Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Stage 2 adenocarcinoma of the lung.
Treatment:  Circulating tumor DNA test/liquid biopsy.

The insurer denied coverage for Circulating tumor DNA test/liquid biopsy.  The denial is overturned.

This patient is a female with stage 2 adenocarcinoma of the lung initially diagnosed.  The patient was staged T3N1 M0 and had an EGFR mutation.  The patient received 4 cycles of Cis Platin/Pemetrexed chemotherapy.  The patient's computed tomography (CT) scan showed 2 solid nodules, and PET scan revealed multiple positive lymph node involvements, and mild increased FDG uptake.  The patient was noted to have bilateral supraclavicular lymph nodes consistent with progression and numerous tiny pulmonary nodules.  The patient's ultrasound guided biopsy of the right supraclavicular nodes revealed on pathology that it was adenocarcinoma.  Molecular studies were sent off and genomic findings were positive for exon-19 deletion, ERBB amplification and negative for KRAS, BRAF,MET, RET ERBB2, ROS1. 

Molecular testing when lung cancer patients progress, especially those with EGFR mutations, ALK, ROS1 and NTRK and now others, create resistance to tyrosine kinase inhibitor (TKI) medications.  Many mutations arise with these tumors along the course of the disease with chemotherapy and targeted therapies.  Studies support that liquid biopsies and tissue biopsies can test and show discordant mutations and results that are useful determine the best target treatment options for the patient with selective medications.  Therefore, the requested treatment was likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of Circulating tumor DNA test/liquid biopsy should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Possible coronary artery disease.
Treatment:  Myocardial Perfusion Imaging (MPI), procedure code 78452.

The insurer denied coverage for Myocardial Perfusion Imaging (MPI), procedure code 78452.  The denial is overturned.

This patient is a male with a medical history notable for a splenic mass.  He had reported lower chest/upper epigastric discomfort for the several months, with shortness of breath on exertion.  He was referred for pre-operative cardiac risk stratification prior to spleen surgery for removal of a large mass.  Results of an exercise stress test showed a 1 mm ST-segment depression.  Per an appeal letter from the patient's cardiologist, the patient has cardiac risk factors of male gender, advanced age and active smoking status.  He was symptomatic, and there is concern for underlying coronary artery disease.  Per his cardiologist, the patient requires a stress nuclear scan, especially due to his symptoms, risk factors and abnormal test results, to evaluate his pre-op status.

Nuclear perfusion stress testing is appropriate and medically necessary.  The patient had undergone attempted exercise stress testing, which was equivocal based on the non-diagnostic EKG findings.  Though neither normal nor abnormal, further evaluation is appropriate and indicated, irrespective of his candidacy for non-cardiac surgery.  The sensitivity of perfusion imaging over exercise stress testing alone is improved, with sensitivity of 88-90% for nuclear perfusion stress testing vs 75-80% for exercise EKG stress testing, in detecting the presence of obstructive coronary artery disease.  Given his risk factors, symptoms, equivocal exercise EKG treadmill stress test, and intermediate pre-test probability for obstructive coronary artery disease, nuclear perfusion stress testing is medically necessary and appropriate in this particular clinical scenario. 

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

The carrier's denial of coverage for Myocardial Perfusion Imaging (MPI), procedure code 78452 is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a male with medical history of Crohn's disease with ileostomy in the right lower quadrant, Billroth II loop gastrojejunostomy to treat duodenal Crohn's disease, gastric ulcers, and gastric reflux. He was transferred to the emergency department from another hospital with concern for pancreatitis. Vital signs were unremarkable. Physical examination was notable for soft, nontender, nondistended abdomen with bowel sounds present. He was treated with intravenous fluids and oral potassium. 

The following day labs showed negative stool culture and Clostridioides difficile toxin. The recommendation was continued intravenous fluids with monitoring of electrolytes and repletion as needed, assessment of erythrocyte sedimentation rate and C-reactive protein, clear liquids and nothing by mouth (NPO) after midnight for esophagogastroduodenoscopy, and magnetic resonance cholangiopancreatography to further assess the biliary tree and pancreatic duct.

Esophagogastroduodenoscopy showed normal esophagus, inflammation (congestion, erythema, and erosion) of the entire stomach (assessed in the discharge summary as multiple ulcerations consistent with Crohn's disease), and normal jejunum. The recommendation was for proton pump inhibitor twice daily and magnetic resonance cholangiopancreatography to evaluate pancreatitis. 

The following day he reported improvement and labs were unremarkable. He was discharged on pantoprazole, with a plan for Gastroenterology follow-up. At issue is the medical necessity for the inpatient stay.

