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

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Physical Therapy. 
The insurer denied Physical Therapy for medical necessity. 
The denial was upheld. 

This is a patient diagnosed with pain in thoracic spine, stiffness of unspecified joints, neuromuscular scoliosis thoracic region, and other cervical disc displacement at cervical (C)5 - C6 level. The physical therapy notes provided indicate the patient had completed at least 17 visits of physical therapy with no change in pain complaints. The patient had met 90% of all short-term and long-term goals and had been provided with home exercise program instruction. It was noted that there was no change in cervical range of motion since prior evaluation, no change in shoulder range of motion, no change in motor strength in the upper extremities, no change in lumbar range of motion, and no change in special tests. Additional physical therapy was recommended.
There is a letter from the patient stating that physical therapy has helped her improve but she is not out of the woods yet and needs the professional help of the physical therapist to heal the major problems in her neck/back. She stated she is very limited in what she can do right now but is on her way to recovery only through physical therapy and requests that more visits be approved.
At issue is the medical necessity of Physical Therapy.
The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of Physical Therapy is not medically necessary for this patient.
Records indicate the patient has chronic neck and back pain and  had completed at least 17 visits of physical therapy with no change in pain level, as well as no change in any range of motion, motor strength or special test measurements. It was noted the patient was already 90% of the way towards meeting all short-term and long-term goals and had been provided with a home exercise program. There were no specific goals outlined that would require ongoing supervised/skilled therapy sessions over that of transitioning to an independent home exercise program as would be standard of care at this point. There were no exceptional circumstances to warrant an extended course of therapy. Thus, medical necessity is not established.
Therefore, the requested health service/treatment of Physical Therapy is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thoracic dystrophy.
Treatment: Synagis.

The insurer denied Synagis.  The health plan's determination is upheld. 

The patient has a number of congenital malformations. The only medical records provided for review are a genetics clinic evaluation which at that time describe the baby as having thoracic dystrophy with rib involvement and chest x-ray suggesting pulmonary hypoplasia. At another visit, she had normal vital signs, including oxygen saturation of 99% on room air. She had mild tachypnea and mild subcostal retractions at that time at baseline. She was identified as being at-risk for pulmonary deterioration should she have a respiratory illness. The provider is requesting second season Synagis (RSV prophylaxis), which was denied as not meeting medical necessity guidelines.

Synagis is not medically necessary for this patient. Based on the medical records, there is no indication that this patient meets the narrow criteria for second season Synagis, that is, Synagis beyond the first year of life. The Centers for Disease Control and Prevention (CDC) and American Academy of Pediatrics (AAP) Guidelines reflect the established standard of care regarding Synagis. These guidelines discuss the use of Synagis for patients with chronic lung disease and anatomic pulmonary abnormalities, both of which this baby arguably has.
With regard to chronic lung disease, the guidelines state:
"Prophylaxis may be considered during the respiratory syncytial virus (RSV) season during the first year of life for preterm infants who develop CLD (chronic lung disease) of prematurity defined as gestational age < 32 weeks, 0 days and a requirement for >21% oxygen for at least the first 28 days after birth.
During the second year of life, consideration of palivizumab prophylaxis is recommended only for infants who satisfy this definition of CLD of prematurity and continue to require medical support (chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen) during the 6-month period before the start of the second RSV season. For infants with CLD who do not continue to require medical support in the second year of life prophylaxis is not recommended."
There is no evidence that this baby at any time met the criteria for Synagis for chronic lung disease in the first year of life or the second year of life.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Buccal crossbite.
Treatment:  Braces.

The insurer denied the braces.  The denial is overturned. 

The patient is a male. The request is for orthodontic benefits.

The photos show the buccal crossbite of #12, which is the problem.

Yes, the braces are medically necessary.

With the patient's tooth #12 totally out of place towards the patient's cheek, it will be susceptible to trauma and fracturing. Orthodontic treatment is needed to move that tooth back into alignment.

Tooth #12 definitely needs to be moved into proper position to prevent trauma to that tooth and the ones around and under it.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male.  At the time of admission to the hospital, he had a past medical history significant for hypertension (HTN), chronic obstructive pulmonary disease (COPD), dyslipidemia, coronary artery disease (CAD), status post (s/p) prior percutaneous coronary intervention (PCI), negative cardiac catheterization, congestive heart failure (CHF) with reduced systolic function, status post (s/p) automatic implantable cardioverter defibrillator (AICD), schizophrenia, and recent left shoulder fracture.  The patient presented to the emergency room (ER) with complaints of left-sided sharp chest pain, radiating to the back and left shoulder, as well as left arm swelling and difficulty lifting the left arm. 

