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

Diagnosis: Prostate Carcinoma
 
Treatment: Oncotype DX for Prostate Cancer

The insurer denied the Oncotype DX for Prostate Cancer. The denial was upheld.     

This is a male patient who had a Prostate Antigen Score (PSA) of 4.4. The patient underwent a prostate biopsy which revealed a Gleason 3+4 prostate adenocarcinoma. Oncotype DX prostate was performed, to further assist in the treatment plan for his diagnosis.   

While it is true that National Comprehensive Cancer Network (NCCN) guidelines state that molecular testing such as Oncotype DX be considered for men with NCCN low or favorable intermediate risk prostate cancer and a >10 year life expectancy, they also note the absence of randomized, prospective trials.  In addition, current American Urological Association (AUA) guidelines regarding management of localized prostate cancer states: "tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer, and are not necessary for follow-up."  The impact of tissue based gene expression tests such as Oncotype DX on clinical practice and long term patient outcomes remains to be empirically demonstrated.  Unfortunately, prospective studies of these tests yielding a true clinical benefit when implemented in clinical practice are still lacking.  There is no long term data showing the clinical utility of Oncotype DX for prostate cancer. 

The carrier's denial of coverage for Oncotype DX for Prostate Cancer test is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain 

Treatment: Sacroiliac Joint Fusion surgery and subsequent inpatient admission

The insurer denied coverage for Sacroiliac Joint Fusion surgery and subsequent inpatient admission. The denial was upheld.

This patient is a female with a history of lower back pain that radiates down the posterior part of her right leg to her knee.  In late-2018 a MRI of the lumbar spine findings state T12-L5 no disc herniation, central canal stenosis or foraminal stenosis.  At L5-S1 disc desiccation and a diffuse disc bulge, no central canal stenosis, mild to moderate right foraminal stenosis.  In early-2019 the patient was seen. She complained of worsening low back and right leg with pain rated at 8/10.  Her assessment/plan stated that she had 4/5 positive sacroiliac joint provocative tests.  She has severe L5-S1 degenerative disc disease.  The possibility of sacroiliitis was discussed.  The plan was for a right sacroiliac joint injection. In mid-2019 she was seen for follow-up of her low back pain that radiates down the right posterior leg to the right knee.  She rates worsening pain as 8/10.  She has the inability to walk greater than 10 blocks prior to having to stop and rest. She underwent a CT guided right sacroiliac joint injection (Celestone and bupivacaine) with 60% relief for the first 1.5 days from an 8/10 to 3/10.  By the third to fourth day her pain returned to 8/10.  Her exam was normal. The plan was for a right SI joint fusion as she had significant improvement with the sacroiliac injection.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The Sacroiliac Joint Fusion surgery and subsequent inpatient admission is not considered medically necessary for this patient.

Standard national guidelines or criteria recommended by the International Society for the Advancement of Spine Surgery are not met.  Minimally-invasive surgical (MIS) fusion of the sacroiliac (SI) joint is considered medically necessary when ALL of a number of criteria have been met.

In this case, it is unknown if the patient has completed at least six months of conservative care to include physical therapy directed at the sacroiliac joint.  An exam in early 2019 notes she had positive provocative findings but these were not listed specifically.  She does not have a positive Fortin's Finger test.  Her last exam in mid- 2019 does not note any abnormal findings. There is no imaging of the sacroiliac joint, pelvis or hip to rule out other possibilities of pain. Her lumbar MRI shows degenerative disc disease at L5-S1.  The request for a right sacroiliac joint fusion is not medically necessary at this time.

The carrier's denial of coverage for the Sacroiliac Joint Fusion surgery and subsequent inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Transient Ischemic Attack
 
Treatment:  Inpatient Admission

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

This is a male patient who presented to the emergency department with complaints of slurred speech and numbness and weakness in his left upper extremity and on the left side of his face.  He had a history of diabetes, hypertension and nonischemic cardiomyopathy with a pacemaker.  On physical exam the patient's vital signs were stable; however, his finger stick glucose was 300.  Neurology consulted over the patient.  A computed tomography (CT) of his head and neck both revealed was negative results.  A CT of his carotid and cerebral arteries were negative.  It was reported that the patient's implanted cardioverter defibrillator was functioning well.