The inpatient stay is not supported as medically necessary. The patient had elevated lipase but not imaging consistent with acute pancreatitis [1-3]. By the second day, he had no significant abdominal pain, and he did not have volume depletion or hypotension [1-3]. Imaging did not show a dilated common bile duct, biliary obstruction, or any significant pancreatic abnormality, and there was no diagnosis of complicated choledocholithiasis, ascending cholangitis, hepatic abscess, active gastrointestinal bleeding, peritonitis, abscess, fistula, or sepsis, which would require the inpatient level of care [4-6].  There was a lack of hemodynamic instability, organ failure, or other sequelae to justify the inpatient stay. The interventions performed, including labs, intravenous fluids, monitoring, imaging, endoscopy, and Gastroenterology consultation could have been performed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Problems.
Treatment:  Crown (D2740) for tooth #18.
The insurer denied the crown (D2740) for tooth #18.  The health plan's determination is overturned. 

The patient is a male who presents for evaluation and treatment of tooth # (number) 18.  Provided for review are previous letters of appeal and denial, multiple periapical and bite-wing radiographic images, one page of American Diabetes Association (ADA) claim forms, and health plan language.  In question is the medical necessity of the planned treatment of porcelain ceramic crown (D2740) for tooth #18.

The Crown placement for tooth #18 is medically necessary for this patient.  The provided clinical and radiographic photos show that the crown has been severely reduced either through occlusal forces or fracture that has resulted in exposure of the underlying metal with porcelain only covering 1/3 of the metal substructure, hence the crown has failed.  As the crown has failed, it requires replacement.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Asthma.
Treatment: Inpatient admission.

Insurer denied the inpatient admission.  The denial is overturned. 

Yes, the Inpatient admission was medically necessary.

The patient is a male.  He presented with shortness of breath and wheezing.  He was found to have asthma exacerbation.  The patient was treated with IV steroids, duonebs, and supplemental oxygen.  The patient also was seen by pulmonary consult for treatment resistant asthma exacerbation, cardiology consult for abnormal EKG (electrocardiogram).  

The patient had failed home treatment for asthma.  In the emergency room the patient was tachypneic and hypoxic with ambulation.  Despite receiving multiple nebulizations, the patient continued to have respiratory distress and wheezing.  The patient was started on IV steroids for asthma exacerbation.  

The patient had continued wheezing and shortness of breath.  Additionally, the patient had abnormal EKG and required cardiology consult and work up.  Pulmonary consultation was also obtained, and recommendation was made for prolonged IV steroids. 

The patient failed outpatient therapy, as well as emergency room therapy, and he had moderate to severe asthma exacerbation with new onset tachypnea, hypoxia with treatment-resistant exacerbation.  He required prolonged IV steroids, as well as cardiac arrhythmias requiring inpatient cardiac work up.  Therefore, the acute in-hospital stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Mental Health/ Depression.
Treatment:  Mental Health Outpatient. 

The insurer denied transcranial magnetic stimulation (TMS) therapy.  The denial is overturned in whole.

The patient diagnosed with major depressive disorder, severe without psychotic features and co-morbid generalized anxiety disorder.  The patient has a documented history of multiple medication treatments for depression including treatment with more than two disparate classes of medication and at least four or more trials with antidepressant medications Selective Serotonin Reuptake Inhibitor (SSRIs,) serotonin norepinephrine reuptake inhibitor (SNRI), and Wellbutrin, as well as combination treatment with Klonopin and Wellbutrin.

Yes, the requested health service/treatment of Transcranial Magnetic Stimulation (TMS) is medically necessary for this patient.

Repetitive TMS therapy as a primary or adjunctive therapy for treatment of major depression has generally been evaluated in patients who have treatment refractory or pharmaco-resistant depression, as defined by one or more, antidepressant medication treatment failures with or without augmentation, and with or without psychotherapy, especially cognitive behavioral therapy.  Transcranial magnetic stimulation therapy, as applied in major depression, is considered to be a safe treatment by the Food and Drug Administration (FDA).  The data as reflected in peer reviewed medical literature supports this assertion.

Specifically, when treatments with antidepressant medication with or without augmentation, electroconvulsive therapy, and/or psychotherapy (especially cognitive behavioral therapy) have failed, then TMS is an appropriate treatment for major depressive disorder.  This assertion is noted in the American Psychiatric Association Practice Guideline for the assessment and treatment of major depressive disorder, referenced below, and consistent with the scientific literature pertaining to TMS and its application to depressive disorder.

