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

Diagnosis: Pseudotumor cerebri.
Treatment: Outpatient Procedure (ambulatory surgery) 37238 x 1, and 37239 x 1 (Venous stent).

The insurer denied Outpatient Procedure (ambulatory surgery) 37238 x 1, and 37239 x 1 (Venous stent).  The denial is overturned.

The patient is an adult female with morbid obesity after liver transplant and pseudotumor cerebri. The patient is recommended venous sinus stenting for pseudotumor.

The requested venous stent would be considered to be medically necessary.

This has been well-studied and supported in the literature as an appropriate management option for patients with pseudotumor. The literature also supports its use.

"VSS [Venous Sinus Stenting] stenting could be a treatment tool for the acute presentation of IIH [idiopathic intracranial hypertension] with severe symptoms and VSS [Venous Sinus Stenting] plus an elevated trans-stenotic pressure gradient.  However, in some cases, additional surgical treatment may be necessary." (2)

"In medically refractive or fulminant cases, optic nerve sheath fenestration, CSF [cerebrospinal fluid] diversion, and venous sinus stenting, have been successfully implemented." (1)
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Plaque Psoriasis. 
Treatment: Taltz autoinjector (3 pack) 80mg/ ml (milligrams/milliliter). 

The insurer denied: Taltz autoinjector (3 pack) 80mg/ ml (milligrams/milliliter). 
The denial is upheld. 

The member is an adult female with psoriasis vulgaris of the scalp and back who has failed Humira, Cosentyx, Cimzia, and Tremfya, for whom Taltz is requested. She has also failed topical steroids and calcineurin inhibitors. 

The health plan should not cover the proposed treatment. 
The formulary offers drugs of classes the patient has not yet failed (Otezla, Stelara), whereas Taltz is an IL17 inhibitor and she has failed Cosentyx (also an IL17 inhibitor). Also, there are no contraindications documented for the use of the formulary drugs in classes she has not failed yet. There is no guarantee that any of the medications would work for this member who has refractory psoriasis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, coronary artery disease and osteoporosis.
Treatment: Personal care worker (PCW) 8 hours per day, 7 days a week.
The insurer denied coverage for PCW 8 hours per day, 7 days a week.
The denial is upheld.

This is an adult female with chronic medical problems including hypertension, coronary artery disease and osteoporosis. She lives alone is a 1-bedroom apartment. The insurer approved PCW 6 hours/day, 7 days/week for a total of 42 hours. Under review is the requested increase in PCW to 8 hours/day, 7 days/week.  

The most recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is described as "modified independent." She is "able to make needs known and summon help in case of an emergency." The patient requires extensive assistance for bathing, lower body dressing and toilet transfer/use. She is frequently incontinent of bladder and infrequently incontinent of bowel. Limited assistance is required for personal hygiene and upper body dressing. She is independent with bed mobility and walks "with a slow and unsteady gait and use of an assist device (walker)." This physician would agree the patient may require additional PCW time for monitoring. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. In addition, the patient's functional ability is much the same as documented in the prior UAS report. 

Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the currently authorized PCW services 6 hours/day, 7 days/week for a total of 42 hours/week.  

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

The insurer's denial of coverage for personal care worker (PCW) 8 hours per day, 7 days a week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genetic Diseases - Down's syndrome
Treatment: Nursing Services (including Private Duty Nursing) -Consumer Directed Personal Care Services (CDPAS), 40 hours per week
The health plan denied 40 hours of Consumer Directed Personal Care Services as not medically necessary. 
The health plan's determination has been overturned.

The patient is a male with moderate intellectual disability, Down's Syndrome, and autism. The patient's primary care physician wrote a letter of medical necessity stating that the patient is completely dependent with activities of daily living (ADL) and instrumental activities of daily living (IADL), and his mother is his current caregiver. The patient underwent an assessment finding the patient with severely impaired cognition and memory problems, noting that the patient was nonverbal, and his mother makes all decisions on his behalf. He has adequate hearing and vision. He was assessed to require total dependence with the tasks of meal preparation, housework, medications, and shopping. The patient was assessed at requiring minimal assistance with the task of bathing and maximal assistance with personal hygiene, dressing his upper body, dressing his lower body, and walking. He was assessed to need supervision with walking and locomotion, supervision with toilet transfers, maximal assistance with toilet use, and supervision with bed mobility and eating. He is noted to be high risk of aspiration due to eating too fast and not chewing completely. He is bladder incontinent and bowel incontinent.

