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

This patient with history of brain cancer with grade 2 right sided oligodendroglioma status post resection as well as seizures, who presented to the emergency department (ED) for evaluation of seizure activity. The patient had been taking Keppra however stopped two days prior for a possible video-electroencephalogram (vEEG). The neurologist recommended for the patient to undergo a vEEG. The patient was admitted for possible recurrent seizure activity and concern for possible status epilepticus and was monitored by vEEG with no noted seizure activity.

The health plan's determination is overturned. The inpatient stay was medically necessary. Given that this patient was having clinical spells or events at home concerning for possible seizures versus potentially non epileptic spells with history of prior seizures and history of brain cancer, inpatient admission for VEEG monitoring for purposes of differential diagnosis and appropriate medical management, especially in this patient who is a higher risk of having seizures due to history of brain cancer and possibly status epilepticus, was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: unsteady gait, dizziness, dyspnea with ambulation

Treatment: Two 12 hour split shifts

The insurer has denied coverage for two 12 hour split shifts. The denial was reversed.

This female patient lives alone.  She has multiple medical problems and requires assistance with most ADLs and IADLs.  The patient was approved for personal care assistance (PCA) services 24 hour live-in.  The patient's son is requesting PCA services two 12 hour split shift because he reports the patient wakes up during the night and requires assistance.  

The Uniform Assessment System (UAS) indicates the patient has some cognitive impairment with decision making and memory loss.  She has a history of wandering, but not out of the house. It is noted that she has some sleep difficulties.  The patient has unsteady gait, dizziness, dyspnea with ambulation and needs assistance for transfers, walking and toileting.  When she gets up at night and attempts to get out of bed, walk, go to the bathroom, there is risk of falls and accidents if she has no assistance.  As per the son's report, it appears that the aide wakes up when the patient is awake.  It is expected that the aide assists the patient when she tries to get out of bed; and the aide remains awake until the patient goes to sleep, as the patient may continue to need assistance with transfers, walking, and toileting when she is awake.

NYS regulations for personal care services require that a 24 hour live-in aide must be able to have at least 5 hours of uninterrupted sleep within an 8 hour sleep period.   

The patient's history (as noted in the UAS) supports the concern that the patient is awake through various times of the night (history of wandering, late night food binging, difficulty falling asleep or staying asleep).  If the patient is awake and the aide is awake for varying intervals at night, this is a potentially harmful situation for the patient and aide.  The patient may try to get out of bed, and if the aide is not yet awake the patient may have a fall/accident before the aide wakes up.  If the aide is not getting adequate sleep, it is harmful to the health of the aide, and decreases her ability to function with full physical and mental capacity during the day, which could also have an adverse effect on her ability to care for the patient. 

It does not appear to be in the best interest of the patient or the aide to continue 24 hour live-in services pending clarification of the nighttime activity of the patient.  The healthcare plan did not act reasonably or with sound medical judgment or in the best interest of the patient.  It is recommended that personal care services are approved for two 12 hour split shift.

The carrier's denial of coverage for two 12 hour split shifts is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
 
Treatment: Inpatient Admission

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


This is a young male patient who presented to the Emergency Department (ED) with abdominal pain. The patient had an ultrasound of his appendix; the appendix was unable to be visualized. A computerized tomography of his abdomen and pelvis was performed which revealed mild appendicitis. He was treated with intravenous antibiotics, with failed results. The patient underwent a laparoscopic appendectomy. He experienced no post-operative complications and was discharged home when medically stable.  

The Milliman Care Guidelines (MCG) indicates an uncomplicated open or laparoscopic appendectomy for a pediatric patient can be performed either on an ambulatory basis or with admission for 1-day post-operatively.  Ambulatory status is appropriate for most children with acute uncomplicated non-perforated appendicitis and those undergoing interval appendectomy after non-operative treatment. Inpatient stays are recommended for children with complicated appendicitis (e.g. perforated without generalized peritonitis) or those requiring prolonged (e.g. more than 24 hours postoperatively) care after surgery (e.g. comorbid illness).  The guidelines also indicate that an exception for ambulatory surgery would include patients in need of an emergent procedure.

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

Diagnosis:  Ehlers-Danlos Syndrome 
Treatment:  Ten additional physical therapy visits 

The proposed continue Physical therapy sessions are not medically necessary.
 
