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

Diagnosis: Alpha-one-antitrypsin (A1AT) deficiency
Treatment: Alpha-1 Proteinase Inhibitors (Human) (Pre-service)
The insurer denied the Alpha-1 Proteinase Inhibitors (Human) (Pre-service)
The denial is overturned. 

The patient is a female active smoker, moderate to severe emphysema with alpha-one-antitrypsin (A1AT) deficiency who is prescribed Prolastin C. The patient has phenotype PiSS with serum level of 61 milligrams per deciliter (mg/dl). The patient also has worsening obstructive lung disease with worsening forced expiratory volume in one second (FEV1). The patient has been on other chronic obstructive pulmonary disease (COPD) medications which include Stiolto Respimat as well as albuterol inhalers as needed.

Yes, the proposed treatment is medically necessary.
The patient has moderate to severe emphysema on computed tomography (CT) of the chest. Although, the patient is an active smoker, the alpha-1-antitrypsin levels are low and she has worsening pulmonary function testing, since the patient has alpha-one-antitrypsin (A1AT) deficiency, the emphysema is likely to worsen rapidly and cause respiratory failure. The augmentation with Prolastin C is likely to reduce or halt the progression of the emphysema. Thus, the use of Prolastin C in this case is medically necessary. The patient should be treated with Prolastin C even though the patient is an active smoker. The Prolastin C is likely to provide positive outcomes and it is the current generally accepted standard of clinical practice.

The use of Prolastin C in this case is medically necessary. The Prolastin C is likely to provide positive outcomes and it is the current generally accepted standard of clinical practice.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Thymic carcinoma
Treatment: FoundationOne CDx Test (0037U)
The insurer denied the FoundationOne CDx Test (0037U)
The denial is upheld. 

The patient in this case is a male diagnosed with thymic carcinoma.  Metastatic disease involving the lung and bones was noted at the time of diagnosis.  He was treated initially with combination chemotherapy, and repeat imaging done revealed evidence of improvement in his cancer. Foundation One testing was performed.

No, the health plan should not cover the FoundationOne CDx Test (0037U).

Foundation One testing is a next generation sequencing (NGS) assay that is done to look for genomic alterations in tumor tissue. This test includes over 300 genes.  It is done to try to find potentially effective treatment options.  There is currently no evidence, based on the results of any prospective clinical trial, that has shown use of broad molecular profiling can improve overall health outcomes.  This test is not recommended as a standard test known to improve overall health outcomes by NCCN (National Comprehensive Cancer Network) guidelines.  Given these considerations, this test is not medically appropriate, and the health plan should not cover it.

No, the FoundationOne CDx Test (0037U) is not likely to be more beneficial.
As noted in the response to Question 1, there is no evidence that this test can improve overall health outcomes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Precocious Puberty. 
Treatment: Lupron Depot-Ped 15 mg (milligrams). 

The insurer denied coverage for Lupron Depot-Ped 15 mg. 

The denial is upheld. 

This is a female diagnosed with precocious puberty. This request is for Lupron depot. As reported; her onset of breast development was during her middle childhood. Breasts development and pubic hair were at tanner 3. Her ultrasound showed both ovaries contain multiple sub centimeters follicles; there is no ovarian mass seen. Her bone age of adolescence at chronological age (CA) middle childhood. Her mother states she spotted brown.  Her lutenizing hormone (LH) was 4.4; Estradiol was 48.9; follicle stimulating hormone (FSH) was 6.3. 

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient as the request is not medically necessary as described below. 

The definition of precocious puberty is children who have the onset of secondary sexual characteristics at a younger age in boys and girls [1-3]. Central precocious puberty (CPP) is diagnosed using a basal LH of >0.3 or stimulation testing with a Gonadotropin-Releasing Hormone (GnRH) analog such as luprolide showing a pubertal response defined as an LH >5 and estradiol greater than 40 [4]. CPP is treated with GnRH agonists [5-10] such as lupron[11] and supprelin[12]. The Food and Drug Administration (FDA) indication for GnRH agonists is for use in central precocious puberty (CPP). In addition, when used for CPP the FDA recommends discontinuation of gonadotropin-releasing hormone (GnRH) agonists before the end of middle childhood for females and before adolescence age for males [11]. This is consistent with accepted recommendations for discontinuation of GnRH agonist therapy at adolescence bone age in boys and girls [2, 4-7]. 

The patient's onset of breast development was not precocious. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary. 

The insurer's denial of coverage for Lupron Depot-Ped 15 milligrams is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea.

