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

Diagnosis: atrial tachyarrhythmias

Treatment: external mobile cardiovascular telemetry (heart rhythm monitoring) with electrocardiographic reading, concurrent computerized real time data analysis

The insurer is denied coverage for external mobile cardiovascular telemetry (heart rhythm monitoring) with electrocardiographic reading, concurrent computerized real time data analysis

The denial is overturned. 

This female patient has a history of amplified musculoskeletal pain syndrome, attention deficit hyperactivity disorder (ADHD), ectopic atrial tachycardia, gender dysphoria, migraines, and paroxysmal supraventricular tachycardia (SVT).

Per Derkac et al. (2017),"In patients with conventional diagnostic monitoring indications, MCOT had significantly higher diagnostic yields for five asymptomatic arrhythmias compared to the AT-LER."

Per Galli et al. (2016), "To overcome many limits of the event recorders, mobile or real-time cardiac outpatient telemetry (MCOT) systems have been developed.[1] They are external ambulatory monitors that can monitor patients for up to 30 days.[1] Their continuous analysis of the ECG and realtime transmission of every single event to the attending cardiac unit gives them an advantage over ELRs."

Per Rothman et al. (2021), "Conclusions: MCOT provided a significantly higher yield than standard cardiac loop recorders in patients with symptoms suggestive of a significant cardiac arrhythmia."   

The external mobile cardiovascular telemetry (heart rhythm monitoring) with electrocardiographic reading, concurrent computerized real time data analysis and greater than 24 hours is considered medically necessary for this patient.

The patient needs the MCOT to make the most expedient diagnosis of Torsades de Pointes possible; failure to do so could risk the patient's life. In the case of possible Torsades de Pointes, MCOT is medically necessary per the literature. (1-2)

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

The carrier's denial of coverage for external mobile cardiovascular telemetry (heart rhythm monitoring) with electrocardiographic reading, concurrent computerized real time data analysis is overturned.  The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: wearable cardiac defibrillator. 
The insurer denied wearable cardiac defibrillator. 
The denial is upheld.

The patient is a male with hyperlipidemia who suffered an anterior wall ST elevation myocardial infarction. He was found to have an occluded proximal left anterior descending and 99% proximal ramps stenosis. Successful percutaneous coronary intervention (PCI) was performed. Ejection fraction (EF) was 30% by echocardiogram (ECHO). He was placed on guideline-directed medical therapy with aspirin, atorvastatin, losartan, metoprolol, spironolactone, and ticagrelor. A wearable defibrillator was prescribed and is under review to determine whether the device is likely to be more beneficial for the patient than other standard treatments.

No, the wearable cardioverter defibrillator is not likely to be more beneficial than standard treatment for this patient. Per the American Heart Association (AHA) science advisory (reference 1 below), "wearable cardioverter defibrillator (WCD) may be appropriate as bridging therapy in situations associated with increased risk of death in which ICDs have been shown to reduce sudden cardiac death (SCD) but not overall survival such as within 40 days of myocardial infarction (MI)." This is a class IIB recommendation, per the advisory, meaning that there is some divergence of opinion, but the weight of evidence is not in favor of the treatment. For patients post-revascularization, the wearable defibrillator is also a class II B indication. That is the situation for this patient, who is within 40 days post-myocardial infarction and post-revascularization.
The wearable defibrillator has not been proven to be beneficial in patients in the immediate post-MI period following coronary revascularization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: diarrhea

Treatment: GI pathogen panel

The insurer is denied coverage for GI pathogen panel

The denial is upheld. 

This male patient has no significant past medical history.

UpToDate has an article titled "Approach to the adult with acute diarrhea in resource-rich settings." Stool testing with stool cultures is a recommended test if a patient continues to have diarrhea for more than 1 week. The article also addresses multi- pathogen molecular panels. It states that a high degree of clinical correlation is necessary when interpreting results of molecular testing since these assays detect genetic material which does not always indicate infection with a viable organism. Any specimens that test positive for a bacterial pathogen on a multiplex molecular panel should be submitted for confirmatory culture.

This patient has diarrhea that has not resolved after a week. Stool testing for an infection is appropriate. However, the patient is not immunocompromised and PCR testing is not a standard part of the workup for acute diarrhea. It has limitations as compared to doing specific stool testing for bacteria or parasites.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for GI pathogen panel is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 diabetes mellitus

Treatment: Januvia (sitagliptin)

The insurer denied coverage for Januvia (sitagliptin).

