and be evaluated and published that may assist in determining the possible benefits and safety for patients with breast cancer and post mastectomy. Therefore, the requested proton beam radiation therapy is not likely to be more beneficial than standard treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis 

Treatment: Otezla

The insurer denied coverage for Otezla.

The denial is overturned.
 

This is an adult patient with a diagnosis of psoriasis and eczematous dermatitis. The patient has failed therapy with topical steroids, calcipotriene, narrow band excimer ultraviolet B therapy, and a handheld ultraviolet light device. The patient's disease is mild to moderate. The requested medication is Otezla.

Based on the submitted documentation, the use of Otezla is medically necessary. The patient has mild to moderate psoriasis with limited areas of involvement. The patient has failed light therapy as well as topical steroids and vitamin D analogues and requires systemic therapy. Otezla is the most appropriate systemic therapy for mild psoriasis and has a Food and Drug Administration indication for mild and moderate psoriasis (4). The patient has failed reasonable alternatives. The use of alternative systemic agents, such as methotrexate, cyclosporin, or biologics, are generally reserved for more moderate to severe disease. The use of Otezla is approved for use in the management of the patient's psoriasis based on the standard of care.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for Otezla is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic Idiopathic Thrombocytopenic Purpura.
Treatment:  Promacta 25mg (milligrams) OR (oral) Tabs.

The insurer denied Promacta 25mg (milligrams) OR (oral) Tabs.  The denial is upheld.

The patient in this case is an adult female. She has stage IV intrahepatic cholangiocarcinoma. She has been treated in the past with chemotherapy and has also been treated with radiation to a sacral soft tissue metastatic lesion. She has had persistent thrombocytopenia despite being off chemotherapy. A progress note indicates that she is felt to have ITP (immune (idiopathic) thrombocytopenia purpura). The platelet count was 91. Treatment with Promacta (eltrombopag) was recommended.

The requested Promacta is not medically necessary.

This patient has mild thrombocytopenia with a platelet count of 91. She does not require treatment for ITP (immune (idiopathic) thrombocytopenia purpura). Additionally, the plan alternative medications are all forms of rituximab, which are effective for treatment of ITP. There is no evidence showing that Promacta (eltrombopag) is significantly safer or more effective than rituximab. Additionally, there is no documentation that the patient has tried and failed rituximab, or that rituximab is contraindicated in this patient. Therefore, given the above, the requested Promacta (eltrombopag) is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, Nausea
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adolescent male with a history of Hodgkin lymphoma. He presented with a fever of 101.8 Fahrenheit and nausea. He had leukocytosis with bandemia but was not neutropenic. His vital signs were stable. The patient's blood cultures were taken, and he was started on ceftriaxone. He had pain in his toe and was started on IV (intravenous) clindamycin for presumed cellulitis. The patient was discharged 
home on day 2.

The Inpatient Hospital Admission was not medically necessary.

The patient did not require acute care hospitalization and could have been safely managed at a lower level of care. The patient was not neutropenic and had an infection that could have been managed with oral antibiotics. There was no evidence based on the medical records that the patient had sepsis and there were no documented co-morbidities which would support the need for acute care hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease.
treatment: Stelara (ustekinumab) 90 MG every 6 weeks .
The insurer denied Stelara (ustekinumab) 90 MG every 6 weeks. 
The health plan's determination is overturned. 

The patient is a female with Crohn's disease, recurrent Clostridioides difficile colitis, and irritable bowel syndrome diarrhea-predominant. She has failed azathioprine (with pancreatitis), high-dose Humira, and Entyvio. 

