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

Diagnosis: Grade III anaplastic astrocytoma 
Treatment: Proton Beam Therapy 
Proton Beam Therapy is medically necessary.

Summary:
This is a woman with WHO grade III anaplastic astrocytoma in the left frontal lobe  status post resection followed by proton beam therapy of 54Gy in 30 fractions.

Proton beam has advantage of being able to deposit high dose of radiation to tumor with sharp dose fall off from normal tissues, thus reducing risks of late radiation effects to normal brain such as decline in neurocognitive function. Proton beam therapy, therefore, can be considered as a modality to deliver highly conformal RT. 

This member's tumor is located in the left frontal lobe, which is neurocognitive  areas of brain and high dose radiation to control this tumor can result in radiation induced permanent memory impairment in this patient. 

Proton beam with superior dose conformity will enable to deliver planned dose to the target with maximum sparing of adjacent normal brain tissues and will decrease risks of such complications in this patient with a good long-term prognosis. 

Thus, the requested proton beam therapy is consistent with 2017 ASTRO model policy for proton beam therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay
Treatment: Nerve treatment on molar tooth, tooth #19 (D3330) and white glass with metal crown, tooth #19 (D2751) 

The proposed nerve treatment and white glass with metal crown on tooth #19 is medically necessary. 

Tooth #19 has severe decay in it. It is, however, restorable by having a root canal procedure and a crown afterwards. There is no reason this tooth cannot be treated as described. The proposed treatment is the proper plan as this is a functioning tooth for this patient. To not treat this tooth and have to remove it will cause other problems that may be avoided with the proposed treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mixed dementia
Issue under review: PCA level 2, 24 hours/day (split-shift) - total of 168 hours/week 

Determination:
The PCA level 2, 24 hours/day (split-shift) - total of 168 hours/week is medically necessary.

This is an elderly female with a history of mixed dementia (Alzheimer's/multi infarct), iron deficiency anemia requiring blood transfusions, chronic vertigo and oxygen dependent CHF.  Due to the severity of her various medical issues, she requires assistance with the majority of her activities of daily living (ADLs).  A face to face clinical assessment performed utilizing the New York State Department of Health's Uniform Assessment System (UAS) tool revealed that the patient's abilities to perform her ADLs had remained stable/consistent with no evidence of additional functional decline since her prior assessment completed on 06/07/2019.  However, per documentation from the patient's primary care physician, he reports that the patient has been experiencing progressive functional decline with nighttime wandering out of bed, frequent trips to the restroom and worsening urinary and fecal incontinence, putting her at increased risk for skin breakdown/pressure ulcer development.  For these reasons, the proposed treatment of PCA level 2, 24 hours/day (split-shift) - total of 168 hours/week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a former smoker with a history of congestive heart failure (CHF), cocaine use, depression, hypertension, seizures, chronic back pain, alcohol abuse (recent admission for detoxification for which patient signed out against medical advice (AMA)), deep vein thrombosis (DVT), PVD (peripheral vascular disease), methicillin-resistant staphylococcus aureus (MRSA) cellulitis, chronic venous insufficiency, and recent superficial wound culture positive for Acinetobacter and MRSA. He presented to the emergency department (ED) with bilateral leg swelling, weeping open wounds and worsening pain. The patient stated that he usually has swollen legs but now has ulcers developing. The patient denied any shortness of breath, chest pain, recent travel, or fevers. The patient was admitted to the hospital. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The Centers for Disease Control and Prevention (CDC) reinforces outpatient management of cellulitis without abscess/purulent drainage. The patient did not demonstrate high risk features which warranted an inpatient level of care admission and IV antibiotics. The patient could have been managed with oral antibiotics at a lower level of care as described by UpToDate, which addresses the treatment of cellulitis: "Oral versus parenteral therapy - Patients with mild infection may be treated with oral antibiotics. Treatment with parenteral antibiotics is warranted in the following circumstances:
1) Systemic signs of toxicity (eg, fever >100.5F/38C, hypotension, or sustained tachycardia).
2) Rapid progression of erythema.
3) Progression of clinical findings after 48 hours of oral antibiotic therapy.
4) Inability to tolerate oral therapy.
5) Proximity of the lesion to an indwelling medical device (eg, prosthetic joint or vascular graft).
Appeal type: Medical necessity
Decision: Overturned