The denial is upheld.

According to the clinical documentation provided for review, the treating provider is requesting plan approval for treatment with Januvia (sitagliptin). The patient has been diagnosed with medical history of type 2 diabetes mellitus, high cholesterol, gastroparesis, gastroesophageal reflux disease (GERD), Hashimoto's disease, stent placement, appendectomy, and cholecystectomy. According to the visit notes, the patient's hemoglobin A1c (glycated hemoglobin) decreased from 13.7% (percent) to 7.6%. The patient's medication list for diabetes treatment included Januvia 100 milligrams (mg) daily with 3 refills, Lantus 100 units per milliliter, 10 units subcutaneous daily, and metformin 500 mg (milligrams) tablet, extended release, 2 tablets daily. The patient also takes metformin and Lantus. The patient's last A1c was 8.0%. This is a continuation request. The treating provider prescribed Januvia (sitagliptin).

The patient's last A1c was 8.0%. This is a continuation request. The treating provider prescribed Januvia (sitagliptin). The requested drug Januvia (sitagliptin) would not be more effective than Tradjenta (linagliptin). The patient has only tried Metformin, Januvia, and Lantus. In order to be approved for Januvia (sitagliptin), the patient must try and fail, have a contraindication to, documented adverse effect to, or provide any clinical reason why the preferred plan medications Tradjenta (linagliptin) cannot be used. There has been no documentation submitted that supports a clinical reason why the patient is not able to try the remaining products on the plan's formulary. The formulary drug is unlikely to cause an adverse reaction.  The formulary drug has not been proven to be ineffective based on the patient's clinical history. The patient has only tried Metformin, Januvia, and Lantus.     

The requested drug would not be more effective than formulary alternative.  

Venkata, et al., (2021), "DPP-4 inhibitors, known as gliptins, are a class of oral diabetic medications approved by the Food and Drug Administration (FDA) for the treatment of type 2 diabetes mellitus in adults. DPP-4 inhibitors that have FDA approval include sitagliptin [Januvia], saxagliptin, linagliptin [Tradjenta], and alogliptin."                                                       
     
The insurer's denial of Formulary Exception for Januvia (sitagliptin) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: psoriasis

Treatment: Otezla 30 milligram

The insurer is denied coverage for Otezla 30 milligram

The denial is upheld. 

This male patient has a history of anxiety disorder, asthma, depressive disorder, asteatosis cutis, eczema, psoriasis, and diabetes mellitus.

Based on the submitted documentation, Otezla is not medically necessary for the patient's condition. There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Otezla for this patient's condition as an accepted standard of practice over available alternatives. There are no comparative, controlled studies showing that Otezla has a superior efficacy and safety profile to the formulary alternatives such as phototherapy and methotrexate.
Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Otezla is not necessary. There is no documentation provided that the patient has tried and/or failed phototherapy or methotrexate. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Otezla medically more appropriate than the other options. Therefore, the administration of Otezla (7) is not strongly supported for this patient, and Otezla is not medically necessary for this patient based on the current evidence-based medical literature.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for Otezla 30 milligram is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: History of stage 4 pancreatic adenocarcinoma.

Treatment hospital admission.

The insurer denied coverage for hospital admission.

The denial is upheld.

The patient had metastatic pancreatic carcinoma and had biliary stents. She developed jaundice with a bilirubin of 6.5. She was receiving chemotherapy. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. An endoscopic retrograde cholangiopancreatography (ERCP) was performed with removal of a plastic stent and placement of a metal stent into the common bile duct. After the procedure, the patient complained about ear pain. An ENT (ear, nose, and throat) consult was done. She was discharged on oral antibiotics.

Milliman Care Guideline (MCG) A-0207 lists indications for ERCP with or without Sphincterotomy or Stent Placement. A pancreatic disorder requiring stent placement for a malignant biliary obstruction is an indication for the procedure. However, this procedure is listed under the category of Ambulatory Care.

MCG Ambulatory Surgery Exception Criteria. Preoperative indications for admission include infection, altered mental status, dangerous arrhythmia, hypotension, and hypoxemia. The patient did not have these conditions. Postoperative indications for admission include hemodynamic instability, acute kidney injury, high fevers, a severe electrolyte abnormality, and an operative site complication. The patient did not have these conditions.