The medical literature indicates that inpatient admission is indicated for patients with hemodynamic instability, focal neurological signs or symptoms that persist or recur, stroke diagnosis, findings on brain imaging that require inpatient care, altered mental status, suspected arteritis, pregnancy, cardiac arrhythmias of immediate concern, clinically significant cardiac disorder identified that requires inpatient care, severe hypertension, parenteral anticoagulation required or intravenous infusion of platelet inhibitors, vasoactive medication or antiarrhythmic medications required. 

The documentation indicated that the patient presented with complaints of transient numbness and weakness to left upper extremity.  The patient had numbness of the left face with slurred speech.  However, stroke was ruled out.  There was no evidence of hemodynamic instability, focal neurological signs or symptoms that persist or recur, stroke diagnosed, findings on brain imaging that requires inpatient care, altered mental status, pregnancy, cardiac arrhythmias of immediate concern, clinically significant cardiac disorder identified that requires inpatient care, parenteral anticoagulation or intravenous infusion required.  The patient's condition was appropriate for level of observational care rather than inpatient level care. 

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

Diagnosis:  Urinary Tract Infection

Treatment:  Acute inpatient admission

The insurer denied coverage for acute inpatient admission.  The denial was upheld.

This patient is a female who was seen in the Emergency Department (ED).  The patient had a past medical history of methadone dependence, hypertension, hepatitis C and high cholesterol.  The patient complained of pain to the right foot, numbness to the left hand and pain to the left jaw.  The patient had a temperature of 98.6 F. with a heart rate of 78, respirations 18, oxygen saturation 98% on room air and blood pressure 129/66.  The patient was seen the day prior to arrival in the emergency department to rule out cerebrovascular accident; after labs and computer tomogram scan were normal the patient then left against medical advice but then came back after experiencing continued symptoms.  The patient had a partially treated urinary tract infection and was admitted for limb weakness.  The patient was started on intravenous (IV) Rocephin.  The patient was then discharged.

She was admitted to the hospital, treated for a urinary infection, underwent imaging of the cervical spine and thoracic spine and right knee and hand, and was discharged.  She had no evidence for acute stroke; she was stable in terms of clinical presentation/vitals/neurological status while in the ED.  The care provided did not warrant admission and was consistent with the outpatient level of care. 

Therefore, the requested acute inpatient admission is not medically necessary.  The health plan acted reasonably and with sound medical judgment in the best interest of the patient.

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

Diagnosis: Seizure
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

This young female child with some developmental delays and history of multiple febrile seizures (or seizures associated with fever) and non-compliance with Neurology evaluation presented to the ED with an acute febrile illness associated with vomiting and diarrhea as well as a two-minute spontaneously resolved seizure. She was admitted for hydration and antibiotics pending culture results. While it was not unreasonable to monitor the child in the hospital, she was overall hemodynamically stable, with no evidence of impending respiratory or cardiovascular failure, and no intractable vomiting or diarrhea. She did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Xerosis of the skin with subsequent desquamation

Treatment: Dupixent, 300 mg/2ml Safe syringe 

The insurer denied coverage for Dupixent, 300 mg/2ml Safe syringe. The denial was upheld.

This patient is a female with a history of atopic dermatitis, xerosis of the skin with subsequent desquamation, primary focal hyperhidrosis of axilla and hair loss. The office visit note with the Dermatologist states the patient has tried Lac-Hydrin 12% cream, Triamcinolone 0.25% ointment and Fluocinolone 0.05% oil.  The patient received a 3cc intralesional injection of Kenalog (5mg/ml) to 4 lesions. The appeal letter states that the patient has severe atopic dermatitis.  She has tried and failed Triamcinolone 0.025% ointment, Lac-Hydrin 12% cream and Fluocinolone 0.01% oil.

There are effective, safe alternatives that have not been trialed.  There is no clinical documentation provided to demonstrate the need for Dupixent over the available preferred medications.  Current medical literature corroborates the safety and non-inferior or superior efficacy of these preferred medications in this clinical scenario.