Treatment: Hypoglossal nerve stimulation or Inspire upper airway system, procedure codes 64568 and 0466T to treat obstructive sleep apnea.

The insurer denied coverage for hypoglossal nerve stimulation or Inspire upper airway system, procedure codes 64568 and 0466T to treat obstructive sleep apnea.

The denial is overturned. 

This is a male patient who has been diagnosed with obstructive sleep apnea.  The documentation indicated the patient has an apnea hypopnea index of 36.80.  The documentation indicated the patient has continued to complain of symptoms and has attempted correction however he refuses to utilize continuous positive airway pressure (CPAP).  He indicated it is too loud and keeps him awake.  The documentation does include a drug-induced sleep endoscopy dated (DISE) revealing the patient has antero-posterior (AP) collapse.  The documentation does indicate he complained of worsening symptoms.  He stated his wife reports he has been snoring for the past year and reports that he is often gasping.  The documentation does indicate the recommendation at this visit was made for the patient to undergo a DISE.  The documentation indicated he was seen for a follow-up after undergoing a sleep endoscopy.  There was no change in his sleep apnea was recommended he undergo surgical intervention.

The patient has failed CPAP due to noise.  He appears to meet the strict criteria for the inspire implant due to the diagnosis and findings on DISE.  This procedure was FDA [Food and Drug Administration] approved in 2014. The inspire implant is medically necessary for this patient. 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 hypoglossal nerve stimulation or Inspire upper airway system, procedure codes 64568 and 0466T to treat obstructive sleep apnea is overturned.  Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: bilateral lower lobe pulmonary embolism (PE).

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission 

The denial is upheld. 

This male patient has a history of chronic kidney stones, left shoulder surgery.

This patient did not need acute inpatient hospitalization. He could have been paced in observation status while diagnostic testing and treatment were initiated. The patient can be under observation for up to 48 hours. This patient was afebrile and hemodynamically stable. He was not hypoxic. There was no respiratory distress noted. He was tolerating orally and ambulating.  Lungs were clear. There was no evidence of right heart strain. Echocardiogram revealed ejection fraction (EF) 70%. The patient was recommended to follow up in the outpatient setting for his back pain with possible injection in the outpatient setting. He had normal bowel movements. The patient was stable for discharge on oral anticoagulants after a period in observation status with further follow up in outpatient setting.

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

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

Diagnosis: bilateral below the knee lower extremity amputations

Treatment: requested prosthetic

The insurer is denied coverage for requested prosthetic.

The denial is overturned. 

This female patient has a history of Lupus and blood clots.

The requested custom liner is appropriate for this patient who is a bilateral amputee (right transfemoral and left transtibial amputations).   This physician agrees with the requesting provider that the patient's "unique limb shape requires her to be fit with a custom fabricated liner (L5683) to provide additional cushioning and better fit around her bony anatomy."  Due to the anatomy of the left residual limb, the requested custom fabricated liner will decrease risk of skin breakdown and provide greater comfort for functional mobility.  
From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the requested prosthetic component (procedure code L5683 -Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only) is medically necessary.

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

The carrier's denial of coverage for the requested prosthetic is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Colitis. 
Treatment: Entyvio 300 mg. 

The insurer is denied coverage for Entyvio 300 mg. 

The denial is upheld. 

This male patient has a history of ulcerative colitis and asthma. 

The patient has left sided ulcerative colitis. He was continuing to have rectal bleeding and rectal urgency. He was on mesalamine and hydrocortisone enemas. His colonoscopy showed severe colitis in the left colon. His physician has advised taking Entyvio. He is reported to have asthma. His chest exam was clear and without wheezing. There was a concern about lung toxicity with Remicade. The American Gastroenterological Association (AGA) has published a clinical practice guideline on the management of moderate to severe ulcerative colitis. Infliximab, adalimumab, and vedolizumab are all recommended treatment. These medications are advised both for induction of remission and maintenance of remission. The patient has ulcerative colitis and asthma. Based on case reports there is a concern that TNF [tumor necrosis factor]-blocking agents can cause lung toxicity. However, this is a rare occurrence. There is no recommendation from the AGA that Remicade is contraindicated with asthma. Giving Remicade to this patient would be appropriate. The lung function can be monitored while on biologic therapy. Since Remicade is a covered medication and is advised by the AGA Entyvio is not medically necessary at this time. 

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

The carrier's denial of coverage for the Entyvio 300 mg is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: BPH with lower urinary tract symptoms

Treatment: acute inpatient hospital

The insurer is denied coverage for acute inpatient hospital.

The denial is upheld. 

