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

Diagnosis: Gynecological 
Treatment: Pharmacy/Prescription Drugs 

This patient is a female under consideration for Orilissa 200 milligrams (mg) tablets for the indication of endometriosis (N80.9). In this case, Orilissa is a non-formulary agent. The patient has no prior trials and failures (usually there month trial each) of each of the formulary approved agents for endometriosis. These agents include ibuprofen, etodolac, naproxen, meloxicam, sulindac, diclofenac, medroxyprogesterone, and norethindrone. In this case, the patient has tried ibuprofen only previously. The patient has been seen for pelvic and perineal pain with excessive and frequent menstruation, menorrhagia and endometriosis on consultation. She was noted to be started on Anaprox-DS at that time. She was reporting pelvic pain and menstrual cramps with heavy bleeding. She had difficulty with urination and reduced stream with dribbling and blood in urine. She had vaginal discharge and dryness with pain with intercourse. She had decreased desire. There was a body mass index (BMI) of 25.7 and normal blood pressure. She had also been assigned a diagnosis of adenomyosis in this case and had a non-tender uterus and nontender adnexa. There was no recent repeat pelvic exam to support endometriosis. The patient is on NuvaRing for contraception and is considering Orilissa for therapy with possible total laparoscopic hysterectomy. 

The health plan's determination is upheld. 

In this case, the formulary drugs of etodolac, naproxen, meloxicam, sulindac, diclofenac, medroxyprogesterone, and norethindrone have not been demonstrated to be ineffective and are approved options for the treatment of pelvic pain and endometriosis. In this case, the patient does not have any medical contraindications to the use of these agents. There are no findings to support that any of these would not be effective or used in management of endometriosis. Each of these is usually tried for three months each prior to considering trial and failure before considering off-formulary agents. 
Based upon a review of the proposed use in this case where there no evaluation for possible contraindications to the use of Orilissa, there has been no trial of safer and recommended alternatives by American College of Obstetricians and Gynecologists (ACOG), and the dosing is not supported to start at the requested 200 mg twice daily (BID) dose, there would be no finding for approval of Orilissa in this case. There is no medical exception in this case to the plan's specific denial reasons or the recommendations of ACOG based upon a review of the clinical information and recommendations of ACOG. 

The ACOG states the following regarding the management of endometriosis and dysmenorrhea: "Evidence suggests that pain associated with endometriosis can be reduced with the use of a variety of medications. Although there is no conclusive evidence that NSAIDS improve pain associated with endometriosis, these agents are reasonable options in appropriately selected patients." Thus, ACOG also supports the use of the formulary agents in management of this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Foot Neuroma
 
Treatment: Foot Magnetic Resonance Imaging (MRI) 

The insurer denied the Foot Magnetic Resonance Imaging (MRI).  The denial was reversed.   

This is a female patient with a history of a neuroma on her right foot.  She presented to her provider with complaints of a neuroma located between the third and fourth toe on her right foot.  It was reported that she was experiencing burning, shooting pain, and edema to the ball of her foot and toes.  An x-ray was performed that showed that there were no fractures at the second or third region.  The deep tendon reflexes were normal and sensory testing was also intact.  It was recommended that she immobilize her foot with a soft cast to alleviate the pressure and have a magnetic resonance imaging (MRI). 

According to the peer-reviewed literature, plantar plate degeneration and tear is a common cause of forefoot pain, typically involving the second metatarsophalangeal joint at the proximal phalangeal insertion laterally, frequently confused with the second web space Morton neuroma.  High-resolution MRI can confirm a diagnosis of plantar plate degeneration and tear and exclude other pathologies, particularly Morton neuroma.  Edema and fibrotic change in the pericapsular fat plane is commonly seen in the setting of an adjacent plantar plate tear and should not be misinterpreted as reflecting a Morton neuroma.  In order to differentiate between plantar plate tears and neuroma, an assessment with MRI is imperative to pre-surgical planning.  Therefore, the request for MRI of the foot is medically necessary to treat the patient's condition and thus the decision to deny the MRI of the foot is reversed.  

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest. 

Based on the above, the medical necessity for Magnetic Resonance Imaging (MRI) of the foot is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pressure

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.   

