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

Respiratory system
inpatient hospital

Diagnosis: bronchiolitis
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a female infant born at term, unvaccinated, who presented to the emergency department (ED) with two-day history of clear rhinorrhea, cough, decreased feeding, decreased urine output, and one-day history of increasing respiratory distress. She was seen by her primary care practitioner, treated with albuterol and Pulmicort, and referred to the ED via Emergency Medical Services (EMS) for evaluation. Vital signs included temperature 38.1, heart rate 151, respiratory rate 52, and 98% saturation in room air. Examination was significant for distress including tachypnea and retractions, belly breathing, increased work of breathing, moist oral mucosa, clear nasal discharge, good perfusion, and non-focal neurologic exam. She was given a preliminary diagnosis of bronchiolitis. Laboratory evaluation was significant for mild metabolic acidosis on venous blood gas, white blood cell (WBC) count 15.5, platelets 519, unremarkable urinalysis, serum carbon dioxide (CO2) 19, random serum glucose 217, and respiratory viral panel that eventually returned positive for enterovirus/rhinovirus. Chest x-ray was non-focal. She was treated with two normal saline boluses and placed on high flow nasal cannula at 10 Lpm (liters per minute) with fraction of inspired oxygen (FiO2) 0.35 with noted improvement, but ongoing tachypnea. She was admitted to the Pediatric Intensive Care Unit (PICU) for continued care.

The inpatient hospital admission was medically necessary for this patient. In this infant's case, with history of maternal untreated GBS (group B streptococcal) positive as well as acute respiratory distress requiring high flow nasal cannula, acute inpatient admission was medically necessary and appropriate. She was ultimately diagnosed with acute viral bronchiolitis secondary to rhinovirus/enterovirus infection. Even though she was able to wean relatively quickly from high flow nasal cannula and advance to oral feedings, the level of management that she received was most consistent with acute inpatient management. She could not have been safely managed at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Family history Factor V mutation.
Treatment: Factor V (five) Leiden Genetic Testing.
The insurer denied the Factor V (five) Leiden Genetic Testing. 
The denial is upheld. 

The patient in this case is a male who underwent Factor V Leiden testing.  Records indicate that he has a family history of Factor V Leiden mutation.  There are no actual medical records detailing his medical history.  The Factor V Leiden test result is provided and indicate that he has a heterozygous Factor V Leiden mutation.

No, the health plan should not cover the Factor V (five) Leiden Genetic Testing.
This patient has no documented personal history of venous thrombosis, and there is no information provided regarding his family history of thrombosis.  He is noted to have a family history of Factor V Leiden mutation.  However, at the present time, there is no published clinical trial showing that testing of asymptomatic family members of those known to have Factor V Leiden mutation can improve health outcomes.  Testing of asymptomatic family members is only recommended in selected cases.  Notably, this practice can be considered appropriate in families with high penetrance (meaning strong family history of venous thrombosis).  That has not been documented in this case.  Therefore, this test is not clearly a standard test in this case, and the health plan should not cover it based on lack of information showing that this patient's family has a strong history of venous thrombosis.

No, the Factor V (five) Leiden Genetic Testing is not likely to be more beneficial.
As noted above, there is no evidence from any published clinical trial showing that Factor V Leiden mutation testing in asymptomatic family members of those diagnosed with this mutation can improve health outcomes, though as noted above, this type of testing is considered appropriate in families with a strong history of venous thrombosis.  Given lack of evidence supporting benefit it cannot be concluded that this test is likely to be more beneficial to the enrollee than not performing this test.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Family history Factor V mutation.
Treatment: Factor V (five) Leiden Genetic Testing.
The insurer denied the Factor V (five) Leiden Genetic Testing.
The denial is overturned.

The patient is a male. His father has a mutation in the factor V Leiden gene. The patient requested molecular genetic testing to test for this mutation.

Yes, testing for the Factor V (five) Leiden Genetic Testing is  likely to be more beneficial than not testing.
The result of the requested test will allow a definitive diagnosis to be established and will provide information about the optimal treatment and management regimens and the anticipated future medical problems for this patient. Furthermore, the results of the requested test will allow accurate genetic counseling of the family, an estimate of the recurrence risks, and identification of other family members at risk of having the disease.

