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

Diagnosis: Insomnia

Treatment: Ambien TAB (tablet) 10 milligram (mg)

The insurer denied coverage for Ambien TAB 10 milligram (mg).

The denial is upheld.

This patient was reportedly taking brand name Ambien 10 mg per night for insomnia for 6 years with reported efficacy in combination with Melatonin. She reported anxiety, depression, and difficulty falling asleep. She had tried generic Ambien which is Zolpidem for 3 weeks but had side effects of vivid dreams and did not have efficacy reported. She had past reported medication trials of Trazodone and Nefazodone for sleeping problems without reported efficacy. She reportedly had past trials of antidepressant, and antianxiety medications including Zoloft, Effexor, Celexa, Cymbalta, and also had taken Topamax. 
  
According to Focus: The Lifelong Journal in Psychiatry: Sleep, Sex, and Eating Disorders, there are 3 FDA [Food and Drug Administration] approved non benzodiazepine agonists at the benzodiazepine receptor site on the GABA [Gamma aminobutyric acid] A receptor complex- Zolpidem, Zaleplon, and Eszopiclone. Ramelteon is a DEA (drug enforcement agency] nonscheduled hypnotic medication, and it is approved by the FDA for insomnia characterized by difficulty with sleep onset. It also was reported that the FDA approved benzodiazepine hypnotics including Triazolam, Temazepam, Estazolam, Quazepam, and Flurazepam. Also, Belsomra, (Suvorexant) is a selective dual orexin receptor antagonist FDA approved for insomnia. This patient tried and failed generic Zolpidem but the medical records did not report that she tried and failed or had adverse effects to the other 2 generic FDA approved non benzodiazepine agonists at the benzodiazepine receptor site on the GABA A receptor complex- which were Zaleplon, and Eszopiclone. She reportedly tried generic Zolpidem and had reports of vivid dreams and lack of efficacy but it was not reported that this patient tried other FDA approved medication on formulary to target insomnia. Also, there were no reports of specific evidence showing life threatening, potentially life threatening, or severe reactions to the generic drug, or the reaction was not caused by other factors, or that switching to alternative preferred agents could worsen her condition and that she would require urgent medical care. It appeared that the health care plan acted reasonably and with sound medical judgment. 

Based on the above, the medical necessity for the Ambien TAB 10 milligram (mg) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders-alopecia areata
Treatment: Pharmacy/Prescription Drugs 
The insurer denied Xeljanz. 
The denial is overturned.

The patient is a male with alopecia areata (AA), treated with topical and oral steroids, topical minoxidil and topical Xeljanz. The patient has responded well to oral Xeljanz. The subject under review is the medical necessity for the medication.

The treatment with Xeljanz is medically necessary for this patient.

A wide range of treatments have been used for the management of alopecia areata, most of which are not highly effective. A dependable and safe treatment for extensive disease (totalis or universalis) has yet to be found. Given the rarity of the disease, large randomized controlled trials are extremely difficult.

Tofacitinib (Xeljanz) first demonstrated efficacy in alopecia areata in the article published in 2014. Since then, further case reports have emerged documenting its efficacy, which has led to the very recently published retrospective studies involving adults and adolescents, as well as others. 

Therefore, given the support in current literature and lack of effective therapies for alopecia areata, and this patient's favorable response to therapy, Xeljanz is medically necessary. Withdrawal of this medication for this patient will result in substantial negative impact on disease course.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Medically Supervised Inpatient Detoxification Admission
The insurer denied medically supervised inpatient detoxification admission. 
The health plan's determination is upheld.

The patient is an adult male who presented for detoxification treatment and was medically screened and admitted to inpatient level services for detoxification of alcohol. He reported using up to four pints of vodka daily. He was also using up to $100 worth of cocaine and up to 4 milligrams (mg) of Xanax one to two times per week. His substance use disorders had onset in young adulthood with initial use of alcohol and progression of the disease with subsequent use of cocaine and Xanax. The patient had no history of withdrawal seizures or delirium tremens, but reported inadvertent overdoses and/or blackouts with at least one hospitalization. His referral was prompted by his desire to receive substance abuse treatment in the context of continued use of substances despite participating in multiple past treatment episodes with approximately 14 or more prior treatments with the last detoxification occurring 2 months prior. He presented with mild symptoms of withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 10/67 with sweats, tremor, anxiety and restlessness/agitation together with normal vital signs or mildly elevated blood pressure.

