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

Diagnosis: Cancer to the sternum.

Treatment: Other metastases, bone; 5 fractions (treatment sessions) of stereotactic body radiation therapy (SBRT) (using protons).

The insurer denied coverage for other metastases, bone; 5 fractions (treatment sessions) of stereotactic body radiation therapy (SBRT) (using protons).

The denial is overturned.

This is a female with history of stage IV (cancer has metastasized) breast cancer, with a sternal metastasis, for which the patient has been recommended to proceed with a course of external beam radiotherapy. The treating provider has requested for SBRT utilizing protons.
 
The patient has cancer to the sternum (sternal metastasis). To protect the patient's heart, lungs and spinal cord, in consideration of two rounds of prior radiation to the same area, toxicity levels and cumulative dosing, the use of proton bean therapy (PBT) is medically necessary.

Stereotactic body radiation therapy (SBRT) (using protons) is considered medically necessary for this patient.  Proton based SBRT is standard of care and medically necessary for management of the member's sternal metastasis. Proton based SBRT allows for optimal target coverage while minimizing re-exposure to the patient's underlying cardiopulmonary tissues.  Proton-based SBRT is supported by the ASTRO (American Society for Radiation Oncology) Model Policy and SABR (stereotactic ablative radiotherapy) COMET (comprehensive treatment of oligometastases) study in the member's setting.

Per Palma, D. A., et al., (2019), "The oligometastatic paradigm suggests that some patients with a limited number of metastases might be cured if all lesions are eradicated. Evidence from randomised controlled trials to support this paradigm is scarce. We aimed to assess the effect of stereotactic ablative radiotherapy (SABR) on survival, oncological outcomes, toxicity, and quality of life in patients with a controlled primary tumour and one to five oligometastatic lesions. SABR was associated with an improvement in overall survival, meeting the primary endpoint of this trial."
Per Astro Model Policies (2017); Proton Beam Therapy (PBT) is recommended for re-irradiation cases (where cumulative critical structure dose would exceed tolerance dose."

Per Moreno, A. C., et al., (2019), "These are exciting times as proton therapy continues to be validated as a valuable treatment modality for patients with HNCs (head and neck cancers). The National Comprehensive Cancer Network (NCCN) guidelines already recognizes the dosimetric and clinical advantages protons provide for treating tumors near critical structures and recommends its usage when normal tissue constraints cannot be met with photon-based therapies."                                                         

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 other metastases, bone; 5 fractions (treatment sessions) of stereotactic body radiation therapy (SBRT) (using protons) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Areata. 
Treatment: Xeljanz. 

The insurer denied coverage for Xeljanz. 

The denial is overturned. 

The patient is a male with a diagnosis of alopecia areata that is severe, affecting 90% (percent) hair loss.  The patient has failed therapy with topical, intra-lesional, and oral steroids. The requested medication is Xeljanz. 

The patient has extensive disease involvement of alopecia which necessitates systemic therapy. Limited systemic options are available for a teenage, aged child. The use of light therapy and topical therapy would not be appropriate given the extent of involvement, the involvement of sensitive areas such as the eyelashes and eyebrows, as well as likely inability to meet school schedule. No Food and Drug Administration (FDA) approved systemic therapies are available for treating alopecia areata. In this clinical situation Xeljanz is an appropriate treatment option for treatment of alopecia areata. As a result, the denial is reversed and the use of Xeljanz is medically necessary for use in the treatment of the patient's condition. 

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 Xeljanz is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis Suppurativa.
Treatment: Humira pen.

The insurer denied coverage for Humira pen.
The denial is overturned.

The patient is a male with a diagnosis of hidradenitis suppurativa.  The patient has significant complicating medical issues and has failed multiple medications, including Cyclosporine, prednisone, and IVIG (intravenous immune globulin). The requested medication is Humira.  

Humira is medically necessary for the treatment of the patient's condition, hidradenitis suppurativa.  The patient has severe hidradenitis suppurativa and has significant medical issues, including diabetes, a below the knee amputation, hypertension, anemia, and gout.  The patient has failed conventional medications used for the treatment of his disease process.  

