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

Skin disease
Pharmacy/prescription drugs

Diagnosis: psoriasis
Treatment: Taltz
The insurer denied Taltz. The health plan's determination is upheld.

The patient is a female with psoriasis of the forearms, thighs, and buttocks. The patient denies joint pains and has no diagnosis of psoriatic arthritis. The patient has tried Narrowband ultraviolet B (UVB) in the past, but stopped after one week because it made her skin red. The patient was only on over the counter products. The patient reportedly used prescription topical medications but did not help, and has used Chinese herbal medications.

Taltz is not medically necessary for this patient.
The patient has no documented treatment failure with, or true medical contraindication to, a sufficient course of standard, first-line systemic therapies such as either Methotrexate, Acitretin, and/or Phototherapy. XTRAC laser is for localized psoriasis, and this patient has more widespread psoriasis of the trunk and extremities. The patient was not on a sufficient dosage of Cyclosporine to conclude that that treatment had been appropriately tried and failed. The patient's liver enzymes were not so elevated (and perhaps was reflective of fatty liver disease) that an adherent and coherent course of Methotrexate, Acitretin, or other oral/traditional therapies could have been utilized prior to considering biologic therapy. Particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, these preferred agents are appropriate for this patient's clinical scenario.
Therefore, consistent with current medical literature, Taltz is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: heroin abuse
Treatment: Suboxone
The insurer denied Suboxone 8-2 mg film QID (4 times a day). The health plan's determination is upheld.

The patient is a man with a history of opioid abuse disorder requesting coverage for Suboxone sublingual (SL) 8-2 MG (milligram) films, one film four times a day (QID). In an office visit note, it was noted that the patient was having breakthrough cravings for heroin on a dose of Suboxone SL 8-2MG films three times per day (TID). The patient was using heroin periodically to relieve the breakthrough symptoms. Consequently, the provider increased the dose to one film QID. 

Suboxone SL 8-2MG film QID is not medically necessary for this patient.
Based on a thorough review of the information provided the requested dose of Suboxone SL 8-2MG film four times a day (QID) (32mg) is not medically necessary. There are no credible controlled trials demonstrating the safety and efficacy of buprenorphine doses greater than 24mg per day. There is nothing in this patient's medical records to substantiate that he in particular would benefit from a dose greater than 24mg per day. Therefore, based on the standard of care, and the peer reviewed literature cited in the references, the Suboxone SL 8-2MG film QID is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Nurtec.
The denial is upheld in whole. 

The patient is a female who is under the care of a neurologist for a history of migraines and pseudo seizures. Notes from a (telemedicine) follow-up visit were provided and the patient's medication list at the time of that consult included escitalopram, fexofenadine, famotine, Norco, phenobarbital, promethazine, hydrochlorothiazide (HCTZ), folic acid, butalbital- acetylsalicylic acid (ASA) -caffeine-codeine, nadolol and diazepam. The patient was noted at that time to have migraines. The patient indicated a reluctance to try any injectable therapies (calcitonin gene-related peptide [CGRP], Botox) secondary to anxiety over needles. The prescriber at that time opted to prescribe her Nurtec oral dissolving tablet (ODT). A request was made of her health plan for coverage of Nurtec. The request was denied by her health plan, as the patient had not met the step therapy requirements.
At issue is the medical necessity of Nurtec 75 milligrams (MG) oral (OR) tablet disintegrating (TBDP).

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

The requested health service/treatment of Nurtec 75MG OR TBDP is not medically necessary for this patient.  
In this case the patient is noted to have migraine headaches. There have been no comparison studies completed to date between Nurtec and other medications for migraine prophylaxis. In as much, it cannot be concluded that the requested drug would be expected to be more effective. While the patient is noted to have a contraindication to at least one formulary agent (venlafaxine) given that she is on escitalopram (drug-drug interaction), she does not appear to have contraindications to the other preferred agents. The other formulary agents have long had level A recommendations for use in migraine prevention by professional society guidelines. There were no other unique factors present that would support an exception to required trials of formulary agents (as supported by current literature). Nurtec is not otherwise noted to result in superior clinical outcomes compared to other agents.
Therefore, the requested health service/treatment of Nurtec 75MG is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Genotropin. 
The denial is overturned.

This is a female diagnosed with growth hormone deficiency (GHD). This request is for Genotropin. Her growth hormone (GH) stimulation test with arginine and clonidine peaked at 6.73. Her Insulin-like Growth Factor 1 (IGF1) was 127 (133-416); Z-score was -2.4 standard deviation (SD). 
Her mother's height is 162.56 centimeters (cm) and father's height is 177.8 cm and mid parental height is 163.68 cm (+0.05 SDS). The subject under review is the medical necessity for the Genotropin.

The health plan's determination is overturned.