The patient was hemodynamically stable. His electrocardiogram (ECG) revealed normal sinus rhythm with right bundle branch block and non-specific T-wave inversion. Cardiac troponin was negative. The patient was admitted to rule out acute coronary syndrome. Repeat troponin was negative. The patient underwent a computed tomography (CT) angiogram, which was negative for pulmonary embolism. He was seen in consultation by cardiology and no further inpatient cardiac work up was recommended. The patient was discharged home with a plan for outpatient follow-up.

No, the proposed inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative. No inpatient ischemic work-up was felt to be necessary by the treating physicians. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leukemia
Treatment: Pharmacy/Prescription Drugs/Venetoclax
The health plan denied the requested prescription medication. The health plan's determination is upheld.

This is a  male with relapsed, refractory, bcr-abl (genetic mutation) negative (mixed -lineage leukemia) MLL-rearranged acute lymphoblastic lymphoma. The patient has failed multiple lines of therapy including CALGB 10403, Bilnatumumab, HyperCVAD. and Inotuzumab. Venclexta has been recommended as a component of therapy bridging to CAR-T (cancer immunology) therapy; this is under review.

The health plan's determination of medical necessity is upheld, in whole.

No. the use of Venetoclax in this clinical scenario remains unproven and is not recommended in the peer-reviewed literature, by the authors of UpToDate, nor by the National Comprehensive Cancer Network (NCCN) Guidelines. The proposed approach remains the subject of ongoing investigation in several clinical trials including, but not limited to, NCT03218683, NCT03504644, and NCT03808610. Given the lack of a proven outcomes benefit, criteria for medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple myeloma. 
Treatment: Venclexta. 

The insurer denied coverage for Venclexta. 

The denial is upheld. 

This is a male patient with multiple myeloma. He was previously treated with Revlimid + Velcade + dexamethasone (RVD). The treating provider has now proposed therapy with daratumumab [Darzalex] and venetoclax [Venclexta]. He has an 11:14 translocation. 

The use of Venclexta is not considered medically necessary for this patient. 

There is no evidence to support the use of venetoclax+daratunumab as therapy for myeloma. The National Comprehensive Cancer Network (NCCN) only supports the use of venetoclax as a single agent to treat 11:14 translocated multiple myeloma. Early studies in multiple myeloma did show activity of the drug venetoclax when given as a single agent to treat myeloma, or with velcade; however the large phase III BELLINI trial demonstrated a 20% risk of death with venetoclax in combination when used to treat myeloma (Kumar, S.K. et al., 2020).  Due to this, the Food and Drug Administration (FDA) placed a hold on all ongoing trials of venetoclax in multiple myeloma. This was eventually withdrawn; however venetoclax has been essentially abandoned in myeloma.  As stated above the NCCN only supports its use as single agent. There are no published trials of venetoclax given with daratumumab and given the results of BELLINI there is significant concern over the potential toxicity of this approach. 

Per Kumar VK, et al. (2015), "Venetoclax monotherapy had a tolerable safety profile in heavily-pretreated relapsed/refractory MM [multiple myeloma], and no new safety signals were observed compared to other venetoclax studies." 

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

The use of venetoclax+daratunumab is not a validated National Comprehensive Cancer Network (NCCN) supported therapy to treat multiple myeloma. 
                                                     
The carrier's denial of coverage for Venclexta is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female who presented to the emergency department complaining of back, left-sided chest and left shoulder pain. Her medical history was remarkable for fatigue. Her blood pressure was 149/90 millimeters of mercury (mmHg) with a heart rate of 69 beats/minute. Her physical exam was unremarkable. Her electrocardiogram and serum troponin level were normal. She was mildly hypokalemic. She was treated with aspirin, potassium, sublingual nitroglycerin and Toradol and admitted to the hospital to rule out acute coronary syndrome. A second troponin level was normal. The patient remained stable and was discharged with plans for a cardiac stress test as an outpatient. Medical necessity for an inpatient stay is at issue.

