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

Diagnosis: Anal Dysplasia

Treatment: high resolution anoscopy (46607)

The insurer denied coverage for high resolution anoscopy (46607)

The denial is overturned.

The patient is a male with a past medical history significant for human immunodeficiency virus (HIV), anemia, anxiety, depression, neoplasm of the thyroid, and asthma. Anoscopy with biopsy showed squamous mucosa with anal intraepithelial neoplasia grade 2 (AIN2)-high grade dysplasia and cytologic features of human papilloma virus (HPV) infection. 

High-resolution anoscopy (HRA) refers to the examination of the anal canal and perianus using a colposcope for lighting and magnification to identify anal lesions, allowing visualization of lesions that may represent the source of abnormal cells on cytology screening or HPV, and to obtain biopsy specimens for histopathologic assessment.
 
Review of medical records, support this patient is a good candidate for this requested procedure based on demographics, co-morbid conditions, and risk factor. Scientific evidence in peer-reviewed literature clearly supports results of improvement in outcomes. Consequently, the New York State Department of Health acquired immunodeficiency syndrome (AIDS) Institute clinical guidelines on "Screening for Anal Dysplasia and Cancer in Adults with HIV"-recommends findings of abnormal anal cytology results should be followed by direct visualization via HRA and directed biopsy. They further conclude that colonoscopy does not screen for anal cancer and is not an acceptable alternative to HRA. Individuals with anal warts or other lesions, anal cytology alone may not be adequate to detect HSILs (high grade squamous intraepithelial lesion), since tissue that has an HSIL may be buried within or under the visible lesion; therefore, it is reasonable to advise HRA in such patients. Therefore, HRA and direct biopsy is considered best intervention for this patient. Potential adverse events meet standard of care. 

Based on above findings including availability of published literature and approval in clinical guidelines, this procedure is not considered experimental or investigational.

The carrier's denial of a high resolution anoscopy (46607) should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease. 
Treatment: Inpatient admission. 

The insurer denied coverage for an inpatient admission. 

The denial is upheld. 

This is the case of a male with a history of coronary artery disease, coronary artery bypass graft, hypertension, and hyperlipidemia. The patient presented to the hospital with left knee pain. He received intravenous (IV) fluids, IV Solumedrol, IV pain medication, diagnostic imaging, an orthopedic consultation, and physical therapy. 

The medical records demonstrate the patient had left knee pain for 6 days to 2 weeks. He was admitted to the hospital based upon possible infection, pain and inability to ambulate. The facts were there was no evidence of infection. His CRP(c-reactive protein) was normal. He was able to tolerate oral pain medications. There was no reason why he could not have been provided with crutches, a wheelchair, or a walker. The orthopedic consultation noted no acute problem, no surgical intervention recommended and advised follow-up as an outpatient. 

His vital signs were stable. He did not require any invasive studies nor additional consultations. There was no indication that he required monitoring. He did not require treatment for other underlying medical problems. 
 
There were no conditions to warrant the admission and level of care. 

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

Diagnosis: Irregular menses

Treatment: Intrauterine insemination (IUI) services (58322, 89261)

The insurer denied coverage for IUI services (58322, 89261).

The denial is upheld. 

The patient has a history of irregular menses and is interested in conceiving with donor sperm. The provider recommended induction of ovulation and intrauterine insemination (IUI). The patient's hysterosalpingogram was questionable for tubal disease. AMH (Anti-Mullerian Hormone) was 9.07. Antral follicle count showed 6 antral follicles on the right and 5 on the left.

The patient is a female who is trying to conceive with donor sperm. 

According to ASRM (American Society for Reproductive Medicine), infertility is a disease which generates disability as an impairment of function. Diagnostic testing for infertility should be initiated without delay upon presentation in any patient with a medical history, sexual or reproductive history, advanced age or physical findings that suggest the possibility of impaired reproductive function. 

Donor Insemination is the process of placing laboratory-processed sperm into the reproductive tract of a woman from a man who is not her intimate sexual partner for the purpose of initiating a pregnancy. Cycle fecundity is significantly lower when donor insemination is performed using cryopreserved donor sperm when compared to use of fresh sperm. In individuals or couples using cryopreserved donor sperm who fail to achieve pregnancy, consideration should be given to performing an evaluation and initiating treatment sooner than 12 months for women under middle adulthood years of age and 6 months for women aged middle adulthood or older.

Based on the above, this patient does not have a diagnosis of infertility. 