At issue is the medical necessity of T1019-Consumer Directed Personal Care Services (CDPAS), 40 hours per week.

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

The requested health service/treatment of T1019-Consumer Directed Personal Care Services (CDPAS), 40 hours per week is medically necessary for this patient.

The patient has an intellectual disability and is highly dependent on his caregiver for assistance with ADLs and IADLs. Based on the assessment, the patient requires maximal assistance to total dependence on multiple tasks including housework, meal preparation, bathing, dressing his upper/lower body, and toilet use. He is incontinent and requires cueing to perform tasks as well. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, T1019-Consumer Directed Personal Care Services (CDPAS), 40 hours per week is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

This case involves a woman who was sent to the emergency department by her ophthalmologist due to headaches for one week. The patient was experiencing blurry right-eye vision and diplopia. The patient denied any fevers or chills; no chest pain, numbness, or paresthesias. The ophthalmologist wanted to rule out Horner syndrome and sent the patient to the emergency room (ER) for brain magnetic resonance imaging (MRI). Vital signs on arrival are stable, including blood pressure of 142/63. On exam, the patient appears well nourished and awake-oriented. Eyes were noted to have right eyelid ptosis, but there were reactive to light. The rest of the exam was unremarkable.
Laboratory studies revealed a normal complete blood count (CBC) and an erythrocyte sedimentation rate (ESR) that was slightly elevated at 34.
The emergency department (ED) requested a neurology consultation and admitted the patient to the hospital. The team ordered a magnetic resonance imaging (MRI) of the brain.

Based on the provided documentation, the inpatient hospital admission was not medically necessary. The patient was sent to the emergency department to obtain an MRI, not to get admitted. The MRI conclusively ruled out an acute stroke as the cause of the patient's cranial nerve III palsy. This hospitalization was essentially a stroke rule out. Based on those facts, admission to inpatient care is not indicated.  A lower level of care was appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Fibroids.
Treatment: Radiofrequency ablation.
The insurer denied radiofrequency ablation. 
The health plan's determination is upheld.

The patient is a female. The patient was seen in the office regarding bladder pressure. The patient noted heavy menstrual bleeding as well as a history of a fibroid measuring 9.3 centimeters (cm) in the largest dimension on ultrasound. Her past medical history is also remarkable for degenerative spine arthritis, a history of cataracts, latent tuberculosis, obesity, PCOS (polycystic ovary syndrome), and psoriasis. The plan is for magnetic resonance imaging (MRI) of the pelvis and the patient was educated regarding transcervical radiofrequency ablation. 

No data is demonstrating that the requested radiofrequency ablation is likely to be more beneficial than the standard of care options.
This technology, while FDA-approved, has not been evaluated in prospective, comparative clinical trials. There are single-arm trials (which are essentially case series) demonstrating the technology to be tolerable and to have myoma volume reductions, and even improve symptoms. There is also cost data comparing it to other standard-of-care options. However, no trial data is comparing this technology to standard-of-care options such as medications or other conservative procedural options, such as uterine artery embolization or myomectomy.
For transcervical radiofrequency ablation of fibroids, there is simply no comparative data upon which to conclude that it is comparable to the standard of care options. A key passage from the pivotal trial data is this: "However, randomized controlled trials, as well as comparative studies, are still lacking. Randomized controlled trials comparing the Sonata System with the already established treatment methods could help to define the future value of the Sonata System as a therapy alternative for uterine myomas." It is noted that in the latest update of the American College of Obstetricians and Gynecologists (ACOG) guidelines regarding symptomatically fibroids, radiofrequency ablation, in general, is noted to be an option. However, the guidelines go on to discuss how laparoscopically-guided ablation has the most data and does not mention transcervical delivery as a reasonable option. Additionally, this patient's childbearing desires are not addressed in the progress note, which is a key counseling point for this technology per ACOG guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Fibroids.
Treatment: Radiofrequency ablation.
The insurer denied radiofrequency ablation. 
The health plan's determination is overturned.

