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

Diagnosis:  Acute lymphoblastic leukemia (ALL).
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This is a patient, who has newly diagnosed acute lymphoblastic leukemia (ALL). The patient was pancytopenic and was found to have a fever of 100.7 degrees Fahrenheit (F). The patient was admitted to the hospital and was started on Inotuzumab ozogamicin in combination with low-intensity chemotherapy. The request is for the approval of the full hospital admission.

Validated scoring systems used to estimate the risk for medical complications include the Talcott rules, the Multinational Association for Supportive Care in Cancer (MASCC) score, and the Clinical Index of Stable Febrile Neutropenia (CISNE) score. These scoring systems assume the states of neutropenia and fever for a given patient and do not focus upon either the degree or duration of neutropenia as predictors of the likelihood of medical complications that require or prolong hospitalization. 

High-risk patients are those who are expected to be severely neutropenic, absolute neutrophil count (ANC) less than (<) 500 for greater than (>) seven days and who have an MASCC score <21 or a CISNE score of three at the time of assessment. Intermediate CISNE scores (one or two) may require clinicians to judge the relative safety of outpatient oral therapy versus hospitalization for parenteral antibacterial therapy. Patients with neutropenic fever, who have ongoing comorbidities or evidence of significant hepatic or renal dysfunction are also considered to be high risk for medical complications, regardless of the duration of neutropenia.  

Some experts have defined high-risk patients as those expected to have profound neutropenia (ANC 100) for > seven days, based on experience that such patients are the most likely to have life-threatening complications. However, formal studies to clearly differentiate between patients with an ANC <500 and 100 are lacking. For the purposes of this discourse, we will combine these groups. Profound prolonged neutropenia (ANC 100 expected to last >7 days) is most likely to occur in the pre-engraftment phase of hematopoietic cell transplantation (particularly allogeneic) and in patients undergoing induction chemotherapy for acute leukemia.

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 a full hospital admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #1:

Diagnosis: Back pain

Treatment: Thermal destruction of intraosseous basivertebral nerves (procedure to destroy some of the nerves between the spinal bones of the lower back)

The insurer denied coverage for thermal destruction of intraosseous basivertebral nerves (procedure to destroy some of the nerves between the spinal bones of the lower back)

The denial is upheld

It is unclear if the scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes. There are several studies; however, no conclusions can be made. No definite statement or guidelines showing definitive efficacy have been reported. 

Intraosseous basivertebral nerve ablation (procedure code 64628) does have final approval from the appropriate regulatory bodies for this diagnosis. Food and Drug Administration (FDA) approval had been granted for Pre Market approval. The FDA does not provide statements regarding benefit.

This patient is not a good candidate for intraosseous basivertebral nerve ablation (procedure code 64628). No defined pain generator is present. The records show chronic back pain with several sties of pathology. Injections and multiple conservative treatments have been completed for facet disease, disc disease, stenosis and herniations. 

The facts are the patient had received 5 series of medial branch blocks (MBB) for the diagnosis of posterior column pain. The patient had undergone percutaneous discectomies to lumbar (L) 3-4 and L4-5. The patient has a herniation to L4-5. The patient has several levels of pathology to different locations. 

The likelihood of the basivertebral nerve causing the back pain is not credible.

Intraosseous basivertebral nerve ablation (procedure code 64628) is not the best available treatment for this patient at this time.

The adverse risks are increased over standard treatment. The procedure is invasive. There have been reported complications of infection, broken hardware and retroperitoneal hematoma.

Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. If approved despite non-recommendation, there should be at least 6 months of chronic low back pain following a defined injury, refractory to conservative care, as well as Modic type I or II changes between L3 and sacral (S) 1 on magnetic resonance imaging.

In summary, the denial of thermal destruction of intraosseous basivertebral nerves (procedure to destroy some of the nerves between the spinal bones of the lower back) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 1 Diabetes Mellitus
Treatment: Humalog
The insurer denied Humalog.
The determination is upheld.

This is a male patient with type 1 diabetes with hyperglycemia on Tandem insulin pump therapy with an A1C (glycated hemoglobin) of 7.0 percent (%). A request for continuation of Humalog is under review.