This is a male patient with a medical history of coronary artery disease with previous percutaneous coronary intervention, diabetes mellitus, and hypertension. He presented to the Emergency Department (ED) with complaints of new onset chest pressure for several weeks. He had reportedly had been to his cardiologist's office earlier that day where it was determined by electrocardiogram (EKG) that he had T wave inversions. He was instructed to go the hospital for further evaluation. He was monitored on telemetry. He had a cardiac catheterization which revealed a diffuse 70% proximal LAD lesion which was stented and left ventricular ejection fraction (LVEF) of 35-40%. He experienced no post percutaneous coronary intervention (PCI) complications. He was discharged home the following day.  

This patient with known coronary artery disease (CAD) and prior percutaneous coronary intervention (PCI) presented with a 2-4 week history of exertional chest pain relieved by rest.  Evaluation in the ED revealed no acute ECG changes and normal troponin levels.  He subsequently underwent uncomplicated PCI of an LAD lesion. The management of the patient absent any evidence of an acute event could have been done during a period of observation. The catheterization and ad hoc PCI did not require inpatient management.

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

Based on the above, the medical necessity for the inpatient hospital admission at the acute level of care is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Blood Disorder
Inpatient Hospital

The patient was admitted to the hospital for anemia. The patient has underlying congestive heart failure (CHF) (ejection fraction (EF) 35-40%), coronary artery disease (CAD), and chronic kidney disease (CKD) 3. The patient presented with fatigue, dizziness, and shortness of breath. On exam the patient was found to have bleeding lesions from hidradenitis, the probable source of  anemia. The patient was felt to be euvolemic and was given oral iron as an outpatient. There were no symptoms of gastrointestinal (GI) bleeding. The initial hemoglobin was 7.7, with an iron saturation of 14%.The baseline hemoglobin was 11.4. The patient was not on anticoagulant therapy. The patient received a blood transfusion with Lasix and responded appropriately with a resultant hemoglobin of 9.3 and was discharged the following day.

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

The requested health service/treatment of an inpatient stay was not medically necessary. The patient had a slow drift down in hemoglobin during the outpatient period. There was the presence of active oozing from open hidradenitis lesions and so the source of blood loss was known. At the time of admission, the patient did have symptoms related to anemia, but they were mild. The patient responded to a single unit of blood and was always euvolemic. The patient could have received the treatment provided, including a unit of blood, at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thyroid nodule
Issue under review: Genetic testing

Determination:
The Genetic testing was not medically necessary.

The patient is an adult female with benign thyroid nodule by cytopathology.  Her AP performed genetic testing. 

There is no evidence to support the use of the testing for management of patients with thyroid nodules that are benign by standard FNA (fine needle aspiration) cytopathology.  Per the NCCN, this testing is only appropriate for patients with unclassified thyroid nodules by cytopathology.  For patients with benign nodules by cytology, ongoing testing is not warranted. 

This patient had a benign thyroid nodule by standard cytopathology. No further testing is warranted.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endodontically treated molar 

Treatment: D2750 white glass with high gold content crown for tooth number 19

The insurer denied coverage for D2750 white glass with high gold content crown for tooth number 19. The denial is upheld. 

This patient is a female who presented for routine comprehensive dental treatment. The provider recommended a replacement full coverage crown on this endodontically treated molar. The objective documentation provided for review is the periapical and full mouth series radiographs. Tooth #19 has a full coverage crown placed and is endodontically treated. 

It appears that there is no evidence of fracture or other pathology specifically affecting #19. There does not appear to be any radiographic evidence of caries.  There is no documentation provided for review that would justify the treatment. The radiographs do not substantiate the requested dental service as enumerated above; therefore, it is deemed not medically necessary. Uphold denial of coverage for the dental service code D2750 white glass with high gold content crown for tooth #19 as not medically necessary as the documentation is insufficient to justify or substantiate the treatment.

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

Based on the above, the medical necessity for the dental service code D2750 white glass with high gold content crown for tooth number 19 is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left submandibular gland adenoid cystic carcinoma 
Treatment: Proton beam therapy
The insurer denied the Proton beam therapy.
The determination is upheld.