This male patient has a history of dementia, weakness, gastroesophageal reflux disease, lumbar stenosis with neurogenic claudication, peroneal palsy, bladder outlet obstruction, bladder stones, complicated urinary tract infection (UTI) and benign prostatic hypertrophy (BPH) with chronic indwelling Foley catheter.

The insurer has denied coverage for the acute inpatient hospital stay as not medically necessary. They noted the scheduled Transurethral Resection (TURP), lack of complications, and patient's medical stability.

Per Milliman care guidelines (MCG): 

i)	Urologic or procedure general recovery guidelines (GRG) patient meets the GRC discharge parameter within 24 hours post-operative.
ii)	Prostatectomy, Transurethral resection (TURP) patient meets the discharge parameter also within 24 hours post-operative.

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

The carrier's denial of coverage for the acute inpatient hospital is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is an adult female with a past medical history of hypertension, arrhythmia, bariatric surgery, and immunocompromised status. The patient presented to the Emergency Department (ED) with an episode of lightheadedness along with left hemiparesis and paresthesias for 1-2 minutes. The symptoms essentially resolved by the time of arrival at the ED. There were no neurological deficits on examination. The laboratory studies were unremarkable. The electrocardiogram (EKG) was normal sinus rhythm at 79 beats per minute. The computed tomography (CT) scan revealed no acute pathology. There was a suspicion of a partial seizure. There was a possible but less likely transient ischemic attack (TIA). The patient was admitted to medicine to rule out seizures requiring comprehensive neuro evaluation. She underwent a neurological evaluation and was felt to have a TIA. The patient underwent an electroencephalogram (EEG), which was normal. The echo was normal. It was noted the patient needed a Holter monitor and follow-up as an outpatient. The patient was stabilized and discharged.

The patient presented to the ED after a discrete episode of left-sided weakness with numbness with complete resolution of symptoms prior to arrival to the ED. Care provided, including specialty consultation, diagnostic studies and medical management did not require inpatient admission. Care provided could have been performed in the ED setting and at an observation level of care with outpatient follow up.

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

The inpatient admission is not considered medically necessary for this patient.

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

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a Female with history of COPD (chronic obstructive pulmonary disease), asthma, alcohol abuse presented to emergency room with shortness of breath for 1 week. Patient tried and failed albuterol inhalers at home without improvement. Patient was thought to have COPD (chronic obstructive pulmonary disease) exacerbation in the ER (emergency room). Patient received IV (intravenous) steroids, nebulization treatments, and IV antibiotics. Patient was admitted to acute in hospital level of care for the management of COPD (chronic obstructive pulmonary disease) exacerbation. Patient was treated with IV steroid, and frequent nebulizations.

No. The proposed treatment is not medically necessary.
The patient received treatment for COPD (chronic obstructive pulmonary disease), exacerbation in the ER (emergency room) with significant improvement. At the time of admission, patient was hemodynamically stable. Patient was able to speak in full sentences. Patient's oxygen levels were above 90%. Patient was tolerating oral diet. The patient was not on any invasive drips. The acute hospitalization is not medically necessary.

The patient received treatment for COPD (chronic obstructive pulmonary disease), exacerbation in the ER (emergency room) with significant improvement. At the time of admission, the patient was hemodynamically stable. Patient was able to speak in full sentences. Patient's oxygen levels were above 90%. Patient was tolerating oral diet. The patient was not on any invasive drips. The acute hospitalization is not medically
necessary. The patient could have received the same treatment at a lower level of care such as observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This female with a history of hypertension (HTN), chronic obstructive pulmonary disease (COPD) and alcohol abuse presented to the emergency department complaining of light headedness, shortness of breath and cough.  

The patient's vital signs revealed the following: temperature 98.2, pulse 108. respiratory rate 16, and blood pressure 126/50. The patient's exam was remarkable for pale and right-sided neck swelling. Her labs revealed the following: white blood cell (WBC) count 19.5, hemoglobin/hematocrit 6/21.2, platelets 554, prothrombin time (PT) 14.7, partial thromboplastic time (PTT) 24.8, and international normalized ratio (INR) 1.2.  Basal metabolic panel (BMP) was normal. The patient's lactate was 7.4, brain natriuretic peptide (BNP) 20.7, troponin .019, and power of hydrogen (pH) 7.26 to 7.4.  The patient's chest x-ray showed no abnormality detected (NAD). Electrocardiogram (EKG) showed normal sinus rhythm (NSR).  

