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

Diagnosis: Ovarian Cancer
Treatment: FoundationOne CDX assay
The insurer denied FoundationOne CDX assay
The determination is overturned.

This is a female patient with a heavily pre-treated stage IV ovarian cancer. A "67 gene panel" genetic test obtained at diagnosis is documented to have been "negative" but specifics regarding this have not been provided. The documentation does not indicate that a next generation sequencing panel was previously obtained. A FoundationOne CDX assay was obtained; this is under review for medical necessity.
Guidelines favor testing patients for both germline and somatic homologous recombination deficiency (HRD) mutations in order to optimize identification of germline mutations (which would open access to cascade testing of family members). Additionally, this strategy would expand identification of patients who may benefit from poly adenosine diphosphate (ADP) ribose polymerase (PARP) inhibitors. Relying only on germline testing will miss approximately 7 percent of patients who have somatic mutations only.
Multiple poly (ADP-ribose) polymerase (PARP) inhibitors have achieved approval for use in patients with recurrent ovarian cancer associated with a breast cancer antigen (BRCA) mutation, in different settings including maintenance after retreatment with chemotherapy and subsequent line treatment regardless of platinum sensitivity. Several trials suggest that patients with platinum-sensitive disease achieve better response rates and progression-free survival (PFS) using maintenance after response to chemotherapy.
The rationale for PARP inhibition in those with somatic BRCA alterations comes from Study 19 and NOVA, both in the setting of relapsed, platinum-sensitive disease. 
The National Comprehensive Cancer Network (NCCN) Guidelines, which recommend testing state, "...In the up-front setting, choice of somatic testing should, at a minimum, optimize identification of molecular alterations that can inform use of interventions that have demonstrated benefit in this setting, including BRCA1/2, loss of heterozygosity (LOH), or homologous recombination (HR) status in the absence of a germline BRCA mutation..".
Further, this patient has highly refractory ovarian cancer. The American Society of Clinical Oncology (ASCO) has issued a provisional clinical opinion that supports somatic and germline genomic testing in patients with metastatic or advanced cancer when there are genomic biomarker-linked therapies approved by regulatory agencies for treatment of their cancer. 
In this clinical scenario in addition to the NCCN, next generation sequencing (NGS) testing is recommended by the peer-reviewed literature, ASCO, and by the authors of UpToDate. Medical necessity criteria have been fulfilled for this service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain, Vomiting
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is an adult male whose hospitalization is being reviewed. The facility is seeking to qualify this hospitalization as an inpatient admission. This was denied initially coverage by the health plan based on the InterQual 2022 acute adult infection, pancreatitis criteria. The patient has a history of alcoholic pancreatitis. The patient presented with right-sided abdominal pain and multiple episodes of nonbloody nonbilious vomiting and watery diarrhea. The pain had radiated to the back. The patient had drunk a fifth of tequila two days prior to presentation. The patient was afebrile and hypertensive on admission. On physical exam, the patient was noted to have abdominal tenderness without any reported rebound or guarding. The patient had a lactic acid of 3.7 and an anion gap of 15. Lipase was 99. Platelets were 438. Computed tomography (CT) of the abdomen/pelvis demonstrated concern for acute pancreatitis. The patient had continued abdominal pain in the emergency room and, thus, the patient's providers admitted the patient for continued intravenous fluids, intravenous medications, and monitoring. Ultimately, the patient left against medical advice.

The Inpatient admission was medically necessary.

The patient had clear evidence of pancreatitis, based on typical abdominal pain and computed tomography abdomen/pelvis findings. In addition, the patient likely has chronic pancreatic disease, and, thus, lipase does not always increase to high levels. The patient had a high lactic acid level, suggesting decreased perfusion and an elevated anion gap. The patient was at high risk of destabilization from acute pancreatitis and, thus, an inpatient admission was warranted. The inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: change in position of his defibrillator pulse generator

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Asked to review the case of a an adult that presented to the hospital complaining that there was a change in position of his defibrillator pulse generator as well as dyspnea on exertion. Past history was significant for ST elevation myocardial infarction and ventricular fibrillation two months prior to presentation.  On arrival to the hospital vital signs were stable. Physical examination upon arrival was benign and no abnormalities were reported. The implantable cardiac device (ICD)  pulse generator was in good position and no evidence of erythema or hematoma were noted. 12 lead  electrocardiogram (EKG) revealed inferior Q waves and T wave inversions which were unchanged from previous EKG .  High sensitivity troponin was elevated (38).  Following examination, the patient was discharged the same day with cardiology follow up. 

