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

Diagnosis: Metastasis to Bones
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a medical history significant for ischemic cardiomyopathy, bradycardia, hypertension, and invasive bladder cancer with metastasis to the lung and left femur. He was admitted to the hospital for placement of a prophylactic intra-medullary nail into the left femoral shaft. The patient had a prolonged hospital stay following this operation.  At issue in this case is the medical necessity of the inpatient hospital stay 
The requested health service/treatment of Inpatient Hospital Admission  is not medically necessary for this patient.
This patient underwent prophylactic intra-medullary nail placement for an impending fracture of the left femoral shaft from metastatic bladder cancer. The surgery was successful and there were no documented complications from the operation. The current, peer-reviewed orthopedic literature, including an article published by Willeumier and colleagues in the Journal of Surgical Oncology in 2018 supports the care rendered in this case. The records show that the patient was able to participate in post-operative physical therapy for gait training. The therapy recommendation was for placement into sub-acute rehabilitation. The provided medical records document that this patient complained of chest pain. An electrocardiogram (EKG) and troponin levels were obtained. These lab values were within normal limits and the EKG revealed no major changes. The chest pain resolved after a bowel movement. The patient was also noted to have had urinary retention however, a Foley catheter could have been placed at a lower level of care for urinary retention. The patient was noted to not participate in occupational therapy due to fatigue, however, this does not justify an inpatient hospital stay.   The medical records do not support the medical necessity of the inpatient hospital stay.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Gender dysphoria.
Treatment:  Estradiol valerate.

The insurer denied coverage for estradiol valerate.  The denial is overturned.

This is a transgender female (male - to - female) patient with a history of gender dysphoria.  The patient has been taking feminizing hormones.  She has tried and failed Estradiol oral tablets and estradiol transdermal patch.  With both of these modalities she experienced insufficient feminization and headaches.  She is requesting the use of injectable estradiol.

Estrogens, finasteride, spironolactone, and gonadotropin-releasing hormone (GnRH) analogs are used to achieve feminization that will induce physical changes that are more congruent with a patient's gender identity (Lakhiani, C., Somenek, M.T.).                                                          

The patient has a diagnosis of gender dysphoria.  She has tried and failed the formulary alternative and is requesting the use of injectable estradiol for feminization.  

The carrier's denial of Formulary Exception for estradiol valerate is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorder. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied: Ilumya. 
The denial is upheld in whole.

The patient is a female with moderate to severe psoriasis. The patient has tried and failed topical triamcinolone and clobetasol. The patient has had significant improvement on Ilumya sample injections for over a year.
The subject under review is the medical necessity for Ilumya.

The health plan's determination is upheld in whole.

Treatment with Ilumya is not medically necessary for this patient.
For the patient to go straight to treatment with the biologic agent Ilumya via samples is to be treated out of convenience, and not true medical necessity. Alternative oral or biologic options exist that would be just as appropriate for this patient.  
The patient has no documented treatment failure with, or true medical contraindication to, either Enbrel, Siliq, or Cosentyx. Modern dermatology literature [1-4] supports use of these preferred medications as similarly efficacious to the requested Ilumya, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommend use of these agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Ilumya is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System, rule out Cerebrovascular accident (CVA)
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is the case of a female with past medical history of prior cerebrovascular accident causing right hemiparesis and dysarthria with no residual deficits, hypertension, and hyperlipidemia, who presented to the emergency department with headache and left arm and neck numbness since earlier in the morning in addition to blurry vision.
On presentation, she was afebrile with blood pressure 126/85, heart rate 85, respiratory rate 16, and with oxygen saturation 99% on room air. Exam otherwise noted her to have exquisite tenderness of her trapezius muscle and left posterior shoulder. Labs resulted with complete blood count and basic metabolic panel within normal limits and troponin undetectable. A computed tomography (CT) of the head showed no intracranial hemorrhage or other acute process and CT angiogram of the head and neck did not show significant stenosis of the neck vessels or other flow limiting lesions.