According to Eichenfield, et al. (2014) "TCIs [topical calcineurin inhibitors (TCIs)] may be combined with TCS [topical corticosteroid] use in a number of ways. Often topical steroids are used first for control of a flare, given greater potency and also to reduce occurrence of some of the local symptoms associated with TCIs..." Furthermore, according to Silverberg (2014), "Atopic dermatitis (AD) is a common inflammatory disorder of skin with significant comorbidities.  AD care often requires a combination of treatment approaches, including emollients, topical steroids, systemic immunosuppressants and/or phototherapy.  Advances have been made with respect to AD treatment in the past few years through the use of well-designed RCTs and comparative efficacy studies.  However, more well designed RCTs and investigator-initiated studies are needed in order to improve the care of AD patients." As concluded by Boguniewicz, et al. (2018), "For all patients, the TCS should be used at the lowest effective dose to achieve disease control, and attaining control is the critical factor for this directive.  Although the "lowest effective dose" is desired, it is equally important that undertreatment be avoided because that contributes to suboptimal outcomes and patient frustration..."

The patient has tried and failed Triamcinolone 0.025% ointment, Lac-Hydrin 12% cream and Fluocinolone 0.01% oil.  The patient has not tried and failed a topical calcineurin inhibitor.  The patient has not tried and failed therapy with a systemic medication (methotrexate, cyclosporine, or azathioprine) all which are supported by current literature and guidelines.     

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

The carrier's denial of coverage for Dupixent, 300 mg/2ml Safe syringe is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lymphedema
Treatment: Pneumatic compression device

The Pneumatic compression device is not medically necessary.

There is no evidence that the Flexitouch is superior to single channel pumps in the management of lymphedema.  The trials of these devices are of poor quality, small samples and of short duration.  The one RTC (randomized controlled trial) that demonstrated a benefit to this system was unblinded and industry-sponsored.  A second study found no improvement with a multi-channel Flexitouch pump over single channel pump.  Therefore, there is no evidence to support the routine upfront use of a Flexitouch device over non segmental pumps.  With the advent of total decongestive therapy, the use of pumps has fallen out of favor, and they are generally no longer used.  There are still situations where pumps may be used; however there is no reliable evidence that a Flexitouch system is superior to single channel pumps in the management of these patients. 

This device should be offered for coverage with a trial and failure of a single channel pump for this patient, as the health plan asserts.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of a large number of medical problems requesting coverage for brand name Valtrex. The patient reports that she has tried six different generic versions for five months in an attempt to treat "shingles" on her upper buttock. A problem list in a clinical encounter note listed postherpetic neuralgia with on onset of early 2019 and herpes simplex. There was no mention of a painful herpetic rash in the history of present illness, review of systems, or physical exam. The assessment for  herpes simplex and the plan was Valtrex 1 gram by mouth daily, 30 tablets, with two refills. There is no provider documentation opining that the patient has not responded to generic valacyclovir but is responding to brand name Valtrex. Nor is there documentation supporting a failure of previous trials of acyclovir or famciclovir. The health plan's determination is upheld. There is no evidence that the patient tried multiple versions of generic valacyclovir, and there is no evidence that brand name Valtrex is superior in any way to the multiple available generic versions of the medication. In addition, there is no evidence that brand name Valtrex, or generic valacyclovir, is superior in any way to offered formulary alternatives, acyclovir and/or famciclovir.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: social anxiety, Post-Traumatic Stress Disorder (PTSD), Major Depressive Disorder, Acute Panic Disorder, and Attention Deficit Hyperactivity Disorder (ADHD)

Treatment: Continued inpatient mental health services

The insurer denied coverage for continued inpatient mental health services. The denial was upheld.

This patient is a male was admitted to this inpatient mental health treatment in this hospital due to depressive symptoms, recent suicidal ideation, poor activities of daily living (ADLs), and anxiety. He was found sleeping in his car and admitted to taking extra Gabapentin and being distraught. He also admitted to cannabis use and his toxicology screen was positive for tetrahydrocannabinol (THC) and benzodiazepines. He took Lexapro, Propranolol, Prazosin, Abilify, and Trazodone. He had diagnoses of Major Depressive Disorder, Post-Traumatic Stress Disorder (PTSD), and Attention Deficit Hyperactivity Disorder (ADHD). He was homeless. He was discharged.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary treatment. They stated that he denied thoughts of self-harm or self-harm behaviors, was not aggressive or threatening, and did not require 24-hour hospital treatment.