Documented Factor V Leiden mutation in a first-degree relative is an indication for the testing of this patient.

Factor V Leiden thrombophilia is characterized by a poor anticoagulant response to activated protein C (aPC) and an increased risk for venous thromboembolism (VTE). Deep venous thrombosis (DVT) is the most common VTE (venous thromboembolism), with the legs being the most common site. The results of the Factor V Leiden genetic test will influence the care of this patient. Individuals heterozygous for the factor V Leiden allele should be tested for other inherited or acquired thrombophilic disorders. Prophylactic anticoagulation of people with Factor V Leiden mutation should be considered in high-risk clinical settings such as surgery, pregnancy, or prolonged immobilization. There is a consensus that factor V Leiden testing is appropriate in the following circumstances:
1) Factor V Leiden mutation in a first-degree relative (MET);
2) A first unprovoked VTE (venous thromboembolism) at any age (especially age <50 years);
3) A history of recurrent VTE (venous thromboembolism);
4) Venous thrombosis at unusual sites (e.g., cerebral, mesenteric, portal, and hepatic veins;
5) VTE (venous thromboembolism) during pregnancy or the puerperium VTE (venous thromboembolism) associated with use of oral contraceptives or hormone replacement therapy (HRT);
6) A first VTE (venous thromboembolism) in an individual with a first-degree family member with VTE (venous thromboembolism) before age 50 years.

Therefore, given the above, as the patient has a first-degree relative with Factor V Leiden mutation, the health plan should cover the Factor V (five) Leiden Genetic Testing, as it is likely to be more beneficial.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Family history Factor V mutation.
Treatment: Factor V (five) Leiden Genetic Testing.
The insurer denied the Factor V (five) Leiden Genetic Testing. 
The denial is upheld. 

The patient is a male. He has no evidence of thrombophilia, unusual thrombosis, or coagulopathy. No laboratory results are included in the review materials for this man, such as an activated protein C level. However, his father has a well-characterized pathogenic variant/mutation in the factor V Leiden gene predisposing to deep vein thrombosis, pulmonary embolism, due to a hypercoagulable state in some individuals carrying this pathogenic variant/mutation. No additional records are provided on the father. This son has requested molecular genetic testing to see if he carries the same pathogenic variant/mutation.

No, the health plan should not cover the Factor V (five) Leiden Genetic Testing.
Generally, Factor V Leiden genetic testing is medically appropriate for the following indications:
1) Age less than 50, any venous thrombosis; or
2) Myocardial infarction in female smokers under age of 50; or
3) Recurrent venous thrombosis; or
4) Relatives of individuals with venous thrombosis under age of 50; or
5) Venous thrombosis and a strong family history of thrombotic disease; or
6) Venous thrombosis in pregnant women or women taking oral contraceptives; or
7) Venous thrombosis in unusual sites (such as hepatic, mesenteric, and cerebral veins).

Factor V Leiden genetic testing is considered to be experimental/investigational for all other indications, because its effectiveness for indications other than the ones listed above has not been established.

As the patient does not meet the above indications, the health plan should not cover the Factor V (five) Leiden Genetic Testing.

Routine clinical surveillance, measurement of activated protein C levels, avoidance of circumstances capable of provoking deep vein thrombosis (prolonged sitting in planes or public transport, dehydration, smoking, etc.) would be the standard of care in this clinical scenario. Because of a lack of documentation concerning father and son, it cannot be established that Factor V (five) Leiden Genetic Testing would be more beneficial for the patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Psoriasis; Psoriatic Arthritis
Treatment: Formulary exception for Stelara SQ 45mg every 8 weeks
The insurer denied the Formulary exception for Stelara SQ 45mg every 8 weeks
The denial is overturned.

The patient is a male with longstanding psoriasis and psoriatic arthritis.  He failed treatment with naproxen, methotrexate, Enbrel, Humira, Cosentyx and Otezla.  He was doing well on Stelara 45 mg (milligrams) every 12 weeks for approximately three years, but recently he notes that joint and skin symptoms recur three to four weeks before his upcoming dosing cycle.  His weight is 197 pounds (89.4 kg [kilograms]).  The patient's provider wishes to increase the Stelara dosing interval to 45 mg (milligrams) every 8 weeks, which is an off-label dosing regimen for psoriasis and psoriatic arthritis.  The appeal is for formulary exception for Stelara 45 mg (milligrams) every 8 weeks.