The patient was admitted with systemic inflammatory response syndrome (SIRS).  Plan of care included intravenous (IV) antibiotics and blood transfusion.  Day two, the patient's vital signs were stable and she was afebrile.  She denied chest pain, dyspnea, and abdominal pain.  Hemoglobin improved to 7.5, white blood cell (WBC) count was 7.1, and lactate was 3.8.  COVID testing was negative.  Ultrasound (US) of the neck revealed a hypo echoic mass.  She was continued on intravenous antibiotics. She was scheduled for an outpatient colonoscopy.  Day three, vital signs were stable and she was afebrile.  Urine analysis (U/A) revealed large leukocyte esterase.  Blood cultures were negative and antibiotics de-escalated.  The patient was discharged.

No, the proposed treatment was not medically necessary.
The inpatient admission was not consistent with generally accepted medical standards.

This patient was admitted with systemic inflammatory response syndrome (SIRS) of unknown etiology after presenting with cough and shortness of breath.  She was hemodynamically stable and afebrile.  Diagnostic studies were remarkable for leukocytosis, anemia and acidosis.  She did not have renal failure or severe electrolyte abnormality.  Electrocardiogram (EKG) was normal.  She did not have active bleeding. She did not have altered mental status.  The patient received a blood transfusion and was empirically treated with intravenous antibiotics.  She was found to have a urinary tract infection (UTI).  She had not failed an observation level of care.  She remained clinically stable during the hospital stay.  She remained hemodynamically stable and afebrile.  Her hemoglobin remained stable.  Based on these findings and lack of failure of an observation level of care, the acute inpatient level of care was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Myocardial Infarction
Treatment: external defibrillator
The insurer denied an external defibrillator. The health plan's determination is upheld.

The patient is a male who developed chest pain. He underwent catheterization and percutaneous coronary intervention (PCI) of the culprit left anterior descending (LAD) stenoses. There was also a left circumflex stenosis. He had an ischemic cardiomyopathy with left ventricular ejection fraction (LVEF) 25-30%. Medical therapy was initiated, circumflex PCI was planned, and a wearable defibrillator was placed which is the subject under review.

The External Defibrillator is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Indications for a temporary wearable defibrillator are similar to those for an automatic implantable cardioverter defibrillator (AICD). A wearable defibrillator is necessary for those requiring a permanent defibrillator but have, at that time, a contraindication to AICD placement (i.e. infection, awaiting cardiac transplant). Those with an ischemic cardiomyopathy status/post (s/p) revascularization and where medical therapy has been initiated, as in this case, have a potentially reversible cardiomyopathy. An AICD at the time of the diagnosis and without an optimal trial of medical therapy (i.e. three months) and subsequent documentation of a persistent severe cardiomyopathy (LVEF less than 35%), is not medically necessary.
Additionally, neither an AICD or a wearable defibrillator (Zoll Life Vest) at the time of the cardiomyopathy diagnosis, compared to optimal medical therapy for 90 days and an AICD if the LVEF remains at or less than 35%, has been established as standard of care towards improved cardiac outcomes. Therefore, the External Defibrillator is not indicated in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Myocardial Infarction
Treatment: external defibrillator
The insurer denied an external defibrillator. The health plan's determination is overturned. 

This man presented to the emergency department complaining of chest pain. An electrocardiogram showed ST segment depression and his serum troponin level was elevated. He was diagnosed with a non-ST segment elevation myocardial infarction. A cardiac catheterization showed an ulcerated 95% obstruction in the left anterior descending coronary artery (LAD) involving the second diagonal branch and a 90% proximal circumflex stenosis. His left ventricular ejection fraction (LVEF) was 30%. The lesions involving the LAD and diagonal artery were successfully treated with stents. The patient was started on guideline-directed therapy for heart failure. He was discharged with a LifeVest wearable cardioverter defibrillator (WCD). 

Sudden arrhythmic death is common in the early post-myocardial infarction period, especially in the first 30 days. The risk is highest in patients with heart failure, left ventricular dysfunction, or both. Accordingly, there has been considerable interest in interventions that might modify this risk. Studies using anti-arrhythmic drugs have been disappointing. The DINAMIT trial (Defibrillators in Acute Myocardial Infarction Trial) was a multicenter, randomized, prospective study designed to assess the impact of implantable cardioverter defibrillator (ICD) implantation, in addition to optimal medical therapy (OMT) vs OMT alone, on all-cause mortality in high-risk patients within 40 days after infarction. Of 14,609 patients, 903 died suddenly, and 164 were resuscitated after cardiac arrest. The risk was highest in the first 30 days - 1.4 percent.
Patients, like this man, with a left ventricular ejection fractions of 30 percent or less were at highest risk in this early period.