The member is a female with history of Ehlers-Danlos Syndrome, joint hypermobility type and complaint of chronic pain limiting her physical functioning and gets regular physical therapy to preserve her functioning and prevent escalation of her current opioid medication use for pain control.

She had ten PT (physical therapy) sessions, approximately one session once every 5-10 days, with request for additional PT sessions once a week towards preserving her functioning and improvement of pain control.  There is no documented evidence of objective progress in therapy and no evidence of a plan for transition to a home exercise program.

The health plan has acted reasonably in this instance, and its decision was with sound medical judgment, which is in the best interest of the patient based on the above rationale.  This patient with history of Ehlers Danlos Syndrome is requesting physical therapy for preservation of her functioning, despite prior ten PT sessions without documented objective evidence of progress and no plan for transition to home exercise program, which is what is needed for continued preservation of her functionality.
Appeal type: Medical necessity
Decision: Overturned

The patient is a young adult who was admitted for residential mental health treatment of persistent depressive disorder, posttraumatic stress disorder (PTSD) with associated symptoms of anxiety, attention deficit hyperactivity disorder (ADHD) with predominantly inattentive type symptoms, and other personality disorder with narcissistic and borderline traits. The patient had received mental health treatment with various levels of care including recent and extensive treatment in the past that included therapy and medication with limited family support. The patient was treated in an acute inpatient level service immediately prior to her referral and admission for worsening symptoms of depression and anxiety with onset of psychotic symptoms that had included delusions and hallucinations best characterized as an unspecified schizophrenia spectrum disorder with brief symptoms of psychosis not otherwise specified. 

The health plan's determination is overturned. The residential mental health services are medically necessary for this patient. The patient's complex and co-morbid conditions treated for the dates of service (DOS) in question could not have been effectively provided with lower level care or in a less restrictive treatment setting. The continued structure and monitoring of a residential setting was medically necessary in order to effectively address the patient's risk of relapse, continue to learn adequate coping skills to achieve better control of impulses and boundaries with peers and family, and prevent treatment failure as the patient had experienced prior to her residential level admission, and to continue the intensity of the treatment with evidence-based psychotherapies and family work, as the treatment team and patient worked toward a clinically appropriate disposition with continued mental health services to address the co-occurring mood, trauma-related and personality disorders and the co-morbid ADHD including the issues within the social environment and family constellation and problematic behaviors associated with the narcissistic and borderline personality traits.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male who presents with decay and bone loss on tooth #7.  Crown and core build-up are being requested at this time.  The health plan's determination is upheld in whole. 

According to the provided radiographs, tooth #7 has severe bone recession that resulted in more than 50% bone level loss.  The ideal crown-to-root ratio for a good prognosis is 1:2; minimum crown-to-root ratio is 1:1.  In this case, the crown-to-root ratio on tooth #7 is 2:1.  Placing a crown on a tooth with severe bone loss will result in poor prognosis and eventual tooth loss.
In addition, there is radiographic evidence of decay on the mesial surface of tooth #7; however, the decay is not large enough for treatment with a crown.  The tooth can be restored by conservative means, such as a filling.  Therefore, a crown on tooth #7 is not considered medically necessary.  Because medical necessity for a crown has not been established for tooth #7, a core build-up is also not medically necessary in this case.  As a result, the denial for crown and core build-up on tooth #7 is upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a male diagnosed with advanced stage Non-small-cell lung carcinoma (NSCLC). The Guardant360 was performed in 2018.
The subject under review is whether the Guardant 360 genetic testing is likely to be more beneficial than any standard treatment for the insured's life threatening disease.
The health plan's determination is upheld.