The health plan's determination is upheld. 

This patient presented with atypical symptoms that were thought to be possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. On the other hand, she was hemodynamically stable, with normal cardiac biomarkers, and a normal electrocardiogram. Based on her HEART score of 2 she was at low risk (0.9-1.7%) for major adverse cardiac events. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level care status. This approach has been shown to be both safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse
Inpatient hospital

Diagnosis: Substance Abuse
Treatment: Inpatient admission
The insurer denied the inpatient admission. The health plan's determination is upheld. 

The patient is a male who transferred from detoxification treatment for inpatient rehabilitation substance use disorder treatment to address substance use disorder with alcohol, opioid, cocaine and cannabis class substances of abuse. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. He had initially shown mild to moderate withdrawal symptoms including nausea, tremor, sweats, restlessness/agitation and anxiety, scoring a 10 to 13 on the Clinical Institute Withdrawal Assessment (CIWA) scale. He had a history of substance use disorder with multiple prior treatments with relapses. He reported daily use of alcohol with up to four 40-ounce beers; and, opioids with up to 3 bags of heroin three times per day plus a history of using three 15 mg Vicodin pills together with a history of cocaine and cannabis use. His addiction to opioids had followed a gunshot wound to the abdomen with exposure to opioids.
His substance use had escalated with significant decline in functioning. Again, the patient had been admitted for detoxification treatment his immediately prior to his admission to inpatient rehabilitation treatment.

The Inpatient Substance Use Disorder Rehabilitation Services was not medically necessary for this patient.
The proposed inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The clinical features and indicated treatment dimensions of this patient's alcohol use disorder, and other substance use disorders, did not require or warrant the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of bipolar disorder and anxiety disorder and ongoing substance use disorder with alcohol and opioids and the history of a chronic relapsing course. Moreover, the patient had been evaluated and cleared with regard to safety concerns and general medical conditions, and the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment.
Any indicated treatment for substance use disorder in this case could have been provided at a lower level of care following the comprehensive assessment and stabilization with detoxification treatment.
This answer is consistent with established practice guidelines, the scientific literature, and American Society of Addiction Medicine (ASAM) Criteria and is consistent with the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Compression Fractures of the Lumbar Spine
Treatment: Home Health Care
The health plan denied the requested increase in home health care. 
The health plan's determination is overturned.

The patient is a female with a past medical history of chronic low back pain, hypertension, diabetes mellitus type 2, hyperlipidemia, anxiety, and depression who had personal care assistance (PCA) services 6 hours/day, 7 days/week to total 42 hours/week based on an assessment tool performed. The compared report indicated the patient was assessed at total assistance for ordinary housework, maximal assistance with transportation, extensive assistance with bathing, dressing lower body, toilet use, and bed mobility, while limited assistance with personal hygiene, dressing upper body, and transfer toilet. The patient was hospitalized with new diagnosis of large B cell lymphoma and oxygen dependence. The patient was started on chemotherapy following transfer to rehabilitation facility. There was a request to increase PCA hours to 12 hours/day, 7 days/week, to total 84 hours/week. 
The patient later had a fall at home and presented to the emergency room and had a subcapital femoral neck fracture.  The patient also had compression fractures of the lumbar spine.  The patient underwent open reduction internal fixation (ORIF) of right hip.  The patient had a kyphoplasty.  There were plans for the patient to go to subacute rehabilitation.
At issue is the medical necessity of the requested increase in PCA services

The health plan's determination of medical necessity is overturned, in whole.

The plan partially reversed its initial denial decision approving an increase in PCA hours to 8 hours/day, 7 days/week, to total 56 hours/week. The patient had documented improvement in multiple activities of daily living (ADL) / instrumental activities of daily living (IADL) tasks from baseline rehabilitation physical therapy notes  to updated PT notes. Specifically, the patient had improvement in tasks of bed mobility, transfers, ambulation, stairs, upper/lower body dressing, toileting, and wheelchair mobility.
 However, based on the patient's new medical problems of right hip fracture and spinal compression fractures, the patient would need an increase in assistance with multiple tasks compared to the assessment performed.  Based on PT / OT notes(Physical therapy/Occupational therapy) from the latest hospitalization the patient would need an increase in assistance with tasks of stairs, bathing, personal hygiene, dressing upper/lower body ,walking, locomotion, transfer toilet, and bed mobility.  The requested increase in PCA hours to 12 hours/day, 7 days/week would be medically necessary based on worsening of her medical condition with new right hip fracture and new compression fractures of the spine resulting in an increase need with assistance with ADLs/IADLs compared to the earlier assessment.
Appeal type: Medical necessity
Decision: Overturned