Yes, the health plan should cover the Formulary exception for Stelara 45 mg (milligrams) every 8 weeks.
Stelara is FDA (United States Food and Drug Administration)-approved for the treatment of both psoriasis and psoriatic arthritis at a maintenance dose of 45 mg (milligrams) every 12 weeks in patients weighing less than 100 kg (kilograms).  This patient (89.4 kg [kilograms]) with psoriasis and psoriatic arthritis failed treatment with naproxen, methotrexate, Enbrel, Humira, Cosentyx and Otezla.  He was doing well on Stelara 45 mg (milligrams) every 12 weeks for approximately three years, but recently he noted that joint and skin symptoms recurred three to four weeks before his upcoming dosing cycle. The provider thus wished to increase the Stelara dosing interval to 45 mg (milligrams) every 8 weeks.

Per published joint American Academy of Dermatology and National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with biologics, "the recommended alternate dosage for Stelara is ... at a greater frequency of injection (e.g., every 8 weeks in its maintenance phase) for those with an inadequate response to standard dosing."  This is an A-level recommendation.

Therefore, given the above, increasing Stelara to 45 mg (milligrams) every 8 weeks for this patient who experiences decreased responsiveness is clinically appropriate, and in accordance with standard of care in the medical community.  Therefore, the health plan should cover the requested formulary exception for Stelara 45 mg (milligrams) every 8 weeks.  The current Stelara dosing every 12 weeks has recently proven ineffective for this patient, and more frequent dosing would be expected to be more effective for this patient, without increased adverse effects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Relapsing remitting multiple sclerosis. 
Treatment: Tecfidera 240 mg. 
The insurer is denied coverage for Tecfidera 240 mg. 
The denial is upheld. 

This male patient has a history of relapsing remitting multiple sclerosis (RRMS). 

Tecfidera's active ingredient is dimethyl fumarate.  The literature does indicate that the generic version of the requested medication is bioidentical.  There is no documentation to support the brand-name use of this medication over generic.  Therefore, given the above it does not appear that the requested Tecfidera brand name medication would be needed in this clinical scenario. 

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 Tecfidera 240 mg, is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical radiculopathy.
Treatment physical therapy services.
The insurer denied coverage for physical therapy services.
The denial is overturned.

This case involves a patient who has a diagnosis of cervical radiculopathy.  The documentation indicated she was seen for a physical therapy session regarding cervical radiculopathy.  The documentation indicated she had improved; however, was not 100% (percent).  She was recommended to continue with physical therapy until she was 100% improved.  Prior to this visit, she was seen with complaints of right shoulder and neck pain.  The documentation indicated the initial evaluation was performed.  It was recommended she participate in therapy services twice a week.  She did indicate her pain was decreased and tolerable however she remained limited.  The objective examination revealed 111 degrees of shoulder flexion with 92 degrees of abduction.  Strength is 4/5 in flexion and 3/5 in abduction.  It was recommended that she continue to participate in therapy services.

This patient has ongoing pain related to cervical radiculopathy. The patient still has decreased muscle strength and weakness. There is ongoing limitation of range of motion (ROM.) Although the patient has had improvement in pain level with prior sessions, there is still ongoing disability and limitations that physical therapy can improve.

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 physical therapy is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Peripheral Neuropathy

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient presented to the hospital complaining of fatigue and inability to pick himself up off the floor following a fall.  He reported several recent falls similar in presentation as recently as two weeks prior to admission.  He also noted chronic blurry vision.  Past medical history was significant for diabetes (DM) and hypertension (HTN).  On physical examination, vital signs were stable.  Neurologic exam revealed ataxia and a wide based gait.  He was admitted to the hospital for further evaluation.  He denied loss of consciousness. Computed Tomography (CT) head revealed an old left cerebellar infarct. Electrocardiogram (ECG) revealed normal sinus rhythm without evidence of acute ischemia. Serum blood testing revealed no significant abnormalities.  Urine microscopy revealed white blood cells (WBC).  Toxicology screen was positive for PCP (Phencyclidine [angel dust]). Holter monitor revealed no evidence of arrhythmia and echocardiography revealed a preserved left ventricular (LV) ejection fraction.  No obvious cardiac etiology for weakness and fall was noted.  Infection work-up revealed no true bacteremia and the patient was treated for urinary tract infection. His wide based gait was attributed to diabetic neuropathy and was deemed to be a chronic condition.