The inpatient stay was not medically necessary for this patient. This is a patient who presented with headache and left arm and neck numbness since earlier in the morning in addition to blurry vision. Given her history of cerebrovascular accident, she was certainly appropriate to bring into the hospital for further monitoring of her neurologic status, and stroke work-up with MRI (Magnetic resonance imaging), telemetry, and echocardiogram. It is noted, however, that her symptoms were thought to be most likely secondary to cervical myelopathy rather than acute cerebral ischemia (transient attack or stroke), that her symptoms resolved quickly, and she did not have any new neurologic symptoms after presentation. Her work-up for cerebrovascular accident otherwise showed no acute cerebrovascular accident and was only remarkable for a discovered patent foramen ovale on echocardiogram with no further interventions required for this in the inpatient setting. Given the patient did not have evidence of acute cerebrovascular accident, persistent or new neurologic deficits after admission, or other process such as cervical cord compression causing her symptoms requiring emergent surgical treatment, this patient with a history of transient ischemic attacks was certainly appropriate to bring into the hospital for further stroke work-up. However, she could have been treated at a lower level of care. The Inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease.

Treatment: Dexilant.

The insurer denied coverage for Dexilant.

The denial is upheld.

This is a female patient with a diagnosis of gastroesophageal reflux disease (GERD). The patient had an endoscopy done. It is reported that pantoprazole did not help with this patient's symptoms. Thus, Dexilant was requested.

The American Gastroenterological Association (AGA) has published guidelines on GERD, and proton pump inhibitor (PPI) therapy is part of GERD management. However, there is no recommendation that Dexilant is superior to other PPI medications. As per UpToDate, a systematic review of 12 randomized trials examining the relative effectiveness of different PPI regimens found no consistent difference in symptom resolution and esophagitis healing rates.

In this case, this patient has a diagnosis of GERD, and PPI therapy is appropriate for her condition. However, there is no evidence that Dexilant is significantly more effective than other PPI medications. Other preferred formulary PPI medications can be given. For instance, the patient has tried pantoprazole, but there is no documentation that the patient has tried and failed Nexium 24HR, which is one of the preferred formulary alternatives for this patient's condition. Thus, Dexilant is not considered medically necessary for this patient. 

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

Based on the above, the medical necessity for Dexilant is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dysmenorrhea
Treatment: Supracervical abdominal hysterectomy 
The insurer denied the Supracervical abdominal hysterectomy. 
The health plan's determination is overturned. 

This patient is a female who was followed by her gynecologist for heavy menses and severe dysmenorrhea that has compromised her quality of life. Her ultrasound showed a large fibroid of 9 centimeter (cm), which was suspected to be the origin of her symptoms. The patient has had hysteroscopy, polypectomy, nonsteroidal anti-inflammatory drug (NSAID), and Lysteda with symptoms only worsening over time. A supracervical abdominal hysterectomy is being requested and is under review.

The Supracervical abdominal hysterectomy is medically necessary and would be expected to relieve her symptoms. This patient details symptoms of heavy bleeding as well as symptoms related to the bulk of the uterus (pelvic pain). The notes clearly document a severe effect on her quality of life. Professional guidelines recommend conservative therapies prior to moving to surgical management, but there are no putative timeframes or even specifics on which products should be tried in any guidelines. She has attempted medical management with lysteda and NSAID's, and conservative surgery with hysteroscopy. Therefore, the patient has had sufficient attempts at conservative management without success and has proven that she deserves definitive management. A hysterectomy would remove the fibroid as well as eliminate her menses with no possibility of future treatment failure. This procedure would be expected to eliminate these symptoms entirely. The mention of a nonspecific cancer susceptibility gene is irrelevant to this case, and should not be considered in deciding the medical necessity of this case. The patient's multiple ultrasounds showing a large fibroid, coupled with her worsening symptoms, are sufficient to justify the requested hysterectomy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack (TIA)
Treatment: Inpatient admission
The insurer denied the Inpatient admission.
The denial is upheld.

The patient is a male. He presented to the emergency ward with the complaint of
left upper and lower extremity weakness and numbness.

At presentation, the patient's vital signs were normal, his examination was non-focal
and computed tomography (CT) brain was negative for acute pathology. He was admitted for possible TIA (transient ischemic attack).

No, the Inpatient admission was not medically necessary.

At presentation, the patient had a normal neurological examination. Current risk
stratification guidelines for TIA do not warrant acute inpatient admission in this
clinical context. The diagnostic studies, neurological evaluation, monitoring and
treatment could have been safely and effectively completed at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Adenocarcinoma of the gallbladder

Treatment: 30 treatments of simple with and without compensation, intermediate and complex proton beam radiotherapy

The insurer denied coverage for 30 treatments of simple with and without compensation, intermediate and complex proton beam radiotherapy.

