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

Diagnosis: Refractory obsessive-compulsive disorder
Treatment: CPT 61735: creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus and associated inpatient hospital stay
The insurer denied: CPT 61735: creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus and associated inpatient hospital stay
The denial is overturned.

The patient is an adult male with obsessive-compulsive disorder. The patient has had significant issues related to his diagnosis. Magnetic resonance imaging and computed tomography showed no significant mass lesion. The patient was recommended for anterior capsulotomy with laser.

The health plan should cover the proposed treatment, CPT 61735: creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus and associated inpatient hospital stay. 

This procedure has been well studied in the literature and is supported by multiple studies and is within the standard of care. The following studies demonstrate the utility of this procedure for patients with obsessive-compulsive disorder. 
73% of patients had a clinical response (i.e (that is), > 35% improvement in Yale-Brown Obsessive-Compulsive Scale (score) and 24% patients went into remission (Yale-Brown Obsessive Compulsive Scale score < 8). In the older publications, published when the Yale-Brown Obsessive-Compulsive Scale was not yet available, 90% of patients were deemed to have had a significant clinical response and 39% of patients were considered symptom free. The rate of serious complications was low. In summary, anterior capsulotomy is a safe, well-tolerated, and efficacious therapy. Its underuse is likely a result of historical prejudice rather than lack of clinical effectiveness. Pepper J, Zrinzo L, Hariz M. Anterior capsulotomy for obsessive-compulsive disorder: a review of old and new literature. J Neurosurg. 2019. 
This systematic review of the literature supports the efficacy of both dorsal anterior cingulotomy and anterior capsulotomy in this highly treatment-refractory population. Brown LT, Mikell CB, Youngerman BE, Zhang Y, McKhann GM 2nd, Sheth SA. Dorsal 
anterior cingulotomy and anterior capsulotomy for severe, refractory obsessive-compulsive disorder: a systematic review of observational studies. J Neurosurg. 2016 Jan;124(1):77-89. doi: 10.3171/2015.1.JNS14681. Epub 2015 Aug 7. PMID: 26252455. 
The requested health is more beneficial than any standard treatment for the patient's condition. This patient is medically refractory, and this is the most appropriate treatment option at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression
Treatment: Transcranial magnetic stimulation
The health plan denied Transcranial magnetic stimulation. The denial is overturned.

The patient is an adult female with a diagnosis of major depressive disorder and treatment resistant depression with associated symptoms of anxiety. The patient's treatment plan includes the use of TMS (transcranial magnetic stimulation) therapy. The patient has a longstanding history of depressive disorder. The patient has a documented history of multiple medication treatments for depression, including treatment with two antidepressants with disparate mechanism of action and at least four or more trials with antidepressant medications including SSRIs (selective serotonin reuptake inhibitors) (Zoloft and Prozac), SNRIs (serotonin-norepinephrine reuptake inhibitors) (Cymbalta and Effexor), and amitriptyline resulting in lack of effectiveness or intolerance due to adverse effects.

The patient has received augmentation therapy with Tramadol and with cyclobenzaprine with associated antidepressant qualities, as well as supplemental use of hydroxyzine. Additionally, the patient has had extensive treatment with at least five years of weekly psychotherapy sessions combined with antidepressant medications. There is no mention of comorbid psychiatric conditions other than anxiety or co-occurring substance use disorder or comorbid general medical conditions that are a focus of treatment or represent a contraindication for TMS (transcranial magnetic stimulation) therapy.

In this case scenario, Transcranial Magnetic Stimulation Services are clinically appropriate and considered medically necessary as an adjunct and augmentation of the patient's antidepressant regimen in order to achieve a remission of symptoms related to severe depressive disorder in the context of treatment refractory/resistant depression and failed trials with at least four antidepressants including antidepressant medications with disparate mechanisms of action. Moreover, the coverage of Transcranial Magnetic Stimulation Services for a patient who meets criteria for treatment refractory depression and who is a reasonable candidate for the requested benefit of TMS (transcranial magnetic stimulation) should be approved in this case scenario; the requested TMS (transcranial magnetic stimulation) therapy proposed is in the best interest of the patient, and reflects sound medical judgment with respect to the use of the requested treatment. Indeed, TMS (transcranial magnetic stimulation) therapy for the treatment of major depressive disorder is a well-established treatment that is proposed for this patient in keeping with prevailing standards of medical practice for the condition under treatment in this case. Additionally, the patient had past trials that included combined medication treatments with weekly psychotherapy.