This request is for the continuation of Humalog for the treatment of type 1 diabetes in a patient on a Tandem insulin pump. The documentation does not support that the patient has tried and failed or had an adverse reaction to Novolog or Fiasp insulin. There are no documented contraindications to these alternatives. Tandem pumps and cartridges are only indicated for use with Novolog and Humalog U-100 insulins, therefore Fiasp is not an appropriate alternative in this clinical situation. Novolog is expected to have similar safety and efficacy as compared to Humalog in this clinical situation. The American Diabetes Association does not support the use of Humalog over Novolog insulin. Therefore, Novolog would not be expected to be ineffective as compared to Humalog and is not expected to have an increase in adverse effects compared to Humalog.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hydrocephalus.
Treatment:  Shunt (ventriculoperitoneal).

The insurer denied Shunt (ventriculoperitoneal).  The denial is overturned.

The patient is an adult female with two to three years of worsening gate and short-term memory loss. The patient underwent three-day lumbar drain trial and noted slight improvement in gait and cognition. The patient's exam reveals no focal deficit. The patient was recommended ventriculoperitoneal (VP) shunt placement for normal pressure hydrocephalus (NPH)

The proposed treatment is considered medically necessary.

The patient has symptoms that are consistent with normal pressure hydrocephalus (NPH), and the lumbar drain trial demonstrated that the patient did receive some benefit with drainage of cerebral spinal fluid (CSF). In this setting, the patient would be considered a good candidate for the procedure, as that is the test of choice to identify patients who benefit from shunting. Therefore, this would be medically necessary based upon the patient's symptoms, and relief of some symptoms with cerebral spinal fluid diversion.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Congestive heart failure, diabetes and osteoarthritis.
Treatment:  Consumer and self-directed personal assistance services 24 hours a day split shift (two 12-hour shifts per day), 7 days a week, a total of 168 hours a week.

The insurer denied coverage for consumer and self-directed personal assistance services 24 hours a day split shift (two 12-hour shifts per day), 7 days a week, a total of 168 hours a week.  The denial is overturned.

This is an elderly adult with chronic medical problems including congestive heart failure, diabetes and osteoarthritis who lives alone in a 2-bedroom apartment.  The insurer approved consumer and self-directed personal assistance services 56 hours per week and the request is for consumer and self-directed personal assistance services 24 hours a day, 7 days a week (split shift), totaling 168 hours per week.

The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as "Minimally impaired."  She is totally dependent to maximal assistance for much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She is also totally dependent for much of her functional mobility including locomotion, ambulation and toilet transfer/use.  Maximal assistance is needed for bed mobility, as well as bathing and dressing.  Extensive assistance is needed for personal hygiene.  Limited assistance is needed for eating.  She is frequently incontinent of bladder and occasionally incontinent of bowel.  There have been no reported falls over the prior 90 days.  

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 consumer and self-directed personal assistance services 24 hours a day split shift (two 12-hour shifts per day), 7 days a week, a total of 168 hours a week services is substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Soft Tissue Sarcoma; Malignant Spindle Cell Neoplasm
Treatment: Proton Beam Radiation Therapy - Phase 1: 25 Fractions (Treatment Sessions), Phase 2: 8 Fractions (Treatment Sessions), Image Guided Radiation Therapy
The insurer denied the Proton Beam Radiation Therapy - Phase 1: 25 Fractions (Treatment Sessions), Phase 2: 8 Fractions (Treatment Sessions), Image Guided Radiation Therapy.
The health plan's determination is overturned.

The patient is a male with history of a high grade leiomyosarcoma of his left anterior chest wall status/post (s/p) resection to negative margins. Request is for approval of postoperative proton beam radiation therapy.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient. 

The requested Proton Beam Radiation Therapy - Phase 1: 25 Fractions (Treatment Sessions), Phase 2: 8 Fractions (Treatment Sessions), Image Guided Radiation Therapy is medically necessary in the patient's situation. The treating provider supplied a proton/photon plan comparison which reveals that photon-based radiation is unable to provide adequate safety/precision. The photon radiation plan resulted in excessive and potentially dangerous exposure to the patient's heart; if delivered this would lead to an unacceptable and unnecessary risk for high grade cardiac morbidity/mortality. The proton radiation plan was able to significantly reduce the exposure to the patient's heart to within known safe tolerance limits. Proton radiation is supported by the American Society for Radiation Oncology (ASTRO) Model Policy in the patient's setting. It is widely utilized throughout the oncology community for similar patients in whom photon radiation cannot provide adequate cardiac preservation.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intellectual disability, schizoaffective disorder, chronic 
low back pain, and left hip pain
Treatment: Personal Care Aide Hours To 49 Hours per Week
The insurer denied: Personal Care Aide Hours To 49 Hours per Week
The denial is overturned