The requested Genotropin is medically necessary. The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below.
Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society, [1] the Lawson Wilkins Pediatric Endocrinology Society, [2, 3] and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists. [4] The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 years of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 years. The biochemical criteria include low IGF1 or Insulin-like growth factor binding protein 3 (IGFBP3) or GH stimulation testing with a peak GH less than 10 nanograms per milliliter (ng/ml).
This patient met biochemical criteria. GH stimulation testing peaked at less than 10 ng/ml. the patient had a low IGF1. The patient met height criterion 2 as his height is more than 1.5 SD below target height SD. The patient has a pretreatment height more than 2 SD below the mean and a pretreatment height velocity more than 1 SD below the mean. The patient met both height and height velocity and biochemical criteria for the diagnosis of GH deficiency. GH in the treatment of GH deficiency is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left buttock cellulitis

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is upheld. 

The patient is a female with a past medical history significant for substance abuse, depression, diverticulitis, sleep apnea, and opioid dependence who presented to the emergency department with complaints of a wound infection to the left buttock. 

Vitals on presentation included: Temperature 36.6 C (Celsius), Blood Pressure 135/79, Pulse 98, Respiratory Rate 19, oxygen (O2) saturation 98% (percent) on Room Air. Laboratory values were notable for the following: white blood cell (WBC) count 8.6, Hgb (hemoglobin) 13.1, Hct (hematocrit) 41.1, creatinine 0.79, glucose 104.

The patient was empirically started in intravenous antibiotics (vancomycin) for left buttock wound at site of intravenous heroin use. Surgery was consulted. A bedside ultrasound was negative for a collection. The patient was also seen by Infectious Diseases and Addiction counselling. The patient remained afebrile, hemodynamically stable and clinically improved. The patient signed out against medical advice after being confronted by hospital security regarding a suspicious substance found in her room. 

According to documentation, the patient presented with left buttock wound after injecting heroin at that site. Otherwise, she was afebrile, hemodynamically stable with unremarkable laboratory findings including a normal WBC count. The patient had a localized infection. There was no evidence for a disseminated infection and no surgical intervention was required. Based on above findings, the patient met criteria for observation level of management. 

Prior determination of denial of inpatient hospital services is upheld.

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

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

Diagnosis: Abdominal pain.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is upheld. 

The patient had a history of a gastric bypass and presented with abdominal pain, vomiting, and diarrhea. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. An abdominal CAT (computed tomography) scan showed that there was no intestinal obstruction. There was no leukocytosis. The renal function was normal. Stool testing was done. IV (intravenous) hydration, Famotidine, and Raglan were given. She was diagnosed with viral gastroenteritis.

Clinical indications for admission for Gastroenteritis (MCG M-170) include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting or dehydration, severe electrolyte abnormalities, or an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had a viral gastroenteritis. IV hydration, Famotidine, and antiemetics could have been given in the ER (emergency room) with observation care. She did not meet MCG (Milliman Care Guidelines) criteria for admission for Gastroenteritis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

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

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

Diagnosis: Back Pain.
Treatment: Pain Injections.

The health plan denied the procedure/treatment of Pain Management - pain injections as not medically necessary.
The reviewer has overturned in whole the health plan's determination. 

The patient has a history of chronic low back pain. A magnetic resonance imaging (MRI) study of the lumbar spine reveals degenerative changes. The records from the provider indicate that the patient had been treated with lumbar facet blocks. On exam there was tenderness in the sacroiliac joint (SIJ) region. A request was made for a bilateral SIJ injections. 

The requested health service/treatment of Pain Management - pain injections is medically necessary for this patient.
The sacroiliac joint can be a debilitating source of low back discomfort. There are no physical exam maneuvers which confirm the diagnosis with 100% accuracy therefore it is very common to inject the sacroiliac joint for diagnostic and therapeutic purposes if the patient has failed at least 4-6 weeks of conservative treatment.
In this case it is clear that the patient was having persisting complaints despite conservative treatment therefore the care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder (ASD). 
Treatment: Autism Related Treatment (including ABA). 
The insurer denied applied behavioral analysis (ABA) Assessment. 
The denial is Overturned.

The patient is a female who has been diagnosed with autism spectrum disorder, Level 3, requiring very substantial support, and mild intellectual disability. At genetics visit, the patient was noted to have mildly dysmorphic features, including macrocephaly (head circumference 55.5 centimeter [cm], greater than[>]98th centile), a short neck, slightly droopy eyelids, narrow high arched palate, pointed chin and short thumbs. The possibility of Noonan syndrome was considered on the basis of her phenotype, but this diagnosis does not appear to have been confirmed. Detailed genetic testing revealed several abnormalities. These included an abnormal female karyotype, with paracentric inversion of chromosome 19 (46XX, inv(19) (p13.12p13.3), a single region of homozygosity of 17Mb (megabases) on chromosome 2 on chromosomal microarray, and a variant of unknown significance in the CACNA1A gene (c2629G>A pG8775). Mutations in this gene have been associated with cognitive impairment, familial hemiplegic migraine, ataxia, paroxysmal dyskinesia and early infantile epileptic encephalopathy. The subject under review is the medical necessity for ABA Assessment. 