The medically supervised inpatient detoxification admission is not medically necessary for this patient.

The inpatient detoxification treatment and withdrawal management could have been safely and effectively provided with lower-level services. The patient in this case was using alcohol on a continuous daily basis, as well as intermittent use of cocaine and Xanax. Withdrawal symptoms were mild and there was no history of complicated withdrawal from alcohol or drugs, other than a remote history of hospitalization for a blackout. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted admission for inpatient level services. Again, the withdrawal symptoms were not reported to be severe; and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring in keeping with New York State OASAS LOCADTR 3 Criteria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Pharmacy/Prescription Drugs 
The insurer denied Xeljanz. 
The denial is overturned.

The patient is a female who has an undifferentiated connective tissue disease with autoinflammatory disease with features of lung disease, anemia, lymphadenopathy, serositis who has responded to steroids but has not responded to interleukin (IL)-1 and IL-6 inhibition. The patient has been prescribed janus kinase (JAK) inhibition, but this was denied. The subject under review is the medical necessity for Xeljanz for this patient.

The health plan's determination is overturned.

Xeljanz is medically necessary for this patient. The use of this medication in this case is supported by literature. This is a rare condition and there are no Food and Drug Administration (FDA)-approved treatments for this condition. This patient has an autoinflammatory disease that is similar to an interferonopathy. With IL-18 elevated, these conditions respond to medications such as JAK inhibitors. There are studies on other JAK inhibitors working for these types of inflammatory disease. This is supported in the literature as medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left arm and neck stab wounds
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient presented to the hospital emergency department (ED) following an altercation in which she was stabbed in the left arm and neck. Comorbid health conditions included bipolar disorder, schizophrenia, and asthma. Her evaluation in the ED identified a nonbleeding stab wound of the left neck in the submandibular area (zone 3). There was also a 1-centimeter (cm) nonbleeding stab wound to the left arm. The left hand was well perfused. Vital signs included a blood pressure of 135/82 millimeters of mercury (mmHg) and heart rate of 93 beats/minute at the time of presentation. A computed tomography (CT) angiogram identified no major vascular injury. There was a small volume extravasation into the left parotid gland. The patient did require sedation while in the ED due to agitation. The wounds were closed with sutures in the ED.

The patient was further evaluated by the Trauma service and the Oral and Maxillofacial Surgery Service (OMFS). A psychiatry evaluation was also completed. Her diet was advanced and pain management was with oral medications. The patient reported no difficulty breathing during this period of monitoring. The records indicate that she was discharged from the hospital.

At issue is the medical necessity of an inpatient stay.

Acute inpatient admission was not medically necessary. There is no compelling reason why she could not have safely and appropriately received evaluation and treatment at this facility at a lower level of care with subsequent transition to outpatient care rather than admission to inpatient care.

This patient presented to the hospital following an altercation in which she was stabbed in the left neck and left upper arm. Evaluation and clinical work up identified no major vascular injury. She was clinically and hemodynamically stable. While the patient required sedation due to agitation/intoxication, she was stable at presentation and remained so during the period of monitoring.

In this case, the care and treatment provided could have safely been rendered with a lower level of care which would allow for provision of intravenous (IV) fluid, IV pain medication, imaging, and surgical assessment/treatment. The patient remained hemodynamically stable without significant aberration of vital signs and was able to be discharged.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder, Self Harming Behavior.
Treatment: Naltrexone HCl 50mg (milligrams) OR (oral) TABS.

The insurer denied Naltrexone HCl 50mg OR TABS.  The determination is overturned.

The patient was diagnosed with major depressive disorder, recurrent and severe with psychotic features; social anxiety disorder; generalized anxiety disorder; as well as self-injurious behavior. The patient has a history of multiple suicide attempts by hanging, and psychiatric hospitalizations, as well as treatment refractory depression; he failed to respond to trials with Zoloft and Remeron with lithium augmentation combined with cognitive behavioral therapy (CBT) / dialectical behavior therapy (DBT). He failed to benefit from a course of electroconvulsive therapy (ECT). With his last hospitalization, the patient was stabilized on a psychotropic regiment of Abilify, Remeron, Prozac and Naltrexone.

The health plan documents were reviewed including prior authorization criteria and peer reviews, as well as correspondence from the health plan and prescribing physician. Case records/progress notes were reviewed, as submitted.

At issue is the medical necessity of Naltrexone with the current dose of 50 mg per day.

The requested health service/treatment of Naltrexone HCl 50 mg is medically necessary for this patient.