This is a patient with a left submandibular gland adenoid cystic carcinoma post resection with close margins. He is staged tumor (T) 1 nodes (N) 0 metastasis (M) 0. He was noted to have extensive perineural invasion. Radiation therapy is recommended to this region to decrease his risk of recurrence and proton beam radiation is requested. At issue is the medical necessity of proton beam radiation therapy.
The requested health treatment of proton beam radiation therapy is not medically necessary for this patient. This a patient with a left submandibular gland adenoid cystic carcinoma post resection with close margins. The recommended proton beam radiation therapy for this patient is not considered medically necessary based on the review of the provided clinical information and the provided medical policy on proton radiation for head and neck cancers. There are lack of any significant data from randomized trials supporting the benefit nor safety of proton beam radiation over photon beam radiation for this clinical scenario. Until further significant studies are performed and published in peer reviewed medical journals, the requested proton beam radiation therapy for this clinical scenario is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney disorder
Treatment: Inpatient hospital
The insurer denied the inpatient hospital stay
The denial is upheld in whole 

The patient with no past medical history who was admitted for persistent flank pain due to a 3-millimeter (mm) small ureter stone on computed tomography (CT) imaging. One day prior to admission, patient was in the emergency department with the same complaints.

No, the admission was not medically necessary for acute inpatient level of care. There were no compelling clinical reasons why the patient could not have been safely and appropriately evaluated and cared for at the lower level of care.

The patient temperature in this case was 98.5, her BUN was 8 and creatinine 0.7 and the wbc count was 5.3. There was no surgical intervention. The patient was treated with intravenous IV fluids and analgesics.

Patient was hemodynamically stable. There was no evidence of urinary tract infection (UTI), pyelonephritis or sepsis/ systemic inflammatory response syndrome (SIRS). Patient did not have a transplanted kidney nor a single functional kidney. There was no acute kidney injury, persistent vomiting or need for surgical intervention. There was no evidence of high intensity pain management in this case. Therefore, the inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Respiratory System /other 
Treatment: Inpatient hospital 
The insurer denied part of the hospital stay 
The denial is partially overturned 

The patient with past medical history of coronary artery disease, mitral regurgitation, and celiac disease who presented to emergency department (ED) with complaints of pleuritic chest pain and shortness of breath. Vitals signs were stable. The patient's chest imaging revealed right mid lateral lung consolidation with differential diagnosis of community acquired pneumonia or Tuberculosis.

Yes, the hospitalization is medically necessary in part.

The patient had a chest tube still in place Multiple subacute rehabilitation facilities refused to accept him in transfer due to presence of chest tube and Heimlich in place. He was not accepted at any of the local subacute rehab centers. The chest tube which was cautiously removed despite the presence of pneumothorax on CXR. There was reasonable and appropriate concern for worsening of pneumothorax because of history of prior worsening/ recurrence and close follow up and hospital monitoring was reasonable and clinically indicated. Pneumothorax was noted to be stable despite slightly increased shortness of breath as reported by patient. Based on available documentation, he could have been safely discharged to subacute rehab.

Since his pneumothorax remained stable, physician team removed chest tube. Considering the patient had a stable but persistent pneumothorax now with multiple previous re-expansion of pneumothoraxes requiring recurrent chest tube place prior in the stay - the standard of care and prudence is towards monitoring him for stability in the hospital with follow up CXR which was done in this case. Once the pneumothorax was stable for 48-72 hours, a discharge could have been considered safely despite need of low amount of oxygen.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult gentleman with a history of diabetes mellitus and gastroesophageal reflux disease. He presented to the ED complaining of left sided chest pain lasting for 10 hours.  

The patient's physical examination was unremarkable, and his vital signs were stable.  12-lead ECG (electrocardiogram) revealed sinus rhythm without ischemic ST or T wave changes. The patient underwent exercise perfusion testing, which was unrevealing, and he was discharged home.

This patient presented with chest pain. His pretest probability of coronary artery disease is low (Reference 1).  Utilizing the HEART (History, EKG, Age, Risk factors, initial Troponin) score, he was considered low risk (Reference 2).  Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1) (Reference 3). 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Melanoma
Radiology Services (including Ultrasound)

The patient is a man with a history of malignant melanoma involving his left 5th finger, status/post (s/p) wide excision and sentinel lymph node biopsy performed. The initial biopsy revealed malignant melanoma measuring 1.5 millimeter (mm) in Breslow depth, Clark's level IV without ulceration and > (greater than) 1 mitosis/mm2, T2aN0, stage Ib. The wide excision specimen contained residual melanoma in situ. One left axillary sentinel lymph node was removed and showed no evidence of metastatic disease. A PET scan is under review.