It is obvious that this patient's inability to conceive is primarily due to non-exposure to sperm. Since this patient does not have exposure to sperm, she should fail at least 3 cycles of physician's supervised donor sperm inseminations before being considered infertile and eligible for coverage of infertility services including insemination. 

Note that based on this patient's age, the odds of a live birth with intrauterine insemination, based on scientific literature, is less than 5% (percent).

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

An IUI service (58322, 89261) is not considered medically necessary for this patient.

The insurer's denial of coverage for the IUI services (58322, 89261) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Humira
The insurer denied Humira. 
The health plan's determination is overturned.

The patient is a female with Crohn's disease. She has had right lower quadrant abdominal pain and hematochezia. A recent colonoscopy showed ileocecal valve stricture, pseudo-polyps, and congested mucosa with erythema. Under review is the use of Humira for the treatment of this patient's Crohn's disease.

Humira (adalimumab) is medically necessary for this patient. In this case, the patient is unlikely to respond to conventional alternatives for induction and maintenance of remission. Comparative trials have shown improvement in outcomes with early initiation of anti-TNF (tumor necrosis factor) medications with azathioprine compared with azathioprine alone, and with initiation of biologic therapy compared with immunomodulators. The patient is at risk for Crohn's disease complications such as fistula, stricture, hospitalization, and need for surgery if effective therapy is not initiated. For these reasons, the use of Humira for the treatment of Crohn's disease is supported as medically necessary per current medical literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo, carpal tunnel syndrome, coronary heart disease, diabetes, myocardial infarction (MI)

Treatment: Consumer Directed Personal Assistance Services (CDPAS) 84 hours per week

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 84 hours per week

The denial is upheld 

This is a with chronic medical problems including coronary artery disease, diabetes and hypertension.  She lives in a private home with her daughter and granddaughter.  She was approved for CDPAS 49 hours/week.  Under review is the requested increase Consumer Directed Personal Assistance Services (CDPAS) 84 hours per week.

According to the Uniform Assessment System (UAS) report, the patient's cognitive skills were described as "modified independent."  She is "capable to dial 911/activate PERS in event of emergency."  Activities of daily living tasks such as bathing, dressing and toilet transfers/use require extensive assistance. Personal hygiene requires limited assistance.  She is frequently bladder incontinent and infrequently bowel incontinent. She lives with her daughter and granddaughter. The clinical records do not substantiate a level of physical/cognitive impairment, debility or significant functional decline to warrant the medical necessity of an increase in CDPAP hours to 84 per week. The approved 49 hours/week is clinically appropriate; allowing the patient to continue living safely at home.  

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, Consumer Directed Personal Assistance Services (CDPAS) 84 hours per week is not considered 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 Consumer Directed Personal Assistance Services (CDPAS) 84 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara 90 mg every 4 weeks 
The insurer denied Stelara 90 mg every 4 weeks.
The determination is overturned.

The patient has Crohn's disease. He has failed corticosteroids, mesalamine, and high-dose Renflexis. He started Stelara, with improvement in symptoms, inflammatory markers, and anemia. He has had increased Crohn's disease symptoms (loose bowel movements), prior to Stelara doses. Testing showed a low Stelara level of 0.4 micrograms per milliliter (ug/mL) (with no anti-Stelara antibodies). Stelara 90 mg every 4 weeks for the treatment of Crohn's disease is under review for medical necessity.

Yes, the requested Stelara 90 milligrams (mg) every 4 weeks is medically necessary in this case per the current medical literature.
Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease. Guidelines for the treatment of Crohn's disease recommend the use of Stelara. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response. One study showed that dose escalation was required and approximately half of patients, and successful in 61.1% of dose escalation attempts. Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted. Additionally, the American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy". A Stelara level of at least 4.5 ug/mL is associated with effective disease control. In this case, the patient has failed multiple other medications for the treatment of Crohn's disease, and failed Stelara every 8 weeks, with symptoms of active disease in the setting of a low Stelara level. Continuation of dosing every 8 weeks, or discontinuation of Stelara (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications of Crohn's disease. For all of these reasons, the request for Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of Crohn's disease in this case.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Paroxysmal atrial fibrillation.
Treatment: Eliquis (apixaban).
The insurer denied coverage for Eliquis (apixaban).
The denial is upheld.

This is a patient with a history of paroxysmal atrial fibrillation treated with apixaban therapy. In the past she was unable to tolerate warfarin due to poorly controlled international normalized ratio (INR) levels. The insurance company does not have apixaban on formulary. A possible alternative includes rivaroxaban/Xarelto.

