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

Diagnosis:  Very early onset inflammatory bowel disease
Treatment: Humira
The insurer denied Humira.
The health plan's determination is upheld.

This is a male patient with a history of very early onset inflammatory bowel disease (VEO-IBD), ulcerative colitis. He has tried and failed mesalamine and Entyvio (vedolizumab). The requested service is Humira (Adalimumab), in addition to Entyvio. At issue is whether the Humira is medically necessary for this patient.

This child has a severe case of very early onset inflammatory bowel disease. There are no Food and Drug Administration (FDA) approved treatments for this age group. The current standard of care is to manage VEO-IBD with the available therapies for older age groups (including infliximab and Humira). The current peer reviewed literature supports using tumor necrosis factor inhibitors, such as Humira, in treating VEO-IBD.
However, there is no sufficient scientific evidence supporting the concurrent use of Humira and Entyvio in treating pediatric ulcerative colitis. The available literature is mainly from case reports and does not allow a well-supported conclusion regarding the long term safety or efficacy of this combination. The clinical practice guidelines have not yet adopted concurrent use of biologics in treating pediatric inflammatory bowel disease.
The requested dual therapy is not well supported by scientific evidence and not consistent with the generally accepted practices. The patient has not tried and failed monotherapy with Humira. Medical necessity cannot be established based on the available literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: atypical parkinsonism
Treatment: PCS (personal care services) hours 24 hours a day, 7 days a week (Live-In) 
The insurer denied PCS hours 24 hours a day, 7 days a week (Live-In) 
The health plan's determination is overturned. 

This is a case review for a female with medical history notable for atypical parkinsonism. The patient and her care team requested an increase to 24 hours per day, 7 days per week live-in personal care services (PCS).

The requested PCS hours 24 hours a day, 7 days a week (Live-In) is medically necessary for this patient.
The documentation provided demonstrates that the patient is completely reliant on others for all activities of daily living and instrumental activities of daily living. She requires assistance with toileting, transfers, bed mobility, and incontinence care. She is unable to direct her own care. Her care needs are by definition continuous and unscheduled throughout any given 24-hour period. Her family is unable to provide any consistent informal support. Therefore, it is medically necessary for the patient to receive 24-hour live-in personal care to address all of her needs. Failure to provide for her needs could result in injury, skin breakdown, and/or infection.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: decreased mobility
Treatment: home health care
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: Increase to 24 Hours per Day (Live In).
the health plan's determination is overturned. 

This is a case review for a female with medical history notable for dementia, incontinence, and gait abnormality. The patient's cardiologist provided a letter of support for this appeal. The letter states that the patient requires hands-on assistance and prompting for all activities of daily living, including ambulation, toileting, transfers, and bathing. Due to her dementia, she does not always recognize that she needs to complete personal care tasks and requires cueing. She is unable to navigate trips to the bathroom during the day and night. The physician notes that the patient is medically stable and able to remain safely in her home if she is provided with adequate personal care assistance.

The requested Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: Increase to 24 Hours per Day (Live In) is medically necessary for this patient.

The patient's most recent assessment was from earlier this year, and this assessment showed a fairly sharp decline in functional status from the prior assessment. More than 6 months have elapsed since the time of that assessment. The letters from her family and physician report that her functional status has worsened, which is not surprising given the progressive and incurable nature of her conditions. She requires personal care assistance with all activities of daily living. Her personal care needs can be expected to be continuous and unscheduled throughout the day and occasionally at night as well. Therefore, the request for 24-hour live-in personal care is medically necessary for the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Stage IV Squamous Cell Lung Cancer

Treatment: Proton Beam radiotherapy and associated services: 77520 - Proton treatment delivery; simple, without compensation; 77523 - Proton treatment delivery; intermediate; 77525 - Proton treatment delivery; complex and coverage for the requested treatment

The insurer denied coverage for Proton Beam radiotherapy and associated services: 77520 - Proton treatment delivery; simple, without compensation; 77523 - Proton treatment delivery; intermediate; 77525 - Proton treatment delivery; complex and coverage for the requested treatment.

The denial is upheld. 

This is the case of a patient with Stage 4 squamous cell carcinoma, Epidermal Growth Factor Receptor (EGFR) exon 19 deletion, status-post carboplatin/Taxol/pembrolizumab with programmed death (PD) followed by afatinib with PD. The patient is status-post palliative thoracic radiation therapy (RT) and stereotactic body radiotherapy (SBRT) to T (thoracic) 3 and left sacrum.  The patient had further PD and started gemcitabine and has multifocal >10 brain metastases status-post stereotactic radiosurgery (SRS) to larger metastases and started Osimertinib with response, with recent oligoprogression at T1 status post stereotactic body radiotherapy SBRT now with oligoprogression in the previously radiated left lung.

This patient presented with stage 4 incurable cancer 2 years ago. The patient was treated with multiple courses of chemotherapy, immunotherapy and radiation.  This is a palliative situation, and it is unclear why such high dose of radiation is given to the lung.

The scientific evidence in peer-reviewed literature does NOT support a result of improvement in health outcomes.

Proton beam has final approval for lung cancer.

This patient is NOT a good candidate for Proton Beam radiotherapy and associated services.

This treatment is NOT the best available treatment for this patient at this time.

The adverse risks are increased over standard treatment/services if such high dose of RT (radiotherapy) is used.