This answer is consistent with the scientific literature and published guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left facial numbness, left arm numbness
Treatment: inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld. 

This is an adult female who presented to the emergency department with complaints of left facial numbness, left arm numbness for two weeks, with pain on the left side of the neck and left shoulder and tingling in the fingers of the left hand. She complained of neck and upper back pain for two years and had received physical therapy that helped. She worked as a housekeeper and performed heavy lifting as part of her job. Examination revealed pain on the left side of the neck and bilateral shoulders, and left upper back, with decreased range of motion of the left upper extremity to passive and active motion. At the time of presentation, her differential diagnosis was transient ischemic attack versus cervical radiculopathy. She was admitted to an acute level of care. Computed tomography (CT) scan of the brain was negative for acute changes. CT angiography of the brain and neck was negative for any acute changes. A brain magnetic resonance imaging (MRI) did not reveal any mass or acute stroke with evidence of white matter disease. Electrocardiogram (ECG or EKG) revealed normal sinus rhythm with no abnormalities.

This is a patient who presented with two weeks of left face and arm numbness. Acute stroke could be ruled out in the emergency department with a head computed tomography (CT) and  angiography and magnetic resonance imaging (MRI). She had no other complaints or findings, other than those pertaining to numbness. Once acute stroke was ruled out, the patient could be discharged with plans for further workup as an outpatient. 

"Stroke is the leading cause of long-term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimize the impact of acute ischemic stroke. The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. Here, we review the data supporting pre-hospital and emergency stroke care, including use of emergency medical services protocols for identification of patients with stroke, intravenous thrombolysis in acute ischemic stroke including updates to recommended patient eligibility criteria and treatment time windows, and advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset." (Phipps, MS. et al.).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Infectious Disease
Inpatient Hospital Stay

Diagnosis: Facial swelling, fever
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient who presented to the hospital for left facial swelling. He also had a decreased appetite and low-grade fever. He had no dysphagia, vision changes or respiratory distress. He was evaluated by oral maxillofacial surgery, who recommended intravenous antibiotics and hospitalization. He received 3 days of intravenous antibiotics and responded well. He was discharged home in a stable condition. At issue is the medical necessity of an inpatient admission.

The admission was medically necessary. This patient presented for acute onset facial swelling, associated with a low grade fever and decreased appetite. The clinical picture was concerning for facial cellulitis.
Given the location of the cellulitis, it is critical to treat it with an aggressive regimen of intravenous antibiotics. The infection can rapidly spread and threaten the member's life or sensitive organs, such as the eyes or airways. The current standard of care is to provide intravenous antibiotics and close monitoring for facial cellulitis.
According to Ritwik, Priyanshi et al: "FCOO [facial cellulitis of odontogenic origin] in children usually requires hospital admission for management. Cellulitis is a common problem in the paediatric population, accounting for nearly 1 in every 500 patients seen in the paediatric emergency department (ED). Facial cellulitis can lead to systemic complications such as sepsis, dehydration, central nervous system infection, and airway obstruction."
According to Kocaba, Bilge Aldemir et al: "Hospitalization is important for children with signs of systemic toxicity and younger than 1 year of age those with inadequate Haemophilus (H) influenzae type B immunization. A sepsis workup should be initiated for children with signs of systemic toxicity and extremely young children. If orbital involvement is suspected and/or clinical diagnosis is unclear, the patient should be consulted with an ophthalmologist first, then a computed tomography (CT) scan can be taken. Blood cultures in patients with preseptal cellulitis usually are negative. Also, it is difficult to obtain the microorganism in the infection site cultures. Even so, blood cultures in children under 2 years are more likely to be positive. The culture of conjunctival discharge is rarely having significant diagnostic benefits". Therefore, the admission was appropriate and consistent with generally accepted practices.
Appeal type: Medical necessity
Decision: Upheld

Respiratory
inpatient hospital

Diagnosis: cough/congestion
treatment: inpatient stay
The insurer denied an inpatient stay. The health plan's determination is upheld. 