This patient that presented with discomfort over his ICD pulse generator site and dyspnea on exertion.  His pretest probability of coronary artery disease is high. (Reference 1)  Utilizing the High blood pressure, Elevated cholesterol, Abnormal EKG, restricted blood flow to the heart, and Tobacco (HEART) score he was considered intermediate risk (5 points). (Reference 2) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement and ischemia work up prior to discharge.

 However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. (References 4,5)  They found no significant difference in outcome at 30 days between the two groups.  Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30 day myocardial infarction rates as those admitted to the hospital. (Reference 5) Admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this patient could have been managed at a lower level of care.

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

Diagnosis: Alzheimer's dementia
Treatment: Leqembi
The insurer denied Leqembi.
The health plan's determination is overturned.

The patient is a female who is requesting treatment with Leqembi. The patient is diagnosed with Alzheimer's disease. At issue is the medical necessity of Leqembi.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Leqembi is medically necessary for this patient. Leqembi is Food and Drug Administration (FDA) approved for the treatment of patients diagnosed with mild Alzheimer's disease. The patient is diagnosed with mild Alzheimer's disease. Leqembi does not cure Alzheimer's disease, and it cannot improve memory and thinking. It is, however, the first drug that has been shown to slow progression of Alzheimer's disease in people with early-stage disease. A large clinical trial of Leqembi showed that the drug slowed declines in memory and thinking by about 30 percent (%) over the course of 18 months of treatment. As such, the drug is medically necessary for this patient as the member has the FDA approved indication, and the drug has been shown to slow progression.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Liver Cancer
Treatment: Positron emission tomography and computed tomography (PETCT) from head to thighs

The health plan denied: Positron emission tomography and computed tomography (PETCT) from head to thighs.
The determination is: Overturned.

This is a female with history of multifocal hepatocellular carcinoma who was recommended to proceed with Yttrium-90 (Y-90) radioembolization. The request is for approval of positron emission tomography (PET)/computed tomography (CT) to evaluate the deposition of radioisotopes within the patient's liver.
At issue is the medical necessity of PET/CT from head to thighs.
The health plan's determination of medical necessity is overturned in whole.
The requested PET/CT is medically necessary for this patient. PET/CT is standard of care and required to evaluate the quality of the radiation dose deposition from the patient's radioembolization procedure. It is critical to determine whether there were areas of the target that were not adequately dosed, as this may necessitate the use of additional therapies to maximize the chance for cancer control. The use of PET/CT is supported by numerous high quality prospective clinical outcomes reported in the peer reviewed medical literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diffuse large B cell lymphoma (DLBCL). 
Treatment: Q2041 axicabtagene ciloleucel (Yescarta). 
The insurer denied coverage for Q2041 axicabtagene ciloleucel (Yescarta). 
The denial is overturned. 
 
According to the medical records, the patient is an adult with a history of diffuse large B cell lymphoma (DLBCL).  The patient was diagnosed and was treated with Rituximab, etoposide phosphate, prednisone, Oncovin, cyclophosphamide and Hydroxydaunorubicin (R-EPOCH) completing 6 cycles. Imaging showed persistent/progressive disease.

According to Westin et al. (2021), "Chimeric antigen receptor (CAR)-T cell therapies have improved the outcome for many patients with relapsed or refractory aggressive B-cell lymphomas. In 2017, axicabtagene ciloleucel and soon after tisagenlecleucel became the first approved CAR-T cell products for patients with high-grade B-cell lymphomas or diffuse large B-cell lymphoma (DLBCL) who are relapsed or refractory to >= 2 prior lines of therapy; lisocabtagene maraleucel was approved in 2021. Safety and efficacy outcomes from the pivotal trials of each CAR-T cell therapy have been reported." 