Thus, the proposed treatment of recurrent major depressive disorder using TMS therapy with a clinically appropriate number of sessions of adequate dose including a maintenance taper is medically necessary in this case.  The usual number of TMS treatment may vary depending on the individual treatment plan and need for booster sessions.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal muscular atrophy type III.
Treatment: Spinraza (nusinersen).
The insurer denied the Spinraza (nusinersen).
The denial is overturned. 

The patient is a female with spinal muscular atrophy type III.  Genetic testing showed she had no copies of SMN1 and more than four copies of SMN2. 

Yes, the treatment with Spinraza is medically necessary.

There are high quality clinical trials, albeit limited by subject number, that support the safety and efficacy of Nusinersen in adults with late onset SMA type-3 (Walter et al., 2019; Veerapandiyan et al., 2020; Moshe-Lilie et al., 2020; Hagenacker et al., 2020).  These studies taken together breech the threshold required to support the use of Nusinersen in this clinical context, as this is a rare condition and large multi-center, randomized, prospective studies are unlikely to be completed in a reasonable time.  Moreover, the scientific validity for treating an infant with this medication is no different in adult onset. Finally, there is no reasonable alternative treatment for these patients who has a progressive neurological condition that will results in irreversible neurological disability if untreated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional-PKU.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied the 60mg Palynziq as not medically necessary.
The denial was upheld in whole.

This patient has classic phenylketonuria (PKU) who has high level of phenylalanine (phe) in blood and treated with dietary adjustment and Palynziq (Pegvaliase) which is a medication for PKU that helps reduce phe levels. The Palynziq dose was 40 mg daily and per the notes of providers "patient had not demonstrated efficacy response at 40 mg per day", so the provider requested reimbursement for a higher dose of Palynziq (60 mg daily). 

Palynziq is considered to be ineffective for this patient and is not medically necessary. The patient has not demonstrated at least 20% reduction over 24 weeks. The phe level (11.78 mg/dL) does not significantly differ from the previous level on  (11.7 mg/dL). Therefore Palynziq proved to be ineffective in this patient. Continuation of Palynziq at any dose would be ineffective in this patient and therefore not medically necessary.
The FDA package insert gives guidelines on discontinuation: "Discontinue Palynziq in patients who have not achieved a response (at least a 20% reduction in blood phenylalanine concentration from pre-treatment baseline or a blood phenylalanine concentration less than or equal to 600 micromol/L) after 16 weeks of continuous treatment with the maximum dosage of 40 mg once daily." This is based on the FDA-approval of Palynziq's efficacy and should be the main source of guidance. Furthermore, review of studies published in Longo et al. (2019) showed that increasing Palynziq's dose beyond 40 mg has shown efficacy in some but not all studies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crossbite
Treatment: Braces
The insurer denied the braces. 
The denial is upheld. 

The patient is a male. The request is for orthodontic benefits and monthly visits.

No, the braces and monthly visit x12 are not medically necessary.  The patient's handicapping index score was ten, which is much less than the 26 threshold. There is no anterior crossbite in the photos. There is no medical necessity in this case. The provider stated there was a crossbite, but it is not evident in the clear photos presented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pediatric Growth Hormone Deficiency.
Treatment:  Norditropin 0.3 mg per week.

The insurer denied the Norditropin 0.3 mg per week.  The denial is overturned.

The patient is a male diagnosed with GHD (growth hormone deficiency).  This request is for Norditropin.  He has ADHD (attention deficit hyperactivity disorder).  He has been on GH (growth hormone) therapy.  His GH stimulation test with arginine and clonidine peaked at 5.96.  His MRI was normal. 

The denial was based on the fact that the requested dose is 0.3 mg per week.  This is higher than the policy approvable dose of 0.24 mg per kilogram per week.

Yes, the Norditropin 0.3 mg per week is medically necessary.

The patient is a continuing-therapy patient, who has benefited from growth hormone.  The dose of 0.3 mg per kilogram per week is appropriate for patients who are in puberty.  This patient is in puberty.  The request is consistent with generally accepted standards of medical and is, therefore, medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure 
Treatment: Skilled Nursing Facility 

The insurer denied the skilled nursing facility stay. The determination is upheld. 

The patient has a past medical history significant for hypertension, atrial fibrillation, cardiomyopathy, dementia and congestive heart failure. She was admitted to the hospital for a congestive heart failure exacerbation and was subsequently discharged to skilled care for further therapeutic services. Services were denied as not medically necessary. At issue is whether the continued skilled nursing facility stay was medically necessary. 