The formulary drug, rivaroxaban/Xarelto is not likely to cause the patient an adverse reaction. The formulary drug has not been ineffective, and no documentation is provided to support that the patient has ever been treated with rivaroxaban. 

Both Eliquis and Xarelto therapies have been found to be non-inferior to warfarin. The 2019 American Heart Association, American College of Cardiology and Heart Rhythm Society Guidelines provide a Class I (level of evidence A) recommendation for treatment with novel oral anticoagulant regimen instead of warfarin. This recommendation was based on several randomized clinical trials that enrolled thousands of patients. The direct thrombin inhibitor medications and the Factor Xa inhibitor medications (including Xarelto/Rivaroxaban) were at least non inferior and in some cases superior to warfarin therapy. When Xarelto was utilized to treat patients with atrial fibrillation in a large randomized controlled study, results demonstrated non-inferiority to warfarin in preventing stroke or systemic embolism. (Reference 2)

There is no evidence provided to demonstrate intolerance to the formulary medications. The requested drug would not be more effective than the formulary drug.

The insurer's denial of coverage for Formulary Exception for Eliquis (apixaban) is upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hypothyroidism.
Treatment: Formulary exception for NP Thyroid 60mg, pre-service.
The insurer denied the Formulary exception for NP Thyroid 60mg, pre-service.
The denial is overturned.

The patient is a female with hypothyroidism. The request for NP Thyroid is under review. The prior request was denied coverage by the health plan, as the health plan requires that the patient has a clinical condition or needs a specific dosage form for which there is no alternative on formulary, the listed formulary alternatives are not recommended based on published guidelines or clinical literature, the formulary alternatives will likely be ineffective or less effective or cause an adverse effect, or the patient is unable to take three of the alternatives due to a trial and failure or contraindication. The formulary alternatives are levothyroxine, Levoxyl, liothyronine, Synthroid, and Unithroid. The denial is being appealed. The patient has tried and failed levothyroxine as it was ineffective. The patient has been on NP thyroid for three years.

Yes, the health plan should cover the Formulary exception for NP Thyroid.
The American Thyroid Association clinical guidelines recommend levothyroxine as the first line therapy for hypothyroidism. This patient has tried and failed levothyroxine. Therefore, the formulary alternative levothyroxine is not appropriate for this patient. The other alternatives include Levoxyl, Synthroid, and Unithroid, which are forms of levothyroxine, and therefore are not appropriate alternatives. Liothyronine is not an appropriate alternative, as the American Thyroid Association recommends against liothyronine as monotherapy for hypothyroidism. In addition, these guidelines recommend that patients stable on a brand of thyroid supplementation continue on the same brand of thyroid supplementation due to a high risk of hypothyroidism/hyperthyroidism with switching to another brand because the strength between brands is not equivalent even at the same prescribed dose. This patient has hypothyroidism and is stable on NP Thyroid. Without NP Thyroid, this patient would be at high risk of hypothyroidism which can cause myxedema coma. The health plan should cover the formulary exception for NP Thyroid.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Tirosint. 
The denial is overturned. 

This is a female with hypothyroidism. Request for Tirosint is under review. She felt jittery on liothyronine. She has been on Armour Thyroid and transitioned to Tirosint. Per appeal letter, the patient has tried Levoxyl, levothyroxine, Synthroid, Unithroid, and Armour Thyroid which cause multiple side effects including hives, fatigue, and palpitations. She is gluten free and has gastrointestinal issues. She is stable on Tirosint.

The health plan's determination is overturned.

This request is for the continuation of Tirosint for the treatment of hypothyroidism. The American Thyroid Association clinical guidelines recommend that patients stable on a brand of thyroid supplementation continue on the same brand of thyroid supplementation due to a high risk of hypothyroidism/hyperthyroidism with switching to another brand because the strength between brands is not equivalent even at the same prescribed dose. This patient has hypothyroidism and is stable on Tirosint. This patient has tried and was intolerant to the formulary alternatives levothyroxine, Levoxyl, liothyronine, Synthroid, and Unithroid. Without Tirosint, this patient would be at high risk of hypothyroidism which can cause myxedema coma.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: S58.112D - Complete traumatic amputation at level between elbow and wrist, left arm, subsequent encounter. 
Treatment: Left Quantum iLimb Terminal Device (L6935x1, L7499 x1, L6890x4, L6686 x1, L6687x1, L6629 x1, L6882x 1, L6621 x1, L6680x 2, L6695 x1, L7400 x1, L7403 x1, L8465 x2). 