This patient required an ERCP with a placement of a new stent. According to MCG, this procedure can be done in ambulatory care. In addition, she did not fulfill any of the criteria for an ambulatory surgery exception. She remained stable for outpatient care. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

The insurer's denial of coverage for the hospital is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Cancer Screening. 
The insurer denied Guardant 360CDx. 
The denial is overturned.

The patient is a female with history of breast cancer and lung cancer. Breast cancer diagnosis was established, stage tumor (T)2 node (N)0, estrogen receptor (ER) positive and human epidermal growth factor receptor 2 (her 2) positive, status post mastectomy followed by adjuvant chemotherapy with Herceptin and antiestrogen therapy (Tamoxifen followed by aromatase inhibitors [AI]). She was diagnosed with lung cancer, adenocarcinoma, staged as T1aN2 metastasis (M)0 and received adjuvant chemotherapy (Cisplatin doublet) after surgery. She was diagnosed with recurrent, now stage intravenous (IV) lung cancer with new areas of involvement of para-aortic and mediastinal lymphadenopathy. Diagnosis was confirmed by biopsy. Guardant 360 molecular profiling--next generation sequencing (NGS) was performed, and patient was found to have EGFR mutation--exon 19 deletion. She was started on therapy with Osimertinib. She is receiving Osimertinib.
The subject under review is whether the Guardant testing is likely to be more beneficial for this patient than standard treatment.

Next generation sequencing (NGS) testing (such as Guardant360 CDx) is now a standard practice in management of newly diagnosed lung cancer. National Comprehensive Cancer Network (NCCN) and European Society of Medical Oncology (ESMO) recommend routine testing of molecular profiling (NGS--Guardant 360CDx is one such commercially available test) at the time of diagnosis. NGS testing allows identification of molecular alteration for targeted therapies. NGS also provides prognostic tools, and many patients are able to enroll in clinical trials based on the discovery of molecular targets if standard Food and Drug Administration (FDA) approved therapies are not available. Obtaining information of the mutations status of following genes is a crucial step in formulating treatment plans for first line and subsequent line setting in lung cancer: epidermal growth factor receptor (EGFR), Anaplastic lymphoma kinase (ALK), proto-oncogene 1 (ROS), B-Raf Proto-Oncogen (BRAF), neurotrophin receptor tyrosine kinase (NRTK), erb-b2 receptor tyrosine kinase 2 (ERBB2), Kirsten rat sarcoma (KRAS) (G12C), mesenchymal-epithelial transition (MET), ret proto-oncogene (RET) and tumor mutation burden (TMB) status and Microsatellite instability (MSI) status.
In this particular case, due to this test, the patient was able to receive molecularly appropriate treatment (Osimertinib) based on the EGFR mutation. Such treatment is not possible without NGS testing such as Guardant360 CDx.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Cancer Screening. 
The insurer denied Guardant 360CDx. 
The denial is upheld.

The patient is a female diagnosed stage four (IV) adenocarcinoma of the lung. The Guardant360 assay was ordered. The subject under review is whether the requested assay is likely to be more beneficial for this patient than any standard treatment.

The health plan's determination is upheld.

The proposed health service, Guardant360CDx is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
According to National Comprehensive Cancer Network (NCCN) guidelines, the following markers are recommended to be tested in the selection of systemic therapy options in cases of advanced non-small cell lung cancer: epidermal growth factor receptor (EGFR), proto-oncogene 1 (ROS1), Anaplastic lymphoma kinase (ALK), BRAF, Kirsten rat sarcoma (KRAS), NTRK, programmed death ligand (PD-L1), mesenchymal-epithelial transition (MET), ret proto-oncogene (RET) and human epidermal growth factor receptor 2 (HER2).
Plasma cell-free/circulating tumor deoxyribonucleic acid (DNA) testing should not be used in lieu of a tissue diagnosis. False negative rates up to 30% have been reported with this type of testing. Standards of analytical performance characteristics have not been established and no guidelines exist regarding the recommended performance characteristics of this type of testing. Cell-free tumor deoxyribonucleic acid (DNA) testing can identify alterations that are unrelated to the lesion of interest. The use of such testing can be considered in situations where the patient is medically unfit for invasive tissue sampling or if there is insufficient material for molecular analysis.
Therefore, the use of Guardant360CDx is considered not the standard of care in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Cancer Screening. 
The insurer denied Guardant 360CDx. 
The denial is overturned.


The patient is a female with advanced adenocarcinoma of the lung. The Guardant360 CDx assay was obtained and is under review to determine whether the testing is likely be more beneficial than any standard treatment for the patient.