Humira is FDA (Food and Drug Administration) medically necessary for the treatment of Hidradenitis supurativa and is a reasonable next step in this clinical scenario based on the appeal and notes presented.  In a randomized study by Kimball et al., it was found significantly better compared to placebo. The decision is reversed and Humira is approved for the treatment of the patient's hidradenitis suppurativa at the discretion of the treating physician.  

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 Humira Pen is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Caries.

Treatment CT (computed tomography) scan, tooth 1 and D6010 implant placement, tooth 9.

The insurer denied coverage for CT scan, tooth 1 and D6010 implant placement, tooth 9.

The denial is overturned.

An implant is the best option, and a computed tomography (CT) scan is needed for #1 and ensures accurate placement of the implant.

The options in this case to restore function are an implant or a bridge. Implants are the best option. A bridge is considered radical treatment as adjacent tooth structure must be drastically reduced in this process. The bridge has been regarded as the standard of care for some time in the replacement of single and multiple missing teeth. However, to obtain optimal functional and aesthetic results for full-veneer bridges, a significant reduction in the amount of tooth structure is necessary occasionally predisposing to endodontic, periodontal, and structural complications. The abutment teeth often become carious and have an increased rate of needing a root canal procedure. If one of the abutment teeth are lost a longer span bridge would be required. The implant procedure is more conservative and has a better prognosis. Implants have a high rate of success, do not require procedures on adjacent teeth and are not susceptible to caries. A Position Paper Subcommittee of the American Academy of Oral and Maxillofacial Radiology (AAOMR) reviewed the literature since the original position statement on selection criteria for radiology in dental implantology, published in 2000. All current planar modalities, including intraoral, panoramic, and cephalometric, as well as cone beam computed tomography (CBCT) are discussed, along with radiation dosimetry and anatomy considerations. They provide research-based, consensus-derived clinical guidance for practitioners on the appropriate use of specific imaging modalities in dental implant treatment planning. Specifically, the AAOMR recommends that cross-sectional imaging be used for the assessment of all dental implant sites and that CBCT is the imaging method of choice for gaining this information.

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

The insurer's denial of coverage for computed tomography (CT) scan, tooth 1 and D6010 implant placement, tooth 9 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Caries

Treatment: Root canal treatment (D3330) for tooth 19

The insurer denied coverage for root canal treatment (D3330) for tooth 19.

The denial is overturned.

Based on the submitted documentation, which includes copies of pre and post treatment periapical radiographs, narrative letters, and insurer correspondence, it appears that this patient presented to the dentist for dental care. Caries was noted on tooth # (number) 19 on examination and endodontic therapy was recommended. The insurer has denied these services, stating that the services are not medically necessary, as the documentation does not meet medical necessity criteria of the NYS (New York State) Medicaid Dental Policy and Procedure Code guidelines.  

Upon review of radiographs, they support the recommended treatment. The tooth exhibits a large carious lesion focally involving or approximating the pulp chamber radiographically. This tooth would require endodontic therapy in order to maintain it and prevent future infection in this patient. This tooth will have adequate residual coronal structure for support of post and core and crowns and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be endodontic therapy for this tooth, which would have an excellent long-term prognosis with the recommendation treatment.

Overturn denial and approve coverage for root canal treatment (D3330) for tooth 19 as medically necessary, as the clinical and radiographic documentation support these services and these services would be a standard of care in general dental practice.

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

Root canal treatment (D3330) for tooth 19 is considered medically necessary for this patient.

The insurer's denial of coverage for the root canal treatment (D3330) for tooth 19 is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction/Alcohol Abuse
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a man with a history of alcohol abuse. He presented to the emergency room with nausea, heavy vomiting, tremulousness, headache, and epigastric pain after suddenly discontinuing his heavy alcohol intake the day before. The vital signs were notable for a blood pressure of 149/87 millimeters of mercury (mmHg) and a pulse of 126 beats per minute (bpm). He was alert and oriented. There were bilateral upper extremity tremors, tongue fasciculations, and epigastric tenderness. Labs were notable for a bicarbonate of 16 milliequivalents (mEq) /liter and a glucose of 65. The chest x-ray was normal. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was treated with intravenous fluids, parenteral Lorazepam, parenteral Ondansetron, vitamins, and oral Diazepam. The patient was admitted for further treatment and evaluation.
Upon admission, treatment was continued with intravenous fluids, Naltrexone, and benzodiazepines. The next day his tremors had improved considerably. Oral Diazepam was continued. He was evaluated by the Addiction Consult Service. The tremors continued to improve. His mental status and vital signs, except for mild tachycardia, were normal throughout the stay. The patient left against medical advice.
At issue is the medical necessity of the inpatient stay.