The use of Naltrexone in this case is consistent with its use in clinical practice and prevailing standards of care with regard to the clinical approach to treating self-harming or self-injurious behavior. The prescribing physician notes that Naltrexone was effective in decreasing the patient's urges to self-harm, and resulted in improved mood prescribed together with Abilify 30 mg, Prozac 40 mg and Remeron 30 mg. Additionally, the patient was noted to have stabilized on this medication regimen while hospitalized including the use of Naltrexone.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer/Colon Cancer
Treatment: Inpatient Hospital
The health plan denied the inpatient stay as not medically necessary. 
The health plan's determination is upheld.

This is a female with metastatic colon cancer and a history of breast cancer. The patient was admitted with severe fatigue and progressive shortness of breath with hypoxia (pulse oximetry 88% (percent) on room air) with failure to thrive and pain at the site of a decubitus ulcer. Of note, the patient was not compliant with her home oxygen. The patient received oxygen and pulmonary toilet. She received a short course of steroids. Her analgesic regimen was titrated (Oxycodone adjusted, Lyrica added) and she received intravenous (IV) fluids. The patient also received supportive care and electrolyte management. The patient received physical therapy and occupational therapy. The patient was discharged home; the medical necessity of the inpatient care is under review.

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

This patient was admitted with failure to thrive and without new complaints requiring inpatient care. The patient had long-standing, mild hypoxemia on room air but was not compliant with her previously prescribed oxygen. She oxygenated well with 2 liters by nasal cannula. She received intervention for her pulmonary complaints with oxygen, steroids, and bronchodilators; these did not require inpatient care.
The patient's pain was addressed with oral therapies that did not require inpatient care.
Finally, due to her failure to thrive, she received electrolyte replacement and rehabilitative services that did not require the inpatient level of care.
Support for inpatient care in this patient's clinical scenario cannot be found in the supplied guidelines, UpToDate, the National Comprehensive Cancer Network (NCCN), nor in the peer-reviewed literature. For these reasons, medical necessity cannot be established for this inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neoplasm of Breast.

Treatment 78815 positron emission tomography (PET) with concurrently acquired computed tomography (CT).

The insurer denied coverage for 78815 positron emission tomography (PET) with concurrently acquired computed tomography (CT).

The denial is overturned.

The patient is a is diagnosed with stage IIb (stage) PT2N1A (metastasized) breast cancer.  She was estrogen receptor positive (ER+), progesterone receptor positive (PR+), and human epidermal growth receptor 2 negative (HER2-).  The patient was in the office for a follow-up.  The patient was status post left total mastectomy and DIEP (deep inferior epigastric perforator) reconstruction.  The patient had left infra-mammary chest wall tenderness for a week with no known injury.  The patient underwent a positron emission tomography computed tomography scan due to recent persistent chest pain.

The 78815 positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation, correction, and anatomical localization imaging; skull base to mid-thigh is considered medically necessary for this patient.

She has completed treatment after initial diagnosis. She now has persistent chest wall tenderness which is concerning for local recurrence. The treating physician has requested a PET/CT to assess for recurrence. 

Per National Comprehensive Cancer Network (NCCN) Guidelines Version 8.2021 for Invasive Breast Cancer, the use of PET/CT is described as optional but acceptable to evaluate for recurrent/metastatic disease. Groheux, et al has shown that PET is useful for assessing both local/reginal and distant metastases for patients with locally advanced stages, including stage IIB that includes this patient's stage. The scan is appropriate per guidelines and is medically necessary.

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

Based on the above, the medical necessity for the78815 positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation, correction, and anatomical localization imaging; skull base to mid thigh is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic Lung Cancer and Hepatitis B

Treatment Tagrisso

The insurer denied coverage for Tagrisso

The denial is overturned

According to the clinical documentation provided for review, the treating provider is requesting plan approval for treatment with Tagrisso (osimertinib). The patient presents with a past medical history (PMH) of metastatic lung cancer and hepatitis B. Per the Office Visit Note, the patient's lung cancer remained stable on the current medications. The patient has been on Tagrisso (osimertinib) 80 milligram (mg) for a few months. This is a continuation request. The patient is currently taking Tagrisso (osimertinib). The patient is stable on the request regimen. The patient is free of adverse side effects. The patient has lung cancer with metastasis to the brain and bone. The treating provider prescribed continuation treatment with Tagrisso (osimertinib). 