The patient is an adult female. She has Intellectual disability, schizoaffective disorder, chronic low back pain, and left hip pain. She has a history of surgery last year for stomach cancer. The health plan is reducing the patient's personal care hours from 49 hours/week to 35 hours hours/week. This reduction is being appealed. The patient's Uniform Assessment System (UAS) evaluation completed 2 months ago shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, shopping, and lower body dressing; extensive assistance with managing finances and medications, bathing, upper body dressing, walking, locomotion, toileting, and bed mobility; limited assistance with personal hygiene; and independent with eating and phone use. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline with bathing, walking, locomotion, toileting, and bed mobility. A statement from the patient notes that she needs help with ADLs (activities of daily living). The patient's physician notes that the patient needs help with ADLs (activities of daily living) and IADLs (instrumental activities of daily living), with 4 hours in the morning and 2 hours in the evening.

The Personal Care Aide Hours To 49 Hours per Week is medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. The health plan is reducing the patient's personal care aide hours from 49 hours/week to 35 hours/week. This reduction is being appealed. The health plan denied continuation of 49 hours/week due to review of UAS (Uniform Assessment System) evaluation and determination that the patient's needs can be met with the approved 35 hours/week. This patient has chronic mental and health conditions. She has a history of abdominal surgery last year. Uniform Assessment System (UAS) evaluation completed 2 months ago shows the patient requires assistance with all ADLs (activities of daily living), except eating. Compared to UAS (uniform assessment system) evaluation completed last year, there has been a decline with bathing, walking, locomotion, toileting, and bed mobility. This patient requires significant assistance with ADLs (activities of daily living). UAS (uniform assessment system) evaluations show a decline in several areas of functioning. The information provided support additional personal care aide hours. The approved personal care aide hours if 35 hours per week is not adequate to meet this patient's needs for assistance with ADLs (activities of daily living). The requested personal care aide hours of 49 per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, chronic back pain, diabetes, congestive heart failure, stroke
Treatment: Increase in Home Health Care (HHC) Level II Personal Care Services (PCS) per 15 minutes to 24 hours/day (live in)

The insurer denied the increase in HHC level II PCS per 15 minutes to 24 hours/day (live in). The denial is upheld.

This elderly female patient has conditions including hypertension, chronic back pain, diabetes, congestive heart failure, and a history of stroke. The patient was admitted to an inpatient level of care 2 months ago with an acute stroke with left-sided weakness. This is an appeal for denial of an increase in home/personal care services (PCS) to 24 hours/day, live in. The health plan approved a partial increase to 42 hours/week.

A letter from the patient's physician notes the patient has developed Parkinson's disease and has difficulty with eating and use of right hand. The patient has dementia. After acute stroke, she developed weakness and memory loss. She was transferred for rehab. Her condition did not improve. She needs reminders, assistance with activities of daily living (ADLs), and cannot be left alone. Medical records show the patient ambulates with a rolling walker 15-30 feet, transfers with contact guard assistance, bed mobility with standby assistance, toileting with minimal assistance.

The proposed treatment is not medically necessary. 

PCS are necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. This patient has multiple chronic conditions and is status post an acute stroke. This is an appeal for the denial of an increase in home/PCS to 24 hours/day, live in. The health plan approved a partial increase to 42 hours/week. The health plan denied the request based on Uniform Assessment System evaluation and no loss of motor function. An appeal statement from the patient's physician notes the patient needs reminders and cannot be left alone. The medical records from rehab show the patient can ambulate with a rolling walker and does not require assistance with transfers and bed mobility. She requires minimal assistance. The information provided does not support that the patient has functional needs that require home/PCS to 24 hours/day, live in. PCS are not indicated for supervision or when no tasks are being performed. The PCS 42 hours/week are appropriate to meet this patient's needs for assistance with ADLs. The proposed increase in home/PCS to 24 hours/day, live in, is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Stiff person syndrome
Treatment: Klonopin
The insurer denied Klonopin.  The health plan's determination is upheld.

The patient is a female diagnosed with stiff person syndrome. Treatment with brand Klonopin is the subject of this review. The drug was denied because the patient has not tried and failed 3 formulary alternatives. 