This patient has been treated for plantar fasciitis for over three months. The treatment has included activity modification, stretching exercises and accommodative orthotics. The patient has not obtained adequate relief after three months of treatment. A request was made for custom functional orthotics. The health plans determination of medical necessity is overturned, in whole.
The requested health service/treatment of Custom Shoe Orthotics is medically necessary for this patient. The use of functional orthotics in the treatment of plantar fasciitis is considered standard conservative treatment. The patient has already attempted other conservative treatment, including activity modification, stretching exercises and accommodative orthotics.
According to the clinical practice guidelines of the American College of Foot and Ankle Surgeons (1), custom orthotics are considered a second tier treatment for plantar fasciitis, most appropriate after 6 weeks of other modalities which may include padding, over-the-counter (OTC) arch supports, shoe gear changes, anti-inflammatory medication, home physical therapy and/or corticosteroid injection.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) complaining of intermittent chest pain for one week. An electrocardiogram (ECG) showed no ischemic changes. Troponin was negative. The patient was seen by Cardiology who recommended urgent catheterization and was admitted. Cath showed a 99% left anterior descending (LAD) stenosis which underwent successful drug-eluting stenting (DES). The patient was observed uneventfully overnight and discharged. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had an urgent diagnostic catheterization and coronary intervention for unstable angina. The cath was successful and the patient tolerated the procedure well. It was reasonable and appropriate to monitor the patient for several hours after the procedure. However, it was very likely that the patient would be ready for discharge with 8-23 hours after the procedure. Thus, the patient could have been observed at a lower level of care without the need for a full inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dizziness
 
Treatment:  Inpatient admission, diagnostic testing, monitoring

The insurer denied the inpatient admission.  The denial was upheld.

The patient was a female who presented to the ER with back pain and dizziness.  She had a past medical history notable for sarcoidosis, pulmonary embolism, deep venous thrombosis and hypertension.  Her symptoms worsened when she stood; she also had numbness on the right side of her face, and headache.  EKG and CT of the head were normal.  She was admitted for dizziness.  An echocardiogram showed normal left ventricular systolic function, and a carotid duplex was normal.  She was discharged home.

The patient's care could have been administered in the ER or under observational level of service.  There were no findings or features which justified the need for a higher level of care.  The initial vital signs were stable and the patient remained hemodynamically stable.  There were no neurological deficits or imaging-confirmed acute neurological injuries.  There was no evidence of myocardial ischemia, hemodynamic instability, severe electrolyte abnormalities, severe derangements of blood counts or other indications for acute inpatient admission.  Therefore, the request for inpatient admission is not medically necessary.  

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

Diagnosis:  Sarcoidosis
Treatment:  Increase in Consumer Directed Personal Care Assistance from 56 hours per week to 84 hours per week

The proposed treatment of an increase in consumer directed personal care assistance from 56 hours per week to 84 hours per week is deemed medically necessary. 