The patient is a female who has been under the care of her gynecologist for a four-year history of symptomatic uterine fibroids. She reports bleeding 6 days a month, where at least 3 of those days she soaks a pad every one to two hours which represents a severe level of menorrhagia. She also has bulk symptoms, endorsing bladder pressure, difficulty emptying her bladder, increasing waistline, and pelvic pain. She has failed oral contraceptive pills as a conservative treatment for this problem and has requested a more aggressive option. Her work-up has shown her to have a dominant intramural fibroid measuring 9.3 x 7.3 x 8.1 centimeters, which is a very large uterine lesion. 

Radiofrequency ablation is likely to be more beneficial than any standard treatment or treatment for the insured's life-threatening or disabling condition or disease. 
The radiofrequency ablation would be beneficial for this patient, and she meets the established criteria for the procedure. This patient demonstrates classic symptoms of fibroids, including heavy menstrual bleeding, bladder pressure, and discomfort from bulk. Her bleeding has been severe enough to compromise her daily activities. Her history indicates that she would have an excellent chance of success with this procedure. Radiofrequency ablation does not carry the same abdominal surgical risks as myomectomy or hysterectomy (infection, abscess, organ injury, vascular injury), so there is no reason to suspect that radiofrequency ablation has a higher risk than those more traditional therapies. A recent American College of Obstetricians and Gynecologists (ACOG) bulletin about fibroids specifically states that this technology is appropriate. It is appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Fibroids.
Treatment: Radiofrequency ablation.
The insurer denied radiofrequency ablation. 
The health plan's determination is upheld.

The patient is a female with heavy menstrual bleeding and uterine fibroids. She was diagnosed with uterine fibroids and complains of abnormal uterine bleeding, pelvic pressure, painful intercourse, and frequent urination for two years. Magnetic resonance imaging (MRI) showed a 10.5 centimeter (cm) anterior intramural fibroid and it had increased in size since then. She was counseled on options for her fibroids and opted for a radiofrequency fibroid ablation. 

The proposed Radiofrequency Ablation Treatment is not likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease.

There are a variety of treatment options for leiomyomas, including expectant, medical, interventional, and surgical therapies. Although evidence exists regarding outcomes with specific therapies, comparative effectiveness data are lacking for leiomyoma management options. When considering treatment options, patient-specific symptoms and severity should be addressed. If a patient describes symptoms that are neither severe nor debilitating, expectant management may be appropriate. Medical treatments primarily address bleeding symptoms. Procedural interventions and surgical approaches treat bulk symptoms by decreasing uterine mass. While radiofrequency ablation is a treatment for uterine fibroids, it is not more beneficial than any other treatment and in fact, would not be considered the gold standard for the treatment of uterine fibroids. The current gold standard for surgical intervention is myomectomy if uterine preservation is desired or hysterectomy if uterine preservation is not desired.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Nausea and Vomiting.
Treatment: Inpatient Hospital Admission.
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

This is an adult female patient with cannabinoid hyperemesis syndrome, irritable bowel syndrome, gluten intolerance, and vitamin D deficiency, who presented with abdominal pain, nausea, and vomiting.  

The patient was treated with famotidine, Maalox, Reglan, and Ringer's Lactate.  Abdominal ultrasound showed mildly increased renal cortical echotexture. She was noted to be banging her head against the bed and screaming. She stated that she had no reason to live. She was seen by psychiatry.  She was given Haloperidol intramuscular (IM). She wad amenable to starting a selective serotonin reuptake inhibitor (SSRI) as an outpatient. The patient was continued with a clear liquid diet.
The next day the patient signed out against medical advice.

The proposed treatment was not medically necessary.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting.

An observational level of stay would have been more appropriate for this patient. An observational level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, did not have fevers, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.

Therefore, based on review of the submitted medical records, the requested inpatient level of care was not medically necessary for the dates of service in question as it exceeded in scope and intensity the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Growth Hormone Deficiency.
Treatment: Norditropin.
The insurer denied coverage for Norditropin.
The denial is upheld.