A formulary exception is not indicated in this case.
Klonopin is prescribed for treatment of stiff person syndrome. Benzodiazepines are seen as a first line treatment for stiff person syndrome. The documentation indicates that the patient has tried and failed generic clonazepam tablets. The documentation indicates that these tablets were not as effective as brand Klonopin. There is no documentation of an adverse reaction provided. In the letter of medical necessity, the prescribing physician notes that the patient has tried and failed "other benzodiazepines" but specific names are not provided.

The available formulary drugs are alprazolam tablet/ODT. This drug is not a recommended treatment for stiff person syndrome, due to the short half-life of the medication. The recommended benzodiazepines for treatment of stiff person syndrome are clonazepam and/or diazepam.

However, the formulary alternatives also include clonazepam ODT. The patient has not tried and failed clonazepam orally disintegrating tablets. There is no reason to believe that the orally disintegrating tablet would not be as effective as the non-formulary drug or would have adverse effects. The documentation indicates that the patient has tried and failed the clonazepam tablet but not the orally disintegrating tablet.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anaplastic hemangiopericytoma, status post left frontal craniotomy, obesity, leg edema, diabetes, bilateral sensorineural hearing loss and falls.

Treatment: Personal care aide (PCA) 12 hours per day - 7 days per week - total of 84 hours per week.

The insurer denied coverage for personal care aide (PCA) 12 hours per day - 7 days per week - total of 84 hours per week.

The denial is upheld.

 
This is an elderly hearing-impaired obese male with diabetes and history of anaplastic hemangiopericytoma (status post craniotomy/resection). He lives alone in a private residence. The insurer approved a personal care aide (PCA) 7.5 hours/day, 7 days/week (52.5 hours total) and the request is for 12 hours/day, 7 days/week (84 hours/week).

According to the Uniform Assessment System (UAS) report the patient's cognition is described as minimally impaired.  He reports being totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. He reports requiring extensive assistance for bathing, personal hygiene, dressing, bed mobility, locomotion, ambulation and toilet transfers/use. He is frequently incontinent of bladder and infrequently incontinent of bowel. These are all unchanged compared to the prior UAS. There have been no reported falls over the prior 90 days. The clinical notes are inconsistent with his self-reported level of functional incapacity.  He is fully oriented, self-directing and ambulates independently using a cane.  He says he needs weight bearing support to walk yet walks with a cane. He is able to walk 300ft (feet) without sitting down -no wheelchair use. This is improved compared to the prior UAS which was 15-149ft.  His functional ability is much the same when compared to the prior UAS report.  The letter from the doctor notes he needs help bathing, household tasks, food shopping and meal preparation. The doctor also notes the need for supervision to prevent falls and medication error. The clinical note notes "today gait is steady though only for a short distance".  There is no mention of any use of any assistive devices. It also notes that his strength is intact.  

The patient's functional deficits are not at a level or unpredictable as to require the requested PCA 84 hours/week.  his physician would agree, given the patient's reported "mild dementia" and decreased balance, he may require additional 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.  Based on the records reviewed, the patient's health and safety can be appropriately provided and maintained by the approved PCA 
52.5 hours/week.  

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 personal care aide (PCA) 12 hours per day - 7 days per week - total of 84 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trouble Breathing (reactive airway disease)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is a toddler female. She was admitted after presenting to an outside urgent care for increased work of breathing, tactile fever, increased heart rate and a respiratory exam concerning for distress. The patient had an oxygen saturation level of 91%. The patient required albuterol, IV (intravenous) steroids and also was given IV (intravenous) antibiotics. The patient was discharged when they were able to tolerate PO (oral) antibiotics as well as demonstrate a comfortable respiratory condition. The patient was given IV (intravenous) fluids and was monitored closely due to their increased respiratory effort.

The Inpatient Hospital Admission was medically necessary.

The patient presented with accessory muscle use, nasal flaring and abdominal respiratory effort noted as well as an increased respiratory rate along with a pulse ox (pulse oximeter) level of 91%. The patient was at risk for aspiration due to their elevated respiratory rate as well as respiratory failure due to fatigue from their continued increased respiratory rate and effort. The patient was not able to be discharged due to their increased respiratory effort, and as such it was medically necessary for the patient to be admitted. The patient required IV (intravenous) fluids, close respiratory monitoring, and there was concern for pneumonia. Due to the demonstration of respiratory distress via the auscultation exam, the accessory muscle use, nasal flaring and increased rate of breathing, the patient was not fit for discharge. The admission was medically necessary.