The denial is upheld.

This is a female patient with gallbladder cancer. The patient underwent surgery followed by 4 cycles of chemotherapy. The patient is now being evaluated for radiation using proton beam therapy.
	
According to Verma and Crane (2019), "An emerging modality with which to deliver ablative radiation therapy in a potentially safer manner is proton beam therapy. Proton beam therapy is a highly conformal modality that yields a sharp dose drop-off between the distal edge of the tumor and surrounding normal tissue, owing to the heavy size of the proton and its associated Bragg peak. Although there have been no dedicated series of proton beam therapy for gallbladder cancer, several studies of liver tumors and cholangiocarcinoma (37-39) along with a phase II trial (40) illustrate favorable safety profiles. The role of proton beam therapy for liver and biliary tumors will be better addressed with a number of ongoing randomized trials, including some that employ dose-escalation." This is further supported by Badiyan et al (2018) that states "Clinical data on [proton beam therapy (PBT)] for extrahepatic biliary tumors is very limited. The only published retrospective series included extrahepatic biliary tumors along with intrahepatic tumors when reporting outcomes."

As to date, the NCCN (2020) guidelines do not recommend proton beam therapy for gallbladder cancer. This is a rare disease for which there is no scientific evidence in peer-reviewed literature to support a result of improvement in health outcome from proton beam radiation therapy (PBRT) for this condition. Therefore, it is unclear which patient is a good candidate for 30 treatments of simple with and without compensation, intermediate and complex proton beam radiotherapy (CPT codes 77520, 77522, 77523, and 77525). Thus, the requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of 30 treatments of simple with and without compensation, intermediate and complex proton beam radiotherapy (CPT codes 77520, 77522, 77523, and 77525) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Adenocarcinoma of the gallbladder

Treatment: 30 treatments of simple with and without compensation, intermediate and complex proton beam radiotherapy

The insurer denied coverage for 30 treatments of simple with and without compensation, intermediate and complex proton beam radiotherapy. 

The denial is upheld.

This is a female patient with a history of invasive adenocarcinoma of her gallbladder status post initial laparoscopic resection, followed by definitive surgical resection (including extended hepatic resection and periportal/hepatic nodal dissections). There were positive margins on the initial laparoscopic resection but no residual tumor seen on the second surgery pathology. The patient received postoperative gemcitabine/cisplatin chemotherapy, and was recommended to proceed with a course of postoperative external beam radiotherapy with curative intent. The request is for approval of proton beam radiation therapy and associated treatment support codes.

According to literature review, proton radiotherapy has the ability to reduce the volume of low dose radiation exposure to surrounding normal critical tissues, but it cannot reduce the high dose exposure. Since it is the volume of high dose normal tissue exposure which has traditionally been correlated with radiation-induced morbidity, it remains unclear as to whether the use of proton radiotherapy in this patient's case would offer clinically meaningful improvements in outcomes. The treating provider has not supplied a detailed slice by slice proton/photon plan comparison in color format to justify the need for proton radiotherapy in this patient's case. The documentation provided for review has not shown that this patient could not be treated safely/effectively with photon-based radiation. 

Based on the review of the medical record and literature, there are not any extenuating circumstances present in this patient's case that would necessitate the use of proton beam radiotherapy such as prior receipt of radiation to the same site or genetic/comorbid condition which increases the radiosensitivity of normal tissue. Per the current peer reviewed medical literature, there are insufficient high quality clinical outcomes reported to allow one to make definitive conclusions regarding the relative safety/efficacy of proton beam radiotherapy for management of resectable gallbladder cancer, as compared to standard of care photon-based radiation therapy. The ASTRO Model Policy does not support the use of proton radiotherapy in this patient's case outside the context of a prospective clinical trial. 

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of 30 treatments of simple with and without compensation, intermediate and complex proton beam radiotherapy (CPT codes 77520, 77522, 77523, and 77525) should be upheld.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female. She presented with abdominal pain, diarrhea and vomiting. It was noted that the vomit had a streak of blood. 