"Conclusions: axicabtagene ciloleucel therapy led to significant improvements, as compared with standard care, in event-free survival and response, with the expected level of high-grade toxic effects. (Funded by Kite; ZUMA-7 ClinicalTrials.gov number, NCT03391466)" (Locke et al., 2022). 

For patients with early first relapse (less than 12 months) or primary refractory DLBCL, the National Comprehensive Cancer Network (NCCN) recommends CD19 (a biomarker for B cell development) - directed chimeric antigen receptor (CAR)-T cell therapy using axicabtagene ciloleucel or lisocabtagene maraleucel, rather than autologous hematopoietic cell transplantation (HCT) or tisagenlecleucel. This recommendation is based on superior survival using axicabtagene ciloleucel or lisocabtagene maraleucel compared with autologous HCT in randomized trials; tisagenlecleucel did not achieve better outcomes than autologous HCT in a separate randomized trial. 

Axicabtagene ciloleucel (Yescarta) is therefore considered medically necessary for this patient. 
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 axicabtagene ciloleucel (Yescarta) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain and Bloating
Treatment: Esophagogastroduodenoscopy (EGD) (code 43239)
The insurer denied: Esophagogastroduodenoscopy (EGD) (code 
43239)
The denial is overturned.

The patient is an adult female. She presented to her gastroenterologist for epigastric pain, nausea, post-prandial fullness, and bloating. Dyspepsia was suspected. At the time of the last review, no clinical information on tried and failed medications or other interventions was provided. An upper endoscopy was recommended to rule out peptic ulcer disease.
The procedure was denied coverage by the health plan due to lack of meeting plan criteria (persistent vomiting, persistent abdominal pain, and gastroesophageal reflux disease [GERD] 
despite 2-month proton pump inhibitor [PPI] trial; suspected internal bleeding; dysphagia; new onset dyspepsia in a patient over 50 years old). Information submitted by the provider notes that the patient had tried and failed a PPI (proton pump inhibitors) for least 4 months prior to the procedure being ordered. The denial is being appealed, which is the topic of this review.

The Esophagogastroduodenoscopy (EGD) (code 43239) was medically necessary.

Provided records note that the patient had abdominal pain, dyspepsia, and nausea that persisted despite a four-month PPI (proton pump inhibitor) trial. Based on the clinical information provided, the patient had an esophagogastroduodenoscopy 
(EGD) for dyspepsia, abdominal pain and nausea despite a four-month PPI (proton pump inhibitor) trial. Given this, the patient met the indication of signs or symptoms suggesting structural disease of the upper gastrointestinal tract such as anorexia, weight loss, early satiety, or persistent nausea. As such, the esophagogastroduodenoscopy was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac ablation with resultant hematoma and 
extravasation
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with multiple medical problems. She underwent cardiac ablation with resultant hematoma and extravasation.

The inpatient hospital admission was not medically necessary.

The patient is an adult female with history of cardiac disease, diabetes, and hypertension. The patient was brought in for a redo atrial fibrillation procedure. The patient underwent ablation to the right groin. The patient developed a small hematoma involving the right groin. Duplex scan shows no evidence of any arterial pseudoaneurysm. Computed tomographic angiography (CTA) showed hematoma involving the right groin with active extravasation. Manual pressure was held with no surgical intervention. Hemoglobin/hematocrit (H/H) remained stable as well as the vital signs. Only observation for the day of the procedure to the next day was medically necessary. This was a patient with multiple comorbidities. The patient developed moderate-sized hematoma with active bleeding based on his computed tomography scan. This required observation for monitoring, assessment, and re-evaluation. Anticoagulation was placed on hold secondary to bleeding. The hematoma did not increase in size and anticoagulation was started. As the hematoma did not increase in size, the patient was able to be discharged the next day.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Treatment: uvulopalatopharyngoplasty and tonsillectomy
The insurer denied uvulopalatopharyngoplasty and tonsillectomy.
The determination is overturned.