The requested health service of skilled nursing facility stay is not medically necessary for this patient. This patient had multiple medical problems. She was admitted to the hospital secondary to shortness of breath and found to be in congestive heart failure. She was treated acutely in the hospital for congestive heart failure and subsequently referred to skilled services for rehabilitation. She had multiple services including physical therapy and occupational therapy services. She was seen by her attending physician on a monthly basis, for her other medical problems. However, none of these other medical problems required inpatient skilled services such as complex wound care or intravenous antibiotic treatment. The patient was mainly in skilled services for rehabilitation. She did previously reside at home. The services were to increase her strength and mobility to her previous level in hopes of returning home. There is a notation in a physical therapy report that the anticipated discharge plan was that the patient was going to reside in this facility as long-term care. She did make some gains in her therapies, however, it was limited. In most activities, she went from moderate assist/maximal assist to a moderate assist. Therefore, ongoing inpatient skilled services would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Inpatient Hospital. 
The insurer denied the inpatient stay. 
The denial is upheld in whole.

The patient is a male with past medical history of hypertension, hyperlipidemia, morbid obesity, coronary artery disease, who presented to the emergency department with left sided weakness and numbness in addition to left-sided chest pressure that began 1 hour prior to presentation.
On presentation, he was afebrile with blood pressure (BP) 129/73, heart rate 74, respiratory rate 20, and with oxygen saturation 97% on room air. Exam performed by neurology on presentation was noted to be inconsistent with good strength throughout and with normal speech and with possible left sided hemianesthesia involving the face, arm, and leg. Labs resulted with complete blood count and comprehensive metabolic panel within normal limits and international normalized ratio (INR) 1.22. Computed tomography (CT) of the head showed no evidence of acute hemorrhage or other acute process. Duplex of the lower extremities showed no evidence of acute deep vein thrombosis. Electrocardiogram (EKG) showed no evidence of acute ischemia or arrhythmia. Neurology impression was that the patient had a possible right cerebral cerebrovascular accident and that the patient refused tissue plasminogen activator. The patient was admitted with plans for neurologic checks, further imaging, and physical therapy. Physical therapy saw the patient with assessment that he had 4/5 weakness throughout without clear focal weakness. He was able to walk 30 feet but then declined to walk further in the setting of knee pain. The patient subsequently left against medical advice on the same day.
The issue in question is the medical necessity for the inpatient stay.

No, inpatient stay was not medically necessary. This patient presented with possible cerebrovascular accident. His neurologic exam was noted to be inconsistent on presentation per neurology and he did not clearly have a cerebrovascular accident, with physical therapy also noting that he did not have clear focal deficits and was able to ambulate 30 feet. In the absence of obvious cerebrovascular accident, concomitant coronary ischemia, arrhythmia requiring inpatient management, or other acute issue requiring hospital level services, this patient with inconsistent neurologic exam could have been safely cared for at a lower level of care status. An inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autoimmune Encephalopathy (P.A.N.S)
Treatment: Immune globulin injection
The insurer denied the Immune globulin injection. 
The denial is upheld. 

The patient is a male with stated autoimmune infectious encephalitis, triggered by systemic mycoplasma and clinical Bartonella and Babesia. His symptoms include severe debilitating anxiety, irritability, difficulties with executive functioning, and emotional lability. According to a Nurse Practitioner note, the patient has failed less aggressive non-invasive therapies including steroids, antibiotics, and many SSRI (selective serotonin reuptake inhibitors) and other mood stabilizing medications without success. The patient had undergone two IVIG (intravenous immunoglobulin) infusions and noted improved cognition, socialization, and less anxiety. The patient was responding positively to this therapy, and NP recommended that he continue receiving it. 

No, the immune globulin injection is not medically necessary. 

The medical records do not support the diagnosis of autoimmune encephalitis (AE). According to the AE criteria, all three of the following are required for the diagnosis:
1) Acute to subacute neurocognitive or psychiatric symptoms,
2) New focal CNS (central nervous system) findings, and/or seizures, and/or abnormal CSF (cerebrospinal fluid) count, and/or abnormal magnetic resonance image (MRI), and
3) Exclusion of alternative cause. (1)

In the patient's case, there are no focal CNS findings, and/or seizures, and/or abnormal CSF count, and/or abnormal MRI. Additionally, alternative causes, such as rheumatological diseases or toxic exposures are not documented to have been ruled out. 

Additionally, the reported positive response to IVIG is not documented or substantiated in any details. The provider does not document any neuropsychological and cognitive scales, and no anxiety scales, before and after the IVIG treatment. Similarly, the responses to prior immunomodulating treatments such as steroids are not quantified as well. 

Also, the patient was seen by a pediatric neurologist and the diagnoses of PANS and autoimmune encephalopathy were ruled out. The diagnosis of PRES by DelSignore is unsubstantiated (this condition lasts a few weeks only, and requires MRI confirmation), and IVIG is not an acceptable treatment of PRES.