This is a male with a history of sarcoidosis, associated chronic respiratory failure and 24/7 supplemental oxygen therapy.  For these reasons, he requires assistance for completion of the majority of his activities of daily living (ADLs).  Per documentation from the patient's attending physician, the patient's respiratory status has been progressively deteriorating to the point where he has chronic fatigue and dyspnea performing even minimal activities.  For these reasons, the proposed treatment of an increase in Consumer Directed Personal Care Assistance from 56 hours per week to 84 hours per week is deemed medically necessary to better assist with completion of the patient's ADLs.  The currently approved 56 hours per week are not sufficient to meet this patient's needs.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a cold and cough for four days and fever for two days. He also had itchy eyes and occasional vomiting. The patient had no history of wheezing in the past although his mother and father both have asthma. A chest x-ray showed left lower lobe infiltrate. Maximum temperature (Tmax) was 102 degrees Fahrenheit (F) at home. His chest had some mild expiratory wheezing.  The admitting diagnosis was pneumonia. Laboratory studies upon admission were unremarkable. He was treated with Rocephin and Clindamycin in the emergency room. He also had albuterol nebulizer treatments times three (x 3) in the ER. The health plan's determination is upheld.
This patient presented with fever, conjunctivitis and intermittent vomiting and was found to have a pneumonia on chest x-ray (CXR). He had an uneventful hospital course and improved as expected. He did not require a high level of care or increased intensity of services. His vital signs were stable apart from intermittent fevers.
He was placed on oral antipyretics as needed, intravenous fluids (IVF), Albuterol every six hours (q6hrs), eye drops and ointment, oral antibiotics as well as oral steroids. He had intermittent fevers that responded to antipyretics.  He did not meet criteria for an inpatient stay.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient with a past medical history significant for benign prostatic hyperplasia (BPH) who was referred to the emergency department by the primary care physician for evaluation of fever, increased urinary frequency, and suprapubic pain that the patient  had for 3 days.
At the time of the initial evaluation, the patient complained of sharp suprapubic pain, which rated 9/10 in severity without radiation. At that time the patient stated that the  urine was dark in color and foul-smelling. The health plans determination is overturned in part. The requested health service/treatment of inpatient stay was medically necessary for this patient at the time of admission, based on the severity of the clinical condition and nationally adopted standards of care. The patient had a complicated urinary tract infection and pyelonephritis, therefore, in accordance with accepted standards of care, the required admission for the administration of intravenous antibiotics. The review of medical records demonstrated that the urine culture was finalized, and came back positive for pan sensitive Escherichia Coli. At that time the patient was afebrile, hemodynamically stable, and reported improved urinary symptoms that had brought the patient  to the hospital. Therefore, the hospital stay beyond the 3rd overnight was not medically necessary at the inpatient level of care. At that time, the care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a left breast carcinoma post neoadjuvant chemotherapy followed by bilateral mastectomies and reconstruction with implants placed. She is staged tumor (T) 2 nodes (N) 1a metastasis (M) 0. She is at risk of recurrence in the chest wall and nodal regions. Radiation therapy is recommended to these areas and intensity modulated radiation therapy (IMRT) with image guidance (IGRT) is recommended to deliver the radiation treatments. The health plan's determination is overturned. The recommended IMRT with image guidance (IGRT) is considered medically appropriate and necessary for this patient and her clinical scenario. The ordering physician has also supplied comparison 3 dimensional (D) and IMRT radiation treatment plans with appropriate dose volume histograms to determine the significant benefit of IMRT over 3D conformal radiation with a significant decrease in volumes of the heart and lung receiving high doses of radiation with IMRT as compared to 3D. This in turn will decrease her risk of side effects. The use of image guidance for daily radiation treatment setup is also appropriate to assist in more precise daily treatments and in turn, a decreased risk of side effects particularly with IMRT treatment patients. There are excellent data published in the peer reviewed medical literature supporting the use of IMRT and IGRT for this clinical scenario. This is also supported by National Comprehensive Cancer Network (NCCN) Guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post root canal
Treatment: White glass with metal crown, tooth #6 (D2751)

The white glass with metal crown, tooth #6 (D2751) is medically necessary.

Tooth #6 has had endodontic treatment (root canal).  This compromises the strength of the tooth, necessitating a crown to help keep the tooth from fracturing. A crown on an endodontically treated tooth is a normal, correct and warranted procedure.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) with a chief complaint of chest pain radiating down her left arm after lifting an oak headboard. The patient had a history of chronic obstructive pulmonary disease (COPD) /asthma, alcohol and cocaine abuse, human immunodeficiency virus (HIV) on ARVT, and major depression. The patient had a cath which did not show obstructive coronary artery disease (CAD). On physical examination, the patient had bilateral wheezing. Laboratory studies including troponin were unremarkable except for urine screen for cocaine which was positive. An electrocardiogram (ECG) showed no ischemia and multiple PVCs (premature ventricular contractions). Chest x-ray showed right upper lobe nodule which had been seen in the past without change. The patient was felt to have COPD exacerbation and was given breathing treatments and intravenous (iv) steroids in ED.
The patient was admitted with the suspicion of acute coronary syndrome as well as COPD exacerbation.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had chest pain with low likelihood of an acute coronary syndrome. It was not unreasonable to observe the patient for several hours to assure there was no MI. This patient could have been observed overnight at a lower level of care. The other tests required could have been performed at a lower level. There was no apparent reason to admit patient for full admission status for cardiac reasons. The patient also had a COPD exacerbation, but it did not appear to be severe enough to require hospitalization. It could have also been treated at a lower level and after 23 hours been re-evaluated for the necessity of admission, which based on the status at that time did not appear severe enough to warrant admission for medical necessity.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male with a listed diagnosis of multiple sclerosis. The patient is reported to have been stable on Tysabri, but previously failed Avonex and Tecfidera. He is reported to have since developed antibodies to John Cunningham (JC) virus. The provider is requesting Ocrevus. The health plan's determination is overturned.