The patient was mildly tachycardic with mild elevation in her BP (blood pressure). Labs revealed WBC (white blood count) of 13k, K (potassium) was 3.6, Hgb (hemoglobin) was 13.9 and a CT scan of the abdomen and pelvis was negative. She was hydrated, and stool was positive for norovirus. 

The patient was seen by GI (gastroenterology). It was noted that she had mild pain, but no further vomiting or diarrhea. Physical exam was negative. WBC was 9.8, Hgb 12.4, K was 3.1. She tolerated a liquid diet that was advanced. GI recommend PPIs (proton pump inhibitors). They felt her pain was related to here gastroenteritis, and that all would resolve. They did not feel an EGD (esophagogastroduodenoscopy) was needed. K was supplemented. 

It was noted that patient was doing well, tolerating diet and wanted to go home. 

No, the Inpatient admission was not medically necessary.


The patient presented with diarrhea and vomiting. She was hemodynamically stable with a mildly elevated WBC and mild dehydration. She had one episode of vomiting while in the emergency room. There was no evidence of obstruction or an acute intra-abdominal process on CT scan. There was no significant bleeding, evidence of coagulopathy, mental status changes, intractable vomiting or a need for surgical intervention. Observation status was therefore appropriate. When there was no further vomiting, when she tolerated a liquid diet, and when stool was positive for norovirus, without sepsis, GI bleeding, electrolyte abnormalities or dehydration, she was medically stable for discharge to outpatient care. Acute inpatient hospital stay was not medically necessary, and the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Abdominal pain.
Treatment: Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is overturned. 

The patient a female, who presented with abdominal pain, diarrhea, and nausea.  She was well until 2 days prior to admission when she developed diarrhea.  She was having 7 episodes of watery, non-bloody diarrhea per day.  She also had generalized abdominal pain and nausea with decreased oral intake.  Importantly, her sibling had recently been admitted to the hospital for similar symptoms.  There was concern that her symptoms were related to hot dogs they both ate a few days prior.

On physical examination in the emergency department, she was found to have abdominal distention with some tenderness.  Laboratory values were obtained and were significant for a urine specific gravity of 1.030.  She was given a bolus of normal saline in the emergency department; however she continued to have diarrhea.  Therefore, the decision was made to admit her to the hospital for dehydration and oral intolerance.

The inpatient hospital admission was medically necessary for this patient.  

This is a young child, who presented with multiple episodes of diarrhea, nausea, and decreased oral intake.  She continued to have diarrhea while in the emergency department and was refusing to drink.  She had a urine specific gravity of 1.030, indicating dehydration.  In addition, her sibling was admitted with similar symptoms and was found to have Shigella infection.  Hospital admission was needed for intravenous hydration, the initiation of parenteral antibiotics, and close monitoring with additional treatments, as needed.  Parenteral therapy for Shigella infection is indicated for children who are unable to tolerate oral medications.

The decision-making at the time of admission for this patient was consistent with her young age, the presence of significant diarrhea and dehydration, and the need for prompt initiation of intravenous fluids, antibiotics, and close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thyroid Nodules.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of bilateral thyroid nodules. She was admitted to the hospital and underwent a total thyroidectomy with intraoperative nerve monitoring. The operative note describes the procedure of total thyroidectomy. No intra-operative complications were described. The post-surgical calcium was measured following surgery and remained within normal limits. Progress notes describe an uncomplicated initial recovery. The pathology report confirms nodular hyperplasia of the thyroid with two foci of papillary microcarcinoma. She was discharged from the hospital.
At issue is the medical necessity of an inpatient stay.

An inpatient hospital stay was not medically necessary in this case. While there is a risk for postoperative hypocalcemia following total thyroidectomy, the nadir for post-surgical calcium is not typically seen until 48 hours. The progress notes do not describe any clinical manifestations of hypocalcemia. Monitoring for hypocalcemia was appropriate in this case; however, this could have reasonably and safely been provided without inpatient admission. The operative report describes a successful and uncomplicated procedure. There was no clinical evidence for neck swelling, postoperative bleeding, or recurrent laryngeal nerve injury. The patient remained clinically stable following an uncomplicated thyroidectomy and was stable for discharge on the first post-surgical day. This patient's clinical needs could have been satisfied at a lower level of care and did not require acute inpatient admission.