Blood Disorder/Other
Inpatient Hospital

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

The patient is a woman who presented to the hospital with a chief complaint of sickle cell pain crisis and flu like symptoms. She reported a dry cough, nasal congestion, chills and diarrhea. She had improvement of the symptoms and then began developing back pain and body aches. Past history included asthma and prior mechanical ventilation. Review of systems was negative for fevers, chest pain and shortness of breath. Vital signs showed blood pressure 121/82, heart rate 74, respiratory rate 18, and oxygen saturation 100% on room air. On physical exam, heart was regular and breath sounds were normal. Labs showed white blood cell (WBC) 10.3, hemoglobin 12.9, platelets 150, creatinine 0.7, and troponin negative. Chest x-ray was negative for pneumonia. The patient was admitted for sickle cell pain crisis. 

The inpatient hospital admission was not medically necessary. Sickle cell pain crisis is associated with an increased risk of uncontrolled pain and can also lead to complications such as acute kidney injury and acute chest syndrome. Overall, this patient had an uncomplicated course but patients who present like this are typically managed at the inpatient level of care.
The patient presented with sickle cell vaso-occlusive crisis and required several doses of IV Dilaudid through her hospital stay. While she did not have evidence of sepsis, active acute infection, or acute chest syndrome, she did present with an acute sickle cell pain crisis and was treated with high-dose intravenous opioids. Patients presenting in this manner and treated with intravenous opioids cannot typically be treated at the outpatient level of care due to the increased risk of an adverse event. It is correct that the patient had a relatively short hospital stay and her labs were stable, but at the time of her presentation it would not have been appropriate to manage her at the outpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Stelara
The insurer denied Stelara.
The determination is upheld.

The patient has severe psoriasis (60% body surface area involvement). The patient has tried and failed topical betamethasone cream, calcipotriene cream, and 0.1% triamcinolone cream. The patient is a non-drinker, according to the clinical records.

The Stelara is not medically necessary. The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, Acitretin. Therefore, the requested Stelara is not medically necessary.
Modern dermatology literature [1-4] supports use of the health plan preferred medications as similarly efficacious to the requested Stelara, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommend use of these preferred agents as appropriate for this patient's clinical scenario.
Therefore, as per current medical standards of care, Stelara is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental or Orthodontic Procedure. 
The insurer denied dental services with emergency provider out of area. 
The denial is upheld.

The patient is a  female who presented to the office of a dental provider for treatment of teeth 36 (#19), 46(#30), and a prophylaxis cleaning. Provided for review are previous letters of appeal and denial, a narrative from the provider explaining that the treatment was rendered to address an infection in gum and bone, that the infection was treated in relation to her diabetes and that the treatment had been done on an emergency basis, flight information, health plan codes, and health plan language.
There is a ledger provided stating that teeth numbers 36 (#19) received a class one composite filling, 46(#30) received a class one composite, and that there was a prophylaxis cleaning provided. Not provided are any clinical notes explaining the condition of the patient, blood glucose levels, glycated hemoglobin (HbA1c) percentages, clinical findings, diagnosis, nor any other documentation of the status of the patient at the time of presentation. The procedures listed in the ledger generally do not fall under emergency procedures.
The subject under review is whether dental services with an emergency provider out of the area was medically necessary.

The health plan's determination is upheld.

No, the documentation provided does not support the medical necessity for dental services with emergency provider out of area.
As there are no clinical notes explaining the condition of the patient, blood glucose levels, HbA1c percentages, clinical findings, diagnosis, or any other documentation of the status of the patient at the time of presentation, none of the therapy is supported. Further, the treatments that were provided are not therapies that address any infections in the bone or the periodontium (gums). A prophylaxis is the simplest of cleanings of the teeth, used to address inflammation and not an infection of the tissue nor the bone as the bone is not involved in the cleaning of the teeth. The composite restorations remove decay not involving the pulp of the tooth and are also not considered to be a tooth infection, for which the standard treatment is a root canal.
The services are not supported as medically necessary.