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

No, the requested health service/treatment of the 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 that required acute inpatient admission. He was not delirious, there were no seizures, and the vital signs were normal except for mild tachycardia. His symptoms were responding to a Diazepam taper, which was well tolerated. The services he received were not at the acute inpatient level of intensity. Therefore, based on the standard of care, and the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is a gentleman with a history of hypertension and diabetes mellitus that presented to the hospital for elective cardiac catheterization following complaints of chest pain at rest and a non-diagnostic exercise stress test. During stress testing, the patient failed to reach maximally predicted heart rate. Duke treadmill score was 2. Cardiac catheterization revealed coronary artery disease involving the mid ramus artery (80% [percent]) and the distal circumflex artery (80%). Stents were successfully placed in both arteries. No perioperative complications were noted, and the patient was discharged the following day.

The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient. This patient presented for elective percutaneous revascularization. He underwent an uncomplicated procedure and stents were placed in ramus and left circumflex arteries. He was discharged the following day. Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital [1-4]. Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care [4]. In conclusion, inpatient hospital admission was not medically necessary. The patient could have been managed at a lower level of care.

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

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

Diagnosis: Cervical spondylitis myelopathy, cervical radiculopathy due to degenerative joint disease, cervical stenosis.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient is a female with a history of chronic neck and bilateral arm pain and hypertension, non-compliant with medications. She had a history of dizziness with associated motion sickness, nausea, vomiting, lightheadedness, photophobia and occasional right sided headache that was treated with medication in Vietnam but none in the US (United States). She presented for an elective anterior cervical discectomy and fusion C [cervical]4-6 for diagnoses of cervical spondylitic myelopathy, cervical stenosis, cervical radiculopathy and spine cord signal change.

The patient had surgery with postoperative nausea that required intravenous medication with relief. Ortho stated a blood pressure of 138/84, vomiting with pain medications overnight. Does not open eyes since surgery. Poor exam due to patient effort, C5-T [thoracic]1. Blood pressure every four hours. Her blood pressure was 128/88 and Ortho stated her nausea was better controlled, pain controlled, off IV [intravenous] pain medicines. Poor exam due to patient effort C5-T1. Blood pressure three times a day.

There is no inpatient need as the medical records show she was stable, and no other treatment was needed on that date. Physical therapy records were not included to show that she had a significant change in functional ability to ambulate. Her pain was controlled, she had no nausea, and her blood pressure was slightly elevated. She had chronic dizziness that she dealt with at home. There were no consults ordered. There was no documentation where she has a continued or change of condition that would have warranted inpatient treatment. She was hemodynamically stable. Postoperative nausea is common and no need to place inpatient unless it is unresponsive to treatment or IV medication is needed around the clock, which is not the case per records. Therefore, her care could have been treated at an observation level with discharge home. She does not meet inpatient criteria.

InterQual Observation:

Delayed recovery from anesthesia and,	One: 
Assessment and monitoring at least 6x/24h (hour) and,	One:
Breathing,
Level of consciousness Mobility,
Sensation,
02 sat 91 % and less than baseline requiring supplemental oxygen,
Vomiting, protracted and, Both:
Antiemetic,	One:
Antiemetic	3x over24hours,
Serotonin antagonist	2x over 24hours,
Pain uncontrolled and, Both:
Pain assessment,
Requiring change in medication, dose, or frequency.

Inpatient: Elderly patients multilevel (3 or more) fusion, patients requiring extended postoperative observation (eg, unstable comorbidities), or procedure on C1-C2 may require overnight stay.

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 in Part

Diagnosis: Sinus pressure.
Treatment: Functional Endoscopic Sinus Surgery.
The insurer denied the Functional Endoscopic Sinus Surgery.
The denial is overturned, in part. 