This is a male diagnosed with GHD (Growth Hormone Deficiency). This request is for Norditropin 2.2 mg (milligrams) daily. As reported; he started on GH (Growth Hormone) therapy, and he was started on ~0.26 mg/kg (kilogram)/week; he is doing well on Norditropin. His GH stimulation test with arginine and glucagon peaked at 6.6 and 7.1 respectively. His pretreatment height velocity is reported to be 2.5 cm/yr (centimeters/year). His IGFBP3 (insulin-like growth factor binding protein 3) was 2.3 (page 13); IGF1 (insulin-like growth factor 1) was 81 (page 14). 

His height on therapy at 16.92 y/o (years/old)  was 171.8 cm (-0.47 SDS [standard deviation score]) His mid parental.

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2, [3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above-referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, and biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD below the mean; 2) height more than 1.5 SD below the mid-parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age.

This patient met biochemical criteria. GH stimulation testing peaked at less than 10ng/ml (nanogram/milliliters). The patient met height criterion 3 as his pretreatment height was more than 2 SD below the mean and a pretreatment height velocity was more than 1 SD below the mean. The patient met both height and height velocity and biochemical criteria for the diagnosis of GH deficiency. GH in the treatment of GH deficiency is medically necessary.

No studies are showing the superiority of one form of growth hormone over another. The requested medication and the formulary alternative are bioidentical. The patient can use the formulary alternative. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.

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

The insurer's denial of coverage for Norditropin is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion
Treatment: Braces
The insurer denied Braces. The health plan's determination is overturned.

The patient in question is a female with a Class I malocclusion and a bilateral posterior crossbite. She has moderate crowding, and appropriate overbite and overjet. She is treatment planned for 24-30 months of braces with rapid palatal expansion to correct her crossbite. 

Braces are medically necessary. This patient presents with a bilateral posterior crossbite and mandibular crowding. She is treatment planned for rapid maxillary expansion to assist with orthodontic correction. Such a procedure can only be performed before the patient reaches skeletal maturity, otherwise the ability to achieve orthopedic expansion is greatly reduced. In that case, the only option to achieve expansion will be to perform it in conjunction with a surgical procedure, which would greatly increase the morbidity to the patient. Research has shown that early intervention is beneficial for patients that have a crossbite with functional shift; making treatment at a younger age the preferable option.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay.
The health plan's determination is upheld. 

The patient is a male with diabetes, hypertension, hyperlipidemia, and atrial fibrillation who presented with palpitations, chest pain, and lightheadedness while sitting. His symptoms were present for 2 hours prior to presentation. His blood pressure was 206/120 millimeters of mercury (mmHg), with a pulse of 175 beats per minute (bpm) and a respiratory rate of 18/minute. His oxygen saturation was 100 percent (%) on room air. He was afebrile. He was started on a Cardizem infusion and admitted to the telemetry unit.
He was seen in a cardiology consultation. The next day, his rhythm had converted to normal sinus. Eliquis was started as well as metoprolol. He was ruled out for myocardial infarction with negative troponin levels. He was then discharged.
At issue is the medical necessity of the inpatient hospital admission.

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

The requested health service/treatment of inpatient hospitalization was not medically necessary for this patient. The patient presented with uncontrolled hypertension, rapidly conducted atrial fibrillation, and chest pain. He was in atrial fibrillation; however, his condition was rapidly stabilized, with blood pressure lowering and control of the ventricular rate with intravenous diltiazem followed by spontaneous conversion of his rhythm to normal sinus. Evaluation of his chest pain for myocardial infarction was ruled out. His admission could have been handled at an alternate level of care rather than full inpatient hospitalization. The patient's condition was appropriately treated and stabilized within less than 24 hours. Per standard guidelines, inpatient admission is indicated for atrial fibrillation or chest pain with hemodynamic instability which persists despite initial care, if there is evidence for acute coronary syndrome, or other conditions requiring treatment such as heart failure, medication toxicity, or a comorbid condition requiring inpatient treatment. Therefore, the inpatient hospital admission was not medically necessary.