The Guardant 360 genetic testing is not likely to be more beneficial than any standard treatment for this patient's disease.
The Guardant360 is not indicated in non-small cell lung cancer management.  The following mutations are indicated for testing in making determinations of systemic therapy:  EGFR, ALK, ROS1, BRAF, KRAS, PDL-1, MET, RET, Her2 and tumor mutational burden.
Plasma cell-free or circulating tumor deoxyribonucleic acid (DNA) testing should not be used in lieu of a tissue diagnosis.  Such testing yields a 30% false-negative rate.  Standard for analytic performance characteristics of such testing have not been established and there are no guidelines regarding performance characteristics.  This testing may identify alterations that are unrelated to a lesion of interest.  
The use of plasma cell-free testing can be considered in specific circumstances such as a patient who is medically unfit for invasive tissue sampling and in patients when there is insufficient material for molecular analysis.  
Based on evidence based standards, the testing is not likely to be more beneficial to the patient than standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a male diagnosed with non-small-cell lung carcinoma (NSCLC) (adenocarcinoma).  A Guardant360 liquid biopsy was performed (the test which is of issue). The available medical records contain no information on the patient's clinical condition (including whether he was unable to tolerate tissue biopsy) or stage of cancer.
The subject under review is whether the Guardant 360 genetic testing is likely to be more beneficial than any standard treatment for the patient's life threatening condition. The health plan's determination is upheld.

No, the Guardant360 testing is not more likely to be beneficial than standard treatment for the insured's condition.

The Guardant360 liquid biopsy test is not Food and Drug Administration (FDA) approved, and is not recommended for use in guiding NSCLC treatment outside of the epidermal growth factor receptor (EGFR) setting and in situations of disease progression on tyrosine kinase inhibitors (TKI's), according to national consensus expert panels (the National Comprehensive Cancer Network (NCCN) guidelines and the College of American Pathologists, the International Association for the Study of Lung Cancer, and the Association for Molecular Pathology guidelines.
In its 2018 Guidelines, the College of American Pathologists, the International Association for the Study of Lung Cancer, and the Association for Molecular Pathology states that, "Physicians may use cell-free plasma deoxyribonucleic acid (DNA) methods to identify EGFR T790M mutations in lung adenocarcinoma patients with progression or secondary clinical resistance to EGFR-targeted tyrosine kinase inhibitors; testing of the tumor sample is recommended if the plasma result is negative." The available medical record indicates the patient is newly diagnosed and his lung cancer has not been treated with a TKI and progressed on this treatment. In addition, these Guidelines do not support liquid biopsies outside of the EGFR setting, such as in a Guardant360 multigene panel.
Therefore, there are no evidence based standards that demonstrate the Guardant360 test improves health outcomes or that the expected benefits of the Guardant360 test exceed the benefits of standard health care services.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a male with advanced stage non-small cell lung cancer. The Guardant360 assay was obtained and is under review.
The subject under review is whether the testing is likely to be more beneficial than any standard treatment for the patient's condition. The health plan's determination is upheld.

No, the Guardant360 testing is not likely to be more beneficial than any standard treatment for the patient's condition.
The use of next generation sequencing gene panels to guide the treatment of patients with lung cancer has not been demonstrated to be of benefit. The assay is question is not Food and Drug Administration (FDA) approved. This approach remains the subject of multiple clinical trials including, but not limited to, National Clinical Trial (NCT)03477474, NCT03615443 and NCT03576937.
To date, the SHIVA trial is the only large randomized trial to study off-label use of molecularly targeted agents on the basis of identified molecular alterations for which results have been published in the peer-reviewed literature. 741 patients were enrolled in this multi-institutional trial that included adult patients with any kind of metastatic solid tumor refractory to standard of care, provided they had an Eastern Cooperative Oncology Group performance status of 0 or 1, disease that was accessible for a biopsy or resection of a metastatic site, and at least one measurable lesion. The molecular profile of each patient's tumor was established with a mandatory biopsy of a metastatic tumor and large-scale genomic testing. Patients with an actionable mutation were randomized these (1:1) to receive a matched molecularly targeted agent (experimental group) or treatment at physician's choice (control group) by central block randomization (blocks of size six). Treatments in both groups were given in accordance with the approved product information and standard practice protocols at each institution and were continued until evidence of disease progression. The primary endpoint was progression-free survival in the intention-to-treat population. Median follow-up was 11.3 months (Interquartile Range [IQR] 5.8-11.6) in the experimental group and 11.3 months (8.1-11.6) in the control group at the time of the primary analysis of progression-free survival. Median progression-free survival was 2.3 months (95% confidence interval [CI] 1.7-3.8) in the experimental group versus 2.0 months (1.8-2.1). The conclusion of the authors was "The use of molecularly targeted agents outside their indications does not improve progression-free survival compared with treatment at physician's choice in heavily pretreated patients with cancer. Off-label use of molecularly targeted agents should be discouraged, but enrollment in clinical trials should be encouraged to assess predictive biomarkers of efficacy".