The patient is a female. Evaluation indicates sinus pressure worse on the left side, prior treatment with nasal sprays, antihistamines, and amoxicillin. Examination with endoscopy indicates deviated nasal septum, congested nasal lining, left polypoid lesion and hypertrophy inferior turbinates. Sinus CT (computed tomography) scan report states moderate opacification left ethmoid air cells and left frontoethmoidal recess, mucosal thickening left maxillary sinus, narrow left ostiomeatal unit due to mucosal thickening, mucosal thickening of the right frontoethmoidal recess, right maxillary sinus clear, sphenoid sinuses clear, right ostiomeatal unit patent, nasal septal deviation to the right. Diagnosis is chronic sinusitis. Review is for Functional Endoscopic Sinus Surgery.

The health plan's reason for denial is imaging scan does not show disease in all the requested sinuses (frontal, sphenoid, or maxillary). Appeal is for approval of Functional Endoscopic Sinus Surgery procedures.

The requested health service is medically necessary, in part.

Specifically, the requested treatment Functional Endoscopic Sinus Surgery for the frontal and maxillary sinuses is medically necessary, and the requested treatment Functional Endoscopic Sinus Surgery for the sphenoid sinuses cannot be confirmed as medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient, in part.

Functional Endoscopic Sinus Surgery for the frontal and maxillary sinuses are medically necessary, and Functional Endoscopic Sinus Surgery for the sphenoid sinuses is not medically necessary.

The prior denial states imaging scan does not show disease in all the requested sinuses (frontal, sphenoid, and maxillary). However, CT scan report states opacification left ethmoid air cells and left frontal ethmoid recesses, mucosal thickening left maxillary sinus, narrow left ostiomeatal unit due to mucosal thickening, mucosal thickening right frontoethmoidal recess, right maxillary sinus clear, sphenoid sinuses clear, right ostiomeatal unit patent, nasal septal deviation to the right.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent Hypoglycemia

Treatment: Inpatient emergency admission

The insurer denied coverage for inpatient emergency admission.

The denial is overturned.

The patient is an adult female with a past medical history of diabetes mellitus (DM), hypertension (HTN), hyperlipidemia who presented to the emergency department (ED) with altered mental status, and hypoglycemia. The treating provider is requesting plan approval for inpatient emergency admission. The patient is on glipizide, metformin, pioglitazone, and ertugliflozin for treatment of the DM. Emergency medical services found her blood glucose to be 26; after receiving oral glucose, her blood glucose improved to 55 in the ED. In the ED, the patient was noted to be alert and oriented. She received oral glucose again. The patient developed acute kidney injury during admission, with her creatinine from 0.9 to 1.5. She was evaluated by Endocrinology and treated with sliding scale insulin. The patient received Kayexalate for hyperkalemia - potassium 5.8. There was no recurrent hypoglycemia during admission. The patient was discharged. 

"Diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), lactic acidosis (LA), and hypoglycemia are acute and potentially life-threatening complications of diabetes... Also... hypoglycemia was listed as an underlying cause in nearly 288,000 hospitalizations, which represented 5.4% (percent) of total hospitalizations due to diabetes. Severe hypoglycemia, i.e. (that is), coma or seizure secondary to diabetes treatment, remains high (up to five episodes per 10 patient-years) and has increased among patients who aim for lower glycosylated hemoglobin (A1c) targets without appropriate initial education and ongoing support. All four acute complications are theoretically preventable; unfortunately, they still account for enormous morbidity, hospitalizations, and mortality among diabetic patients and contribute significantly to the high costs of diabetes care." (Rewers, et al 2018)

The inpatient emergency admission is considered medically necessary for this patient. The patient had recurrent hypoglycemia on an intermediate lasting sulfonylurea with initial altered mentation. Glipizide is a sulfonylurea with 2 to 5 hours half-life, and duration of 12 to 24 hours. It is metabolized by the liver and excreted mainly via the kidneys, but given the patient's acute kidney injury, she was at high risk for recurrence of hypoglycemia. The patient requires a higher level of monitoring than at observational level of care. Therefore, the request is approved and medically necessary for this patient.

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

The insurer's denial of coverage for the inpatient emergency admission is overturned. Medical necessity is substantiated.