The patient is a male infant with recent presentation for croup who presented to the ED (emergency department) with one-day history of cough, congestion, diarrhea (more than ten episodes) and vomiting (six to eight episodes). The mother was treating with cough syrup and Pedialyte. Vital signs included temperature 37.9 degrees Celsius, heart rate 148, respiratory rate 32 with 98 percent saturation in room air, and weight 8.8 kilograms. 

The inpatient hospital admission was not medically necessary. In this case, the infant presented with signs and symptoms of dehydration secondary to respiratory syncytial virus (RSV) infection with vomiting and diarrhea. Laboratory testing revealed hypernatremia with metabolic acidosis. Fluid resuscitation was initiated in the ED, and he was admitted for further management. While it was appropriate to monitor him in the hospital for worsening of RSV symptoms while providing safe fluid resuscitation, he was overall hemodynamically stable with no evidence of impending hypovolemic shock or complications from hypernatremia. He did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Retroperitoneal fibrosis
Treatment: Ruxience
The insurer denied Ruxience.
The determination is overturned.

This is a patient with a history of retroperitoneal fibrosis (RPF). He initially presented with a retroperitoneal soft tissue mass. A biopsy showed lymphoplasmacytic lymphoma. An open procedure did not reveal a neoplasm or significant inflammation. A computed tomography (CT) scan and magnetic resonance imaging (MRI) showed extensive retroperitoneal fibrosis extending in to the bilateral anterior perinephric space. He also had bilateral hydronephrosis and an acute kidney injury (AKI). Ureteral stents were placed and the AKI improved to creatinine of 1.4. A worsening creatinine was again noted with a creatinine of 2.6 which got up to 14.9 when he was admitted to the hospital. Serum protein electrophoresis (SPEP) showed an elevated immunoglobulin G (IgG). He underwent ureteral stents exchange. The creatinine improved to 2.0. At issue is whether the Ruxience is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Ruxience is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. There are no proven/effective treatments available for idiopathic retroperitoneal fibrosis. Retroperitoneal fibrosis is characterized by the proliferation of fibrous tissue in the retroperitoneum. Recent studies on IgG4-related disease (RD) have shown rituximab to be an effective treatment (1). The current first-line treatment for idiopathic RPF is glucocorticoid therapy but long-term use can result in several severe adverse effects, some of which are irreversible. Rituximab has previously been demonstrated as an effective treatment for IgG4-RD (2). A prospective open label clinical trial demonstrated 97 percent (%) disease response rate at 6 months post-rituximab therapy in 30 IgG4-RD patients, providing strong evidence that B cell depletion is an effective treatment for IgG4-RD (3).

Another more recent study of rituximab therapy in retroperitoneal fibrosis looked at 26 patients, 7 of whom were diagnosed with idiopathic retroperitoneal fibrosis. The remaining 19 patients had IgG4-RD. Treatment response was defined as either improvement in RPF symptoms, shrinkage of RPF on imaging, or resolution of laboratory markers [IgG4, C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR)]. On post-treatment imaging, 21 of the 25 patients (84%) had treatment response, as defined by improvement in RPF size in at least 2 imaging planes (4).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Retroperitoneal fibrosis
Treatment: Ruxience
The insurer denied Ruxience.
The determination is overturned.

This is a patient with chronic kidney disease and retroperitoneal fibrosis secondary to immunoglobulin (Ig) G4 nephropathy and the treating physician requested Rituximab (Ruxience) due to progressing fibrosis and multiple episodes of obstructive uropathy. At issue is whether Ruxience is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Ruxience is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

In patients who are resistant to glucocorticoids alone or unable to reduce their dose sufficiently to avoid adverse effects of the medication from chronic use, Rituximab is the standard therapy. Case series suggest that B-cell depletion therapy is an effective treatment in many of the patients with immunoglobulin G (IgG) 4-related disease (IgG4-RD) that is refractory to glucocorticoids and other medications. A retrospective nationwide study in France showed that rituximab was effective as both induction and maintenance treatment. Relapses occurred when rituximab was discontinued. Systematic rituximab infusion (before evidence of relapse) was associated with longer relapse-free survival. In addition, in an open-label trial, 30 patients with IgG4-RD were treated with two doses of rituximab, most without concomitant use of glucocorticoids, the disease responded in 97 percent of the patients, and 40 percent remained at complete remission at 12 months.