The insurer denied the Left Quantum iLimb Terminal Device (L6935x1, L7499 x1, L6890x4, L6686 x1, L6687x1, L6629 x1, L6882x 1, L6621 x1, L6680x 2, L6695 x1, L7400 x1, L7403 x1, L8465 x2). 

The denial is upheld. 

The patient is a male with history of complex traumatic amputation that is a Left Below-Elbow Amputation (BEA) due to trauma. He uses his arms as a full-time self-employed businessman in masonry, carpentry, and in other extra-curricular activities. 

The patient was unable to use a properly fitting and classified prosthesis directly, as it affected his functionality, and this is the reason for the request for a Myoelectric BEA (below-elbow amputation) prosthetics. 

No, the requested Left Quantum iLimb Terminal Device (L6935x1, L7499 x1, L6890x4, L6686 x1, L6687x1, L6629 x1, L6882x 1, L6621 x1, L6680x 2, L6695 x1, L7400 x1, L7403 x1, L8465 x2) is not medically necessary. 

The requested Myoelectric BEA (below-elbow amputation) Prosthetics is not medically necessary and should not be covered by the health plan. 

The request does not meet medical necessity, as it is not necessary to meet the patient's basic health needs; rendered in the least intensive and most appropriate setting for the delivery of the service or supply; consistent in type, frequency and duration of treatment with scientifically based guidelines of national medical research or health care coverage organizations or government agencies; consistent with the diagnosis of the condition; and required for reasons other than the comfort or convenience of the patient or patient's physician or other provider. 

According to Carey et al, "Currently, evidence is insufficient to conclude that either system provides a significant general advantage. Prosthetic selection should be based on a patient's individual needs and include personal preferences, prosthetic experience, and functional needs. This work demonstrates that there is a lack of empirical evidence regarding functional differences in upper-limb prostheses." 

There is no significant difference between myoelectric prosthetics and body-powered upper limb prosthetics. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interests of the patient, because requested Myoeletric Upper limb prosthetics is not medically appropriate, as there is alternative body-powered that can do the same job. The denial is not reasonably expected to affect the patient's health adversely.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: auditory processing disorder, attention/concentration deficit, cognitive communication disorder and mild cognitive deficit due to concussion
Treatment: Speech Therapy Services
The insurer denied the Speech Therapy Services
The denial is upheld.

The patient is a female with chronic deficits (mild cognitive, attention, processing, concentration, auditory, and communication) following a concussion several years ago from a fall while ice skating. The request was made for outpatient cognitive rehabilitation program (outpatient speech therapy visits) to address these and other deficits; however it was denied by the insurance carrier because it was deemed experimental/investigational.

No, the health plan should not cover the requested health service.
A speech therapy outpatient cognitive rehabilitation program is indicated as part of an interdisciplinary program for post-concussion symptoms and deficits, not as a stand alone program.

No, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease.
The standard of care would be a comprehensive or interdisciplinary cognitive rehabilitation program that includes physical therapy and occupational therapy, not just speech therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: auditory processing disorder, attention/concentration deficit, cognitive communication disorder and mild cognitive deficit due to concussion
Treatment: Speech Therapy Services
The insurer denied the Speech Therapy Services
The denial is upheld.

The patient is a female with history of concussion and attention deficit, auditory processing deficits and concentration deficits. Her concussion took place several years ago due to a sports related accident. The patient had history of selective mutism and ADHD (attention deficit hyperactivity disorder). The patient started to receive speech services for auditory processing difficulties as well as memory deficits.

The requested for speech therapy services have been denied by the health plan as experimental and investigational. Based on the clinical policy cognitive rehabilitation when rendered as a standalone program is considered investigational in the treatment of traumatic brain injury.

No, the health plan should not cover the requested health service.
Based on the review of medical records, this stand alone cognitive therapy for TBI (traumatic brain injury) is considered experimental and investigational.

No, the requested health service is not more beneficial.
There is not enough evidence in support of skilled speech therapy services for provision of concussion related therapies for remote history TBI (traumatic brain injury). Medical records do not show previous therapy interventions and outcome in relation to TBI (traumatic brain injury) / concussion related symptoms.

Typically, TBI (traumatic brain injury) related interventions are multidisciplinary and comprehensive. Clinical information provided for the purposes of this review describe standalone cognitive therapy service proposed for the treatment of remote TBI (traumatic brain injury)/concussion injury, which is not supported by valid peer reviewed literature.