Yes, the Guardant assay is likely to be more beneficial for this patient than any standard treatment. This service is not a treatment. It is a laboratory assay to help guide treatment.
The use of next generation sequencing gene panels to guide the treatment of patients with metastatic lung cancer is recommended by the National Comprehensive Cancer Network (NCCN) Guidelines, which state "...t is recommended at this time that when feasible, testing be performed via a broad, panel-based approach, most typically performed by next generation sequencing (NGS).... The assay in question is Food and Drug Administration (FDA) approved and evaluates the cancer for the recommended biomarkers - epidermal growth factor receptor (EGFR), Anaplastic lymphoma kinase (ALK), proto-oncogene 1 (ROS1), mesenchymal-epithelial transition (MET), ret proto-oncogene (RET), Kirsten rat sarcoma (KRAS), and tropomyosin receptor kinase (TRK).
The authors of UpToDate state "...ext generation sequencing (NGS) overcomes many of the shortcomings of direct sequencing and allele-specific testing...It retains sensitivity even in specimens with low tumor cellularity, which is an improvement over direct sequencing, and can identify new abnormalities, which would not be detected by allele-specific testing. Moreover, NGS can often detect abnormalities that would historically be tested by fluorescence in situ hybridization (FISH)...". Finally, NGS panel testing has been demonstrated in multiple trials, to be less expensive than single gene testing for the recommended biomarkers. The service under review is not the subject of ongoing investigation for these purposes. For these reasons, the use of this assay would be considered a standard of care for this diagnosis in this clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crown Removal

Treatment D2750 white glass with high gold content crown on tooth #10 and tooth #8

The insurer denied coverage for D2750 white glass with high gold content crown on tooth #10 and tooth #8

The denial is upheld

Upon review of the documentation provided which includes copies of periapical radiographs, and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended replacement full coverage crowns for #8 and #10. The insurer has denied these services stating there is no clinical/ radiographic evidence, such as traumatic injury or decay, provided to support the necessity of this service and therefore these services do not meet medical necessity criteria.

The objective documentation provided for review is copies of radiographs. It appears that there is no evidence of fracture or other pathology specifically affecting #8 or #10 based on the images provided for review. There does not appear to be any radiographic evidence of caries or other factors that would necessitate replacement of these preexisting crowns. The radiographs do not substantiate the requested dental services as enumerated above and therefore the replacement crowns are deemed not medically necessary.

The documentation is insufficient to justify or substantiate the treatment.

The healthcare plan did act reasonably and with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for D2750 white glass with high gold content crown on tooth #10 and tooth #8 is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

According to the medical records, the patient has diagnoses of insulin dependent diabetes mellitus, cerebrovascular accident (CVA), hypertension, ulcerative colitis (UC), and hyperlipidemia.

Per progress note, the patient presented to the emergency room with complaint of blood sugar level of 524 milligrams per deciliter (mg/dl). His blood pressure was 167/104 millimeters of mercury (mmHg), and heart rate 110 beats per minute (bpm). Creatinine level was elevated 1.32; sodium 132; carbon dioxide 32; anion gap 4; and calcium 8.4.  An electrocardiogram (EKG) revealed T (interval on EKG) wave inversions in the lateral leads. Troponin was negative and the patient was admitted with hyperglycemia. The patient was afebrile, with no leukocytosis. Cardiac enzymes were negative. A rapid viral panel (RVP) was negative, and a chest x-ray (CXR) was clear. Intravenous (IV) fluids were given, and insulin was given as ordered. The patient's condition improved, and he was discharged with instructions to follow up with the primary care physician (PCP) within one week of discharge. 

"Diabetic ketoacidosis (DKA) is characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased body ketone concentration. It is a life-threatening complication of diabetes and is usually seen in patients with type-1 diabetes mellitus.

The patient did not meet diagnostic criteria for diabetic ketoacidosis (DKA).

Blood glucose (BG) greater than 250 milligrams per deciliter (mg/dl), (greater than 13.9 millimoles per liter (mmol/L)) with:

1) Arterial pH less than 7.35, venous pH less than 7.30, or serum bicarbonate level less than 15 milliequivalents per liter (mEq/L)

2) Ketonuria and/or ketonemia.

Specifically, his BG was 524 with a carbon dioxide (Co2) or bicarbonate of 32, anion gap of 4, and with no evidence of acidosis or ketonemia or ketonuria.
                                       
The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission is not considered medically necessary for this patient.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.