Therefore, Rituximab (Ruxience) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Retroperitoneal fibrosis
Treatment: Ruxience
The insurer denied Ruxience.
The determination is upheld.

This is a male patient with a history of atrial fibrillation, supraventricular tachycardia status post ablation, hypertension (HTN), obstructive uropathy due to retroperitoneal fibrosis who was admitted to the hospital in September for an acute kidney injury with a creatinine as high as 14.9 secondary to obstructive uropathy. A computed tomography (CT) scan showed confluent soft tissue density or the retroperitoneum circumferential around the abdominal aorta consistent with retroperitoneal fibrosis. Serum protein electrophoresis showed elevated immunoglobulin (Ig) A and IgG levels without monoclonal antibodies. He had ureteral stents placed with improvement in his creatinine. His provider wishes to use rituximab to treat his retroperitoneal fibrosis in conjunction with corticosteroids and mycophenolate. The health plan has stated that the use of rituximab 1000 milligrams (mg) intravenous (IV) every 2 weeks for 2 doses for the diagnosis of retroperitoneal fibrosis is not covered and is considered an off-label use. At issue is whether Ruxience is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The use of rituximab (Ruxience) for the treatment of idiopathic retroperitoneal fibrosis has not been proven to be more effective than the standard of care treatment for this condition.

The first line therapy for idiopathic retroperitoneal fibrosis are corticosteroids. Rituximab, while holding some promise in the treatment of this disease, is not considered first line therapy as further prospective studies are required. It is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar disorder
Treatment: Vraylar 1.5 milligrams (MG) OR CAPSULES
The insurer denied coverage for Vraylar 1.5 milligrams (MG) OR CAPSULES.
The denial is overturned.

This adult patient has a diagnosis of bipolar disorder and past reports of mood instability and psychotic symptoms including paranoid delusional thinking, internal preoccupation, poverty of thoughts and speech, not eating, and being guarded and withdrawn. The patient has multiple past psychiatric hospitalizations and a past suicide attempt by dangling out of a window. The patient tried multiple atypical antipsychotic medications to target mood stabilization and past psychotic symptoms. Medications included Risperidone, Aripiprazole and Olanzapine. The patient had side effects of sedation and constipation from Quetiapine. The provider prescribed Vraylar to target mood instability and the plan was to taper Quetiapine (Seroquel). The patient was also taking Depakote for mood stabilization. The insurer denied the request for Vraylar 1.5 milligrams (mg).
   
Vraylar 1.5 mg is considered a medically necessary treatment for this patient. There was sufficient documentation in the provided medical records which indicated that the patient tried 4 atypical antipsychotic medications in the past including Risperidone, Aripiprazole and Olanzapine, and had side effects or lack of sustained efficacy including sedation and constipation from Quetiapine which the patient is currently prescribed. The plan was to taper Quetiapine and start Vraylar to target mood instability. The patient tried and failed or had intolerance to at least 4 other Food and Drug Administration (FDA) approved medications for bipolar disorder including preferred medications. Vraylar (Cariprazine) is a dopamine partial D2 agonist and partial serotonin 5HT1A receptor agonist and antagonist of serotonin 5Ht2A.Typical starting dosages are 1.5 mg with a maximum dosage of 6 mg per day. This medication is FDA approved for Schizophrenia or Bipolar I Disorder. This patient has a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) diagnosis of Bipolar 1 disorder and had past psychotic symptoms as well. The use of Vraylar for this patient is considered a medically necessary, standard, and appropriate treatment. Vraylar is considered one of the antipsychotic medications for the treatment of psychotic symptoms and mood stabilization due to bipolar disorder. Vraylar (Cariprazine) has distinct advantages in drug pharmacology and pharmacodynamics and has good efficacy, tolerability and is a drug of choice for long-term management of bipolar disorder, schizophrenia and related psychotic disorders. Vraylar was prescribed to target mood symptoms including mood instability and to target past psychotic symptoms. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Vraylar 1.5 milligrams (MG) OR CAPSULES is substantiated.