Based on the paucity of supporting data, neither the National Comprehensive Cancer Network (NCCN) nor the authors of UpToDate recommend the use of the Guardant360 assay in this clinical scenario. Treatment based on published literature and guideline recommendations has been encouraged.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with alopecia totalis, treated with topicals and intralesional steroids.  The provider is requesting oral Xeljanz.  At issue is the medical necessity of this medication.  
The health plan's determination is overturned.  This patient's hair loss is caused by a disease and can lead to functional impairment with loss of eyelashes and brows and substantial psychosocial burden.  Xeljanz for alopecia areata is now well-supported in the current peer-reviewed literature.  A wide range of treatments have been used for the management of alopecia areata, most of which are not highly effective.  Treatments include topical or intralesional corticosteroids, topical minoxidil (2% or 5%), topical anthralin, systemic corticosteroids, cyclosporine, and other immunosuppressants.  There have been no effective therapies for totalis and universalis before Xeljanz was discovered.  Given the rarity of the disease, large randomized controlled trials are extremely difficult.
Xeljanz is currently Food and Drug Administration (FDA)-approved for rheumatoid arthritis and undergoing approval trials for psoriasis and psoriatic arthritis.  It is known to be safe and effective in the conditions for which it is FDA approved.  Biologic medications as a whole have many off label uses, leading to better outcomes in rare diseases for which large randomized trials are not readily available.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient substance abuse admission, medication, monitoring

The insurer denied the continued inpatient substance abuse services. The denial was reversed.

This male was admitted to inpatient substance detoxification treatment for alcohol and substance detoxification treatment. He had withdrawal symptoms, an elevated systolic blood pressure of 149, and an elevated heart rate of 103. He had a Clinical Opiate Withdrawal Scale (COWS) score of 16 and a Clinical Institute Withdrawal Assessment (CIWA) score of 10. He had a history of withdrawal seizures. He had daily intake of alcohol (twelve 12 ounce beers and a pint of vodka), and used several bags of intravenous heroin daily, and 1 strip of buprenorphine twice a day. He also used tens of dollars' worth of crack and 1/2 gram of cannabis per day. His toxicology was positive for opiates, cocaine, cannabis, and buprenorphine. He was put on a Librium and Methadone protocol. He was homeless and had a past inpatient detoxification treatment in 2018.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. This patient was using large amounts of alcohol daily, and was at significant risk for complicated withdrawal symptoms, including withdrawal seizures, which he had in the past. He required the entire 5-day detoxification protocol to avoid severe and complicated withdrawal.  He was using multiple substances and could not stop use on his own. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he required 24-hour treatment as he needed and received two detoxification medications. He had relapsed after a past inpatient substance treatment; therefore, he was at high risk for relapse again. 

Based on the above, the medical necessity for the continued inpatient substance abuse services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Acute cholelithiasis
Treatment:  Inpatient Admission 
The insurer denied the Inpatient Admission.  The denial was upheld. 

This is a middle aged male who presented to the emergency department in early 2019 with complaints of vomiting and abdominal pain in the right upper quadrant for 3 days.  The patient had a past medical history of peptic ulcer disease and gallstones.  The patient underwent polypectomy 4 days prior to presentation.  An ultrasound of the abdomen performed which was negative for gallstones; however mild gallbladder wall thickening was noted.  A positive sonographic Murphy sign was reported, suggesting the possibility of a cystic duct stone and acute cholelithiasis.  The records indicated the patient underwent a surgical consultation and surgical intervention.  The patient was placed nothing by mouth and was treated with intravenous antibiotics.  He underwent a laparoscopic cholecystectomy.  He was stabilized and discharged. 

The MCG indicate that the goal length of stay for a patient needing a laparoscopic cholecystectomy is ambulatory.  An inpatient stay may be appropriate for patients who have a failure to achieve discharge status criteria or those who have active comorbidities.  The guidelines also indicate that an exception for ambulatory surgery would include patients in need of an emergent procedure.  Although the diagnosis was acute cholecystitis, the patient was admitted and did not require an emergent procedure.  The patient underwent a laparoscopic cholecystectomy.  The patient was stable both pre-operatively and post-operatively.  The records failed to support the patient could not have been placed on observation status prior to the procedure.  The patient could have been discharged from the post-anesthesia care unit.  

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.