Stelara 90 milligrams (mg) every 6 weeks is medically necessary. Stelara is FDA-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease. Guidelines for the treatment of Crohn's disease recommend the use of Stelara. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response. One study showed that dose escalation was required and approximately half of patients, and successful in 61.1% of dose escalation attempts. Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted. Additionally, American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy". A Stelara level of at least 4.5 is associated with effective disease control.
In this case, the patient has failed Stelara every 8 weeks, with symptoms of active disease in the setting of a low Stelara level. Continuation of dosing every 8 weeks, or discontinuation of Stelara (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications of Crohn's disease. For all of these reasons, the request for Stelara 90 mg every 6 weeks is supported as medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute stroke
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Overturned

The patient is a male who developed the acute onset of left-sided facial droop and left arm weakness, numbness, and tingling. The patient presented to the emergency department for evaluation and was administered intravenous tissue plasminogen activator, or thrombolytic therapy. The patient was admitted to the hospital for care and underwent a magnetic resonance imaging (MRI) of the brain that showed a subacute stroke in the left cerebellum. The patient was evaluated by medicine, neurology, and rehabilitation therapies. The patient was treated with aspirin and a statin following thrombolytic administration. The patient was discharged home without the need for acute rehabilitation due to improvement in stroke symptoms. The medical necessity for an inpatient admission is the subject under review.

The health plan's determination is overturned.

The inpatient admission is medically necessary. The patient has hypertension and hyperlipidemia and presented to the emergency room with signs and symptoms of an acute stroke including left sided weakness, numbness, and facial droop. The patient was administered intravenous thrombolytic therapy in the emergency room. The administration of this drug requires neurological assessments to be performed by nursing every 1-2 hours. The drug is associated with a 5% risk of cerebral hemorrhage. Patients who receive this therapy are generally assessed in a neurologic intensive care unit or step-down unit.
The patient underwent a magnetic resonance imaging (MRI) of the brain that showed a subacute stroke in the left cerebellum. The patient had rapid improvement of symptoms. This is the intended outcome after treating a patient with thrombolytic therapy -- to relieve the symptoms of stroke. The patient was treated with aspirin and statin therapy, which is the standard of care following stroke. The patient was evaluated by rehabilitation therapies for any home-going needs.
It is not the standard of care or any national recommendation that a patient treated with thrombolytic therapy is placed under a lower level of care. These patients are appropriately treated as acute inpatients regardless of the duration of the hospital stay or the functional outcome of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Monkey Pox. 
Treatment: Inpatient Stay. 

The insurer denied: Inpatient Stay. 
The denial is upheld. 

The patient is a male with human immunodeficiency virus (HIV) on Biktarvy, with non-detectable viral load, cluster of differentiation (CD4) 722, 15.7%, presented to the emergency department (ED) with rash and symptoms suggestive of Monkey Pox. He was having sore throat, fevers, lymphadenopathy, went to ED and was prescribed antibiotics. Rash developed, started on left (L) hand, spread to face, chest legs, scrotal and perineal regions. He returned to the ED for evaluation. He reported having been exposed to a high risk group. He had been treated recently been treated for syphilis and Chlamydia. The rash was described as maculopapular pustular, with some central umbilication, different stages of development. He was afebrile with normal white blood cell (WBC) count, clear chest x-ray. He was polymerase chain reaction (PCR) positive for Monkey Pox and admitted and treated with supportive care in isolation. On admission he was afebrile 37.4 Celsius, blood pressure (BP) 130/88, heart rate (HR) 89, respiratory rate (RR) 20, room air (RA) oxygen saturation of 99%. He was noted as "no acute distress" and alert and oriented to person, place, time. 

The patient was kept in isolation with airborne precautions, per Centers for Disease Control and Prevention (CDC) guidelines and remained in the hospital until cleared by the Department of Health. It appears the patient did not have a home, and there is discussion about possible discharge to a shelter. The subject under review is the medical necessity for the inpatient stay. 

The inpatient stay was not medically necessary. Monkeypox is spread among people through close physical contact such as skin-to-skin contact or prolonged unmasked face-to-face contact but is currently not considered a sexually transmitted infection. It is important to know that anyone can get monkeypox, and the virus does not spread exclusively through any one gender, sexual, or social network. 

The patient could have been provided proper isolation instructions, masks, and advised to avoid any direct, close physical and sexual contact with others until all lesions fully resolved. 

This patient had well controlled HIV with high CD4 and nondetectable viral load. He had Monkeypox but did not require anything more than supportive care. Medically, he did not require an inpatient hospital stay.