The reviewer agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital as the medical records did not provide enough specific evidence to support that he still only required this acute psychiatric hospital level of care then or that he could not be safely and effectively treated in a less restrictive level of care then. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or inability to adequately care for basic needs are candidates for hospitalization. The patient had suicidal thoughts and depression interfering with his ability to care for basic needs. He was approved for and received 24-hour acute psychiatric hospital treatment.  However, by a specified date the medical records did not report further suicidal ideation, severe depressive symptoms, or inability to adequately care for his basic needs. Notes on that same date reported he was isolating, but less anxious and there were no reports of suicidal ideation, plan, or intent. Also, that date, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.

As a result, uphold the previous decision and deny coverage for inpatient mental health treatment at this hospital. The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

Based on the above, the medical necessity for the continued inpatient mental health services is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of eosinophilic esophagitis, gastric bypass, cholecystectomy, and multiple prior admissions for epigastric pain with nausea and vomiting over the past three months who presented with acute on chronic vomiting and epigastric pain. The patient reported vomiting six times and stated that the last bowel movement was earlier that day. The patient stated the symptoms were similar to prior symptoms. There were no fevers or chills. The patient reported the pain as eight out of 10 in severity and sharp in the epigastric region. Vital signs showed blood pressure 125/89, heart rate 66, temperature 98.3 Fahrenheit, and respiratory rate 17. On physical examination, the abdomen was soft, tender, and nondistended. Heart was regular, breath sounds were normal, and skin was warm and dry. The assessment by the emergency department (ED) attending was that the patient should be admitted for pain control. Labs showed white blood cell (WBC) 8.6, hemoglobin 11.7, platelets 232, creatinine 0.74, potassium 4.1, and glucose 73. The patient was admitted for acute on chronic abdominal pain, nausea and vomiting. The plan of care included pain control, gastroenterology consult, endoscopy, proton pump inhibitor, Zofran, intravenous (IV) fluids, and monitor liver enzymes. The endoscopy was negative for acute findings. His symptoms improved and he was discharged. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had a significant history of eosinophilic esophagitis and a recent history of elevated liver enzymes but this admission did not represent acute progression of his disease. He primarily received oral pain management and a diagnostic evaluation, both of which could have been provided at a lower level of care safely and effectively. In addition, there was no evidence of sepsis, intra-abdominal abscess, gastric perforation, small bowel obstruction, ischemic bowel, acute pancreatitis, or other acute intra-abdominal conditions.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive Alzheimer's 
Treatment: Increase in PCA level II to live-in per diem - 24 hours per day - seven days per week 
The proposed treatment of an increase in PCA level II to live-in per diem - 24 hours per day - seven days per week is deemed medically necessary. 

This is a female with a history of Alzheimer's dementia, ulcerative colitis and anxiety. Due to the severity of her multiple comorbid conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Per the case manager's clinical assessment, the patient was observed to require the need for "hands on transfer" from sit to stand, stand and ambulation while walking to the toilet. Furthermore, she required assistance with transfers to and from the toilet, on and off the toilet and with personal hygiene. Lastly, the patient is waking up multiple times at night and requires assistance with toileting and incontinence care. 

The currently approved schedule of 9.5 hours per day - seven days per week for a total of 66.5 hours per week is not sufficient to meet the patient's needs. For these reasons, the proposed treatment of an increase in PCA level II to live-in per diem - 24 hours per day - seven days per week is deemed medically necessary for increased assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who complained of intermittent snoring. There is no documentation of excessive daytime sleepiness. His body mass index was 24.39. Past pertinent surgical history includes a septoplasty three years ago. An exam of the ears, nose and throat was unremarkable. A previous home sleep study was performed which revealed one apnea and 39 hypopneas. An In lab (attended) polysomnogram was recommended and is under review for medical necessity.
The health plan's determination is upheld.
According to Bruyneel (2015) unattended home-based polysomnography is a reliable tool for the diagnosis of obstructive sleep apnea. According to the American Academy of Sleep Medicine, it is recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of obstructive sleep apnea (OSA) in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. and it was recommended that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA. 
A previous home sleep study demonstrated during the sleep period one apnea and 39 hypopneas. There is no documentation in the clinical information provided that this was considered an inconclusive or technically inadequate study and an in lab (attended) polysomnogram necessary as moderate to severe obstructive sleep apnea. Based upon the clinical information provided and the evidence based literature, an in lab polysomnogram was not medically necessary for this patient.