The health plan's determination is overturned.

The requested health treatment of ABA assessment is medically necessary for this patient. She has been diagnosed with autism spectrum disorder, level 3, requiring very substantial support, and intellectual disability. She has several behavioral issues which are most appropriately treated with ABA therapy. Her symptoms include difficulty with social interactions, lack of respect for social boundaries, very delayed self-care skills, echolalia, tantrum and stereotypic behaviors. Applied Behavioral Analysis (ABA Therapy) covers a variety of methods concerned with the application of behavioral science to socially important functions, particularly in individuals with autism spectrum disorder and intellectual disabilities [1]. Common features of ABA-based therapies include the objective measurement of behavior, structured control of the environment, and the implementation of procedures based on scientifically established principles of behavior.

ABA has been defined as "the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior. The use of ABA methods to treat symptoms of ASD suggests that behaviors exhibited can be altered by programmatically reinforcing skills related to communication and other skill acquisition. Thus, ABA treatments may target development of new skills (e.g., social engagement) and/or minimize behaviors (e.g., aggression) that may interfere with a child's progress."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, glaucoma, hypertension, hyperlipidemia, and malignant neoplasm of the bladder.

Treatment: Home care/personal care HHC (home health care)- level 2, personal care services per 15 minutes increase to 84 hours per week.

The insurer denied coverage for home care/personal care HHC- level 2, personal care services per 15 minutes increase to 84 hours per week .

The denial is overturned.

This patient has experienced functional decline over the past year associated with several medical conditions and needs assistance with all daily activities. He relies mostly on personal care services (PCS) for help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). He lives with his wife who provides very limited (if any) assistance due to her age and health. The patient's son helps with some IADLs (example: shopping, finances).

The patient's medical conditions have resulted in substantial functional impairment. Comparison of the Uniform Assessment System (UAS) reports indicate significant decline in patient's ability to perform most ADLs and IADLs over the past year. He needs assistance with meal preparation/service, eating; medications; all household related tasks; all routine ADLs, and ADLs that occur at unscheduled and recurring times through the day (walking, transfers, toileting/incontinence care). Therefore, it is medically necessary for the patient to have a caregiver to assist with these daily activities throughout the day to help prevent adverse health and safety events (example: falls/injuries, incontinence associated skin damage, weight loss/malnutrition). Managed long-term care (MLTC) policy states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. These care needs must be considered in the determination of the patient's personal care service hours.

The request for additional personal care services is for 84 hours per week. The patient will benefit from additional help with ADLs for a more extended period of time each day. As per New York State (NYS) regulations for personal care services, assistance from informal caregivers is voluntary. Considering the son (as designee) is requesting PCS 84 hours per week, it is reasonable to conclude that there are no informal caregivers who can provide care for that amount of time on a regular basis throughout the week. When informal caregivers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed throughout the day.

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

The insurer's denial of coverage for home care/personal care HHC- level 2, personal care services per 15 minutes increase to 84 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Melanoma

Treatment: Procedure code 78816, positron emission tomography (PET) scan

The insurer denied coverage for procedure code 78816, positron emission tomography (PET) scan

The denial is upheld.

This is a male with a history of left shoulder melanoma, which was metastatic, followed by regular PET scans. The patient had a positron emission tomography (PET) scan to identify any new growths, related to melanoma.

The plan felt that other tests can adequately stage melanoma. There are other tests to detect melanoma, such as biopsy and imaging (CT (computed tomography), Xray, and or MRI (magnetic resonance imaging)).      

"FDG (fluorodeoxyglucose) PET/CT is an important clinical tool for cancer evaluation because it combines metabolic and anatomic imaging to provide guidance in staging locoregional and distant metastases, as well as monitoring response to therapy. However, the utility of FDG PET/CT in cancer varies based on the cancer type, stage, and clinical course. Knowledge of the particular indications in which FDG PET/CT is best utilized is important to appropriately guide clinicians to order the correct study, ensure optimized protocols for imaging, and generate relevant reports." (Anderson, T. 2017)

"The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network (NCCN) makes no representations or warranties of any kind regarding their content, use, or application and disclaims any responsibility for their application or use in any way." (NCCN Guidelines 2019)

The use of routine PET/CT for surveillance of resected melanoma is of no established benefit. The NCCN states that the use of surveillance imaging is a 2b (weak) recommendation. Either computed tomography (CT) or PET/CT can be used, and therefore, the treating provider can use a CT scan. The majority of studies of imaging in melanoma are retrospective, and not surprisingly, the majority of recurrences are discovered by physical exam and laboratory values.                                                         

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

The insurer's denial of coverage for the procedure code 78816, positron emission tomography (PET) scan is upheld. Medical Necessity is not substantiated.