The patient is a male with a history of mild obstructive sleep apnea as documented on a home sleep study with associated symptoms of hypersomnia and daytime fatigue. The patient was unable to tolerate the use of continuous positive airway pressure (CPAP) therapy due to a history of claustrophobia and a sensation of feeling suffocated. The treating otolaryngologist has recommended uvulopalatopharyngoplasty and tonsillectomy for the treatment of underlying obstructive sleep apnea. The insurance denied benefits for the above as not medically necessary to treat the patient's condition since the patient has not attempted continuous use of CPAP therapy for at least 1 month. At issue is the medical necessity of the requested procedures.

Uvulopalatopharyngoplasty and tonsillectomy are medically necessary and considered the standard of care to treat the patient's condition. The patient was diagnosed with mild obstructive sleep apnea as demonstrated on a home sleep study. He has severe hypersomnia/daytime fatigue. He is not able to tolerate CPAP therapy due to claustrophobia. Clinical examination revealed anatomy amendable to surgical correction including tonsillar hypertrophy. The American Academy of Otolaryngology's position statement dated 2021 states "Surgical management may also be indicated for adult patients with obstructive sleep apnea (OSA) when positive airway pressure (PAP) therapy is inadequate, such as when the patient is intolerant of CPAP or CPAP therapy is unable to eliminate OSA. For example, uvulopalatopharyngoplasty (UPPP) and tonsillectomy has been shown to be effective in improving OSA in approximately 80 percent (%) of patients with favorable anatomy." Given his inability to tolerate CPAP therapy due to claustrophobia, surgical correction with the above is the next reasonable treatment course.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dentures
Treatment: Custom Fabricated Abutment (D6057)
The insurer denied: Custom Fabricated Abutment (D6057)
The denial is upheld.

This is an adult male. The request is for Custom Fabricated Abutment. Prior denial was due to alternate benefits clause.

The Custom Fabricated Abutment (D6057) was not medically necessary.

The custom abutment (D6057) is not medically necessary. Alternatives exist that were available to the patient, such as a new, better fitting lower partial denture. These alternatives are reasonable and consistent with the standard of care. Therefore, the Custom Fabricated Abutment (D6057) was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intractable focal epilepsy, hydrocephalus
Treatment: Durable Medical Equipment (Lift)
The insurer denied Durable Medical Equipment (Lift).
The determination is overturned.

The patient is a female with a complex medical history including intractable focal epilepsy, hydrocephalus status post ventriculoperitoneal (VP) shunt placement, stable pachygyria, feeding difficulties with dependence on gastrojejunostomy feeds, and growth hormone deficiency complicated by hypoglycemia. She is non-ambulatory,but can tolerate some weight bearing and partial weight supported stepping with maximal therapeutic support. Her biological parents have both psychiatric and substance abuse histories and there is concern for prenatal drug and alcohol exposure. She has significant hypotonia, including nuchal and central hypotonia, no spasticity and no dystonia. She has a wheelchair, adaptive car seat, and Rifton Activity Chair with tray.
The current prescription is for a Hoyer lift with sling to aid with daily lifting and transferring. At the last clinic appointment, according to the documentation provided, her weight was 43 pounds (lbs). She is hypotonic throughout, with poor head, neck, and trunk control. She is fully dependent for all activities of daily living. Because of her increasing size and hypotonia, the child requires two caregivers for all transfers. When her father is at work, her mother must transfer her alone, causing increasing back pain because of the child's increasing size/weight. A Hoyer lift would allow for safe independent transfers, protecting both caregiver and child.
At issue is the medical necessity of durable medical equipment (Lift).
The Hoyer lift with sling is medically necessary for this child.
The American Academy of Pediatrics has published guidelines for home care of infants, children, and adolescents with chronic disease: "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens." Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." (1)
This young child has significant and severe disability as a result of and in addition to her genetic condition and intractable seizures. She is fully dependent upon caregivers for all activities of daily life including transfers and changing position. She has hypotonia throughout and is unable to assist with any activities. At almost 45 pounds, she is extremely difficult to transfer alone. Her mother is developing back pain and stress injury from transferring her alone during the day when the father is at work. The child requires two-person transfer when two people are available. However, when only one caregiver is available, the Hoyer lift is essential to protect both the child and caregiver.