Treatment with Ocrevus is medically necessary for this patient.
The patient has failed two different treatment options for multiple sclerosis, Tecfidera and Avonex, and given the recent development of antibodies to the JC virus, indicating infection, it is recommended Tysabri be discontinued. Tysabri has been associated with development of progressive multifocal leukoencephalitis (PML), in patients with JC virus positive antibodies. The current guideline recommendation is substituting Tysabri for an alternative agent such as Ocrevus.
Continuation of Tysabri therapy carries a substantial risk of PL, which is a fatal brain infection associated with Tysabri in patients with positive JC virus antibodies. Therefore, treatment with Ocrevus, which is an alternative treatment, is medically necessary, recommended and the appropriate next step in the treatment of this patient, based on current standards of care for multiple sclerosis treatment.
Appeal type: Medical necessity
Decision: Upheld

Influenza/Flu
Inpatient Hospital

The patient is a male with a history of diabetes, stroke, hypertension, and bladder cancer (status/post [s/p] ileo-conduit). He presented to the emergency room with a one day history of fever, chills, and vomiting. The temperature was initially 102.8 degrees but then quickly came down to 99.4 degrees. The vital signs were otherwise normal, and the oxygen saturation was 98%. He was in no acute distress, and the physical exam was unremarkable. Labs were notable for a modest leukocytosis of 11,400, hematocrit of 27.3%, and creatinine 1.8 milligrams per deciliter (mg/dl). The urine revealed multiple white blood cells, and he was positive for influenza A. The chest x-ray was non-contributory and the electrocardiogram (EKG) was negative for ischemia. For unclear reasons, it was concluded that the patient had sepsis and was admitted for further evaluation and treatment.
Upon admission, the patient was treated with intravenous fluids, intravenous antibiotics, Tamiflu, and oral medications. He remained afebrile and hemodynamically stable throughout the hospital course, which was clinically uneventful. He was discharged.
The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

No, the requested health service/treatment of inpatient stay was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. There is no compelling evidence of sepsis requiring acute inpatient care and prolonged intravenous antibiotics. Urine specimens from ileal conduits are frequently colonized with bacteria and have other abnormalities, making the diagnosis of a urinary tract infection challenging. The blood cultures were negative. His care could have been safely and efficiently provided at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trigeminal neuralgia
Issue under review: Brain surgery

Determination:
The Brain surgery is not medically necessary.

The patient's symptoms of periorbital pain that radiates into the right face and lip is an atypical presentation of trigeminal neuralgia, and the imaging does not clearly demonstrate a vascular compressive etiology as would be expected based upon the classic trigeminal neuralgia findings. The patient's symptoms do not correlate with classic trigeminal neuralgia, and based upon the documentation provided, there is no clear compressive etiology. Therefore, the proposed surgery for microvascular decompression is not considered to be medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: osteoarthritis, congestive heart failure (CHF), hypertension, and diabetes type II
Treatment: Personal care aide 168 hours/week split shift 
The proposed treatment with personal care aide 168 hours per week split shift is not medically necessary.

Based upon the medical records and other documents, the patient's current medical needs can be met by 13 hours PCA Level II with five (5) sleep hours, seven (7) days per week.  The patient's medical condition has been stable based upon recent nursing assessments.  There are no changes in adult daily living abilities in the last 90 days.  There have been no falls in the last 90 days.  There have been no hospitalizations in the last 90 days.  The patient based upon recent nursing survey is in a stable satisfactory condition.  The medical records do not support medically necessity of Level II, PCA services 168 hours a week/split shift. 

The plans approved 13 hours Level II PCA with five hours sleep seven days per week which meets the patient's needs and is in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

The patient is presents with diagnosis of benign prostatic hyperplasia (BPH) and elevated prostate-specific antigen (PSA). His PSA was 4.7 in 7/19, 3.8 in 8/2018 and 3.6 in 8/2015. At issue is the medical necessity for magnetic resonance imaging (MRI) of the pelvis due to the patient not having undergone a biopsy. Performing MRIs in men with rising PSA and prior negative biopsies has been increasingly studied over the last few years. Multiparametric (MP)-MRI and magnetic resonance imaging/transrectal ultrasound (MRI/TRUS) fusion-guided prostate biopsy improve the cancer detection in patients with low apical lesions, anterior lesions, enlarged prostates, and even disease outside the prostate. However, the value of performing MRI's and doing MRI guided biopsy in men without previous biopsy is still under evaluation. Although some clinical trials have showed improved detection rate of prostate cancer and high-risk prostate cancer in patients who underwent MRI guided biopsy, it is not considered a generally accepted standard of care in patients who have not had prior prostate biopsies. Therefore, this request is determined to be not medically necessary.