The health care plan acted reasonably and in the best interest of the patient. This patient had no evidence of cardiac disease by history or physical examination. There was no evidence of congestive heart failure (Reference 1) and no evidence of an acute neurologic event. 

According to the European Society of Cardiology, this patient with a fall was a low risk patient for future morbidity and mortality (Reference 2). 

In a study of individuals presenting to the emergency room following near syncope or syncope, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing (Reference 3).  

Ultimately, this patient was diagnosed with chronic peripheral neuropathy and a urinary tract infection. These conditions could have been managed at a lower level of care (Reference 4). 

In conclusion acute inpatient admission was not medically necessary in this case. 

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

Diagnosis: left lower quadrant (LLQ) abscess.

Treatment: acute inpatient stay.

The insurer denied coverage for the acute inpatient stay.

The denial is upheld. 

This male patient has no significant past medical history.

According to documentation, patient presented with a skin abscess in the lower abdomen. Otherwise, he was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC(white blood cell). The patient had a localized skin abscess or "boil" that required a bedside incision and drainage (I&D). He had no evidence for a disseminated infection. Based on above findings, the patient met criteria for observation level of care and not inpatient level care.
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 stay is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Chest Pain.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

This is a male with hypertension (HTN), diabetes mellitus (DM), hyperlipidemia (HL) with complaints of intermittent pressure like chest pain for 3 days prior to presentation. The patient was transferred from urgent care due to HTN and hyperglycemia. He was noted to have an elevated blood pressure at presentation. He complained of nausea and vomiting at presentation. His blood pressure was stable, in fact slightly hypertensive. There was no shortness of breath, diaphoresis, palpitations or volume overload noted. The rest of the physical exam was essentially unremarkable. Serial electrocardiogram (EKG) and cardiac enzymes were negative. He was started on Losartan and Amlodipine, Atorvastatin at home dose, and sliding scale insulin (SSI) for DM. Subsequently the patient left against medical advice. The patient was being scheduled for further evaluation of coronary artery disease (CAD) status including the possibility for stress versus (vs) cardiac catheterization. No malignant arrhythmias or congestive heart failure (CHF) were noted during this admission.
At issue is the medical necessity of the inpatient stay.

I uphold, in whole, the health plan's determination of medical necessity.

The patient is a male with significant clinical risk factors and anginal presentation and subsequently needed further evaluation with a stress test vs cardiac catheterization. The patient could have been managed initially at a lower level of care and then depending on the clinical course could have been converted to inpatient stay depending on work up including stress test results and difficulty in blood pressure control and optimizing medical therapy. The patient was placed on appropriate medical therapy and care was delivered based on sound medical judgement and in the best interest of patient.
There were no malignant arrhythmias, no signs of hemodynamic instability, no additional conditions requiring inpatient stay. A stress test if performed and negative would have resulted in the discharge of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral hip osteoarthritis.
Treatment: Full hospital admission.

The insurer denied coverage for full hospital admission.  The denial is overturned.

This is the case of a male patient who presented to Hospital for Special Surgery for a total hip replacement. He has a significant medical history of morbid obesity and hypertension with cardiomyopathy. He presented with a two-year history of progressive, right lateral hip pain and stiffness. The patient's pain was exacerbated by walking and negotiating stairs. Bilateral hip osteoarthritis is present, severe on the right with bone-on-bone apposition superolaterally.  His post-surgical course was complicated. He was later discharged.

The medical record demonstrated a complicated post-surgical course in a patient with multiple comorbidities - American Society of Anesthesiologists (ASA) classification 3 (severe systemic disease). Although his hip surgery by itself was without problem, there were several other issues to require additional management. 

The records showed urinary retention and requirement for Foley catheter. The records showed metabolic abnormalities with elevated potassium and glucose. Medications were provided to correct the condition. 

He was found to have fluid imbalance and required bolus of Albumin on two occasions. His course was atypical, and additional monitoring to evaluate response to treatment was medically necessary and appropriate. 

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

The admission and length of stay were medically necessary. These services could not have been provided at a lower level of care. 

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