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

The reason for not certifying is misapplied, since this is not an adjuvant, but a metastatic. 
Tagrisso considered medically necessary for this patient.

The treating provider prescribed continuation treatment with Tagrisso (osimertinib). The reason for not certifying is misapplied, since this is not an adjuvant, but a metastatic situation. This is an individual with metastatic lung cancer that is being kept under control by Tagrisso. It is not a case of adjuvant therapy. As such, Tarisso would be needed to continue as long as cancer remains stable and under control, which it currently is. Switching medications would jeopardize the patient's clinical stability. Therefore, the request for Tagrisso (osimertinib) is approved and medically necessary for this patient.
                                                    
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Tagrisso is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Postinfectious Encephalitis

Treatment: Gammaplex

The insurer denied coverage for Gammaplex.

The denial is upheld. 

This is a patient with encephalopathy. Her diagnoses include post-infectious encephalitis, tic disorder, obsessive-compulsive disorder (OCD), and avoidant/restrictive food intake disorder (ARFID). The request is for Gammaplex.

As per Swedo, et al (2004), "Systematic observations of children with OCD revealed that, although the majority of children had a gradual onset of symptoms over several weeks to months, a subgroup of the patients experienced an explosive 'overnight' onset of obsessions and compulsions followed by a relapsing-remitting symptom course.5 Closer observation revealed that the neuropsychiatric symptom relapses frequently occurred after episodes of streptococcal pharyngitis or scarlet fever. These findings in OCD closely paralleled those from a series of investigations of Sydenham's chorea. [6] In those studies, 65% (percent) to 100% of children with Sydenham's chorea were noted to have obsessive-compulsive symptoms, typically presenting 2 to 4 weeks before the onset of the adventitious movements and peaking in severity simultaneously with the chorea. [6]"

As per Williams, et al (2016), a randomized trial of intravenous immunoglobulin (IVIG) in 35 children who met criteria for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and moderate to severe OCD failed to demonstrate a benefit of IVIG over placebo. 

Based on the review of the medical literature, the evidence support for the treatment of IVIG for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) diagnosis is lacking. Thus, the requested IVIG is not considered medically necessary and/or standard of care for this patient. The medical literature does not recommend immune therapy for PANDAS.                                                    

The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. In this case, there is a lack of robust studies which have consistently shown that immune globulin is effective for the patient's condition.      

Therefore, Gammaplex for the treatment of encephalopathy would not be considered medically necessary for this patient.

The insurer's denial of coverage for Gammaplex for the treatment of encephalopathy is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung cancer screening
Treatment: Computed Tomography (CT) Scan (71271)
The insurer denied the Computed Tomography (CT) Scan (71271).
The denial is upheld.

The patient in this case is a woman. Records indicate that she has a half-pack per day smoking history for several decades, and she was exposed to dust at the time of the World Trade Center bombing.  A CT (computed tomography) chest without contrast was obtained.

No, the Computed Tomography (CT) Scan (71271) is not medically necessary.
This patient has a 17 pack year smoking history.  Current guidelines only support low-dose CT (computed tomography) chest for lung cancer screening if the patient has at least a 20 pack year history. There is no evidence supporting this testing for those with less than a 20 pack year smoking history.  While this patient was exposed to toxic fumes at the time of the World Trade Center bombing, the impact of that or other toxic fume exposures on the potential benefit associated with low-dose CT (computed tomography) chest screening for lung cancer remains undefined.  The CT (computed tomography) chest in this case is not medically necessary based on current consensus recommendations.

Yes, the medical records and accompanying information are sufficient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Sleep Apnea.
Treatment: E0486 (oral device/appliance).

The insurer denied the E0486 (oral device/appliance).  The denial is overturned.

The patient is a male. The patient has severe sleep apnea. He cannot tolerate a CPAP (continuous positive airway pressure). He tried an Inspire nerve implant device but was unsuccessful with it alone. An oral appliance alone also was unsuccessful. Prior denial was because reviewer stated the Inspire alone was successful, so the oral appliance was not needed.

Yes, the oral appliance is medically necessary.

Per the letter from the provider, the sleep studies indicated that the use of just the Inspire alone was not effective enough in reducing the patient's apneas. The use of just the oral appliance alone also was not effective enough in the reduction of his apneas. However, combined therapy with the use of both the Inspire and the oral appliance at the same time was very effective in reducing the patient's apneas. Therefore, the oral appliance is medically necessary for the health of the patient.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.