The health plan's determination is overturned. A PET scan is medically necessary for this patient. The PET scan was medically necessary for this patient in order to further evaluate equivocal findings in the left axilla 1.5 years following wide excision and sentinel lymph node biopsy for a stage Ib melanoma of his left 5th digit. The left axilla was the primary draining nodal basin of his melanoma, the location of his symptoms and the site of his initial sentinel lymph node biopsy.
A PET scan is appropriate and medically necessary for further work-up in this case of a patient who is 1.5 years s/p wide excision and left axillary sentinel lymph node biopsy performed for a stage Ib melanoma, who presented with symptoms in the draining nodal basin, and who had inconclusive results of an ultrasound examination of the draining nodal basin.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal - Osteoarthritis
Home Health Care

The patient is a female with past medical history of generalized osteoarthritis (severe in bilateral knees), osteoporosis, hypertension and urinary incontinence who has had personal care aide services. The patient had been approved for 6 hours/7 days a week to total 42 hours per week. The patient had an assessment using Uniform Assessment System (UAS)-NY tool indicating that she had improvement in certain tasks. The assessment tool indicated the patient had improved by one level in tasks of eating, upper and lower extremity dressing, locomotion, toilet use and bathing. The patient previously needed maximal assistance with lower extremity dressing and bathing but was downgraded to extensive assistance per assessment. Her personal care aide service hours were reduced to 4.25 hours per day/7 days per week to total 29.75 hour per week. The provider asked for an appeal of this decision. The patient's daughter wrote a letter indicating the patient had no improvement in her medical condition and continued to need maximum help with bathing and lower extremity dressing. The patient wore compression stockings and was not able to apply these herself due to arthritis in her hands. The daughter also indicated that the patient had difficulty understanding the assessor's questions due to language barrier and was concerned about the validity of the assessment. The health plan upheld its decision to reduce hours to 4.25 hours per day/7days per week to total 29.75 hours per week.

The health plan's determination is overturned.

Yes, 42 hours a week (6 hours a day x 7 days personal care aid level 2) is medically necessary for this patient. The patient's medical condition did not change from previous assessment. The patient had concern about the assessment performed as she had difficulty understanding and answering the questions due to language barrier. The patient continued to need maximum help putting on her compression stockings (lower extremity dressing) and with bathing due to arthritis. Personal care services may not be reduced or terminated without justification which must be stated in the notice of change. The notice indicated the patient "improved" in multiple tasks without specific verbiage of how the patient's condition improved. The plan has burden of proof to show a change in the patient's medical condition or circumstance or show that a mistake was made in the original assessment. Assessment did not document specific reasons for improvement in certain tasks. In summary, 6 hours per day/7 days per week to total 42 hours per week are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted canine
Issue under review: Braces

Determination
The braces are medically necessary.

The patient is a female child. The patient presents with two "automatic qualifiers." She has an impacted permanent tooth (#11, upper left canine) which is not indicated for extraction. She also has a crossbite of tooth #10 with attachment loss and recession of the gum. Both of these conditions individually are reasons for orthodontic benefits, with medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Persistent ataxia
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld.   

This is a male patient who has a medical history of hypertension, anemia and prediabetes.  He presented to the emergency department (ED) with complaints of dizziness and feeling off balance.  He reported going to the ED two weeks prior to this ED presentation after having a similar episode.  He was advised that he had anemia and needed iron supplements.  A laboratory work up was performed; his hemoglobin was 14.2, and his hematocrit was 43.1.  He had a chest x-ray that was normal.  He was consulted by cardiology.  An echocardiogram was performed revealing an ejection fraction of 55-65 %.  It was recommended that the patient continue with aspirin 81 mg.  Neurology consulted on the patient.  A computed tomography/compute tomography angiography (CT/CTA) was performed which suggested sinusitis with no acute disease process.  It was recommended that the patient start meclizine and Flonase.  A magnetic resonance imaging (MRI) of the brain was performed which revealed no anomalies.  The patient was discharged home with follow up instructions.

According to current literature, a patient may be admitted to inpatient services when there is evidence of vasculitis, severe central nervous system [CNS] infection, cerebral aneurysm or other issues needing continued inpatient monitoring such as amyotrophic lateral sclerosis, Parkinson's disease, or multiple sclerosis flare.
 
In this case, the CT of the brain along with an MRI of the brain could have been performed in the Emergency Department along with appropriate neurological and cardiac consultations.  The patient could have been discharged from the Emergency Department with meclizine and Flonase.  The care provided did not justify an inpatient admission and was consistent with a lower level of care. 

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.