In summary, the denial of Proton Beam radiotherapy and associated services: 77520 - Proton treatment delivery; simple, without compensation; 77523 - Proton treatment delivery; intermediate; 77525 - Proton treatment delivery; complex 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 risk are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic jaw pain
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
Patient is an adult with a past medical history significant for hypertension (HTN), hyperlipidemia, atrial fibrillation, chronic obstructive pulmonary disease (COPD), implantable cardioverter defibrillator, and gastroesophageal reflux disease (GERD) who presented to the emergency department (ED) with complaints of chronic jaw pain for six months. 

Vital signs on presentation included: Temperature -98.1 degrees Fahrenheit, Blood Pressure -104/67, Pulse -70 beats per minute (bpm), Respiratory Rate -17, oxygen (O2) saturation -98% on room air (RA). Laboratory values were notable for the following: White blood cell count (WBC) -9.1k, hemoglobin (Hgb) -12.3, hematocrit (Hct) -38.5, glucose-97, creatinine-1.31.

The patient was empirically started on intravenous (IV) antibiotics (Ampicillin/Sulbactam) for possible odontogenic infection. Maxillofacial computed tomography (CT) scan showed diffuse osteosclerosis of the entire left mandible with periosteal reaction, and diffuse left facial tissues swelling. Oral and maxillofacial surgery (OMFS) consulted and deemed no surgical intervention was required. Patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics as an outpatient. 

According to documentation, patient presented with a chronic jaw pain for six months. 
Otherwise, was afebrile, hemodynamically stable with no evidence for systemic toxicity. Laboratory values were unremarkable including a normal WBC. OMFS deemed no surgical interventions was required; the patient was placed on oral antibiotics. Based on above findings, patient met criteria for observation level of management. The patient did not fulfill criteria for acute inpatient admission. 

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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hernias
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a female patient who presented to the hospital to undergo the scheduled repair of two ventral hernias and concomitant bilateral breast reduction. Her past medical history included thyroid disease. She refused a blood transfusion. The vital signs were normal at the time of presentation to the hospital.

The records indicate that the patient underwent repair of the ventral hernias and breast reduction. The records do not document the hernia defect size, but state that the abdominal wall was undermined to the xiphoid via a lower abdominal incision of 20-centimeter (cm) length (abdominoplasty). The hernia sac was closed with suture and the abdominal wall was imbricated with suture. Overlay mesh was placed. The abdominal wall was excised of excess tissue. Surgical drains were placed. The records state that the operation was completed without complication and she was stable at the time of transfer to the recovery area. 

The patient was provided intravenous (IV) fluid. She remained hemodynamically stable and was deemed to be stable for discharge from the hospital.

At issue is the medical necessity of an inpatient stay.

Based on the information provided, inpatient level of care was not required or medically necessary for this patient.

This patient presented to the hospital for the scheduled procedure of bilateral breast reduction, abdominoplasty, and ventral hernia repair. She was hemodynamically stable at the time of presentation. The operation was completed without complication. The patient responded promptly and appropriately to IV fluid resuscitation. She was tolerating a diet and oral medications.

Per generally accepted guidelines for patient care, inpatient stay is needed for hemodynamic instability, peritoneal signs, suspected acute mesenteric ischemia, foreign body ingestion with signs of obstruction, surgical complications or other clinical issue that requires inpatient confinement. In this case, there is no documentation to support that these criteria existed to warrant an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces and Monthly Visits
The insurer denied: Braces and Monthly Visits
The denial is overturned.

The patient is a teenage female. The request is for orthodontic benefits and monthly visits. Patient has a Class III (reverse bite) malocclusion. She has mild upper and moderate lower spacing. The health plan's prior denial of the request was due to a score of 9 points on the handicapping index scale. The denial is being appealed.

The Braces and Monthly Visits are medically necessary.

The patient has a Class III malocclusion, which is when her lower front teeth are in front of her upper front teeth. There is a crossbite with clinical attachment (gum) loss with gingival recession. This is an automatic qualifier for orthodontic benefits according to the handicapping index scale. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vasovagal syncope
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay. 
The determination is upheld.

This is a male patient with a past medical history (PMH) of hypertension (HTN), generalized anxiety disorder (GAD), major depressive disorder (MDD), hepatic cirrhosis, and recurrent syncope status/post (s/p) negative cardiology work-up who was admitted with complaints of (c/o) syncope while driving. His vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD). Lab work was notable for hypokalemia. Imaging studies, including a computed tomography (CT) scan of the head showed no acute intracranial pathology, CT of the abdomen/pelvis (A/P) showed mild ascites, sigmoid colitis (patient denied change in bowel habits), chest x-ray (CXR) showed no active pulmonary disease. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) with non-specific ST-T changes. The patient was diagnosed with vasovagal syncope and treated with clinical monitoring, expert consultations, and intravenous fluids (IVF). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) syncope. The patient did not have structural heart disease, hematocrit (HCT) less than (<) 30, shortness of breath (SOB), hypotension, or family history of sudden cardiac death. Additionally, the patient did not have any history of dilated cardiomyopathy, aortic stenosis, hypertrophic cardiomyopathy (HCM), left ventricular outflow disease, pre-excitation syndrome, Brugada syndrome, QT interval abnormalities or conduction blocks. The patient did not have a subarachnoid hemorrhage, pulmonary embolism, acute gastrointestinal (GI) bleed, malignant arrhythmia, sustained bradycardia, supraventricular tachycardia (SVT) or ventricular tachycardia (VT), confirmed acute coronary syndrome (ACS), evidence of heart failure, cerebrovascular accident (CVA), shock, coma major trauma or cardiac arrest, or exertional syncope. Cardiology evaluated the patient and doubted cardiac origin of the syncope and recommended outpatient transthoracic echocardiogram (TTE). The patient was diagnosed with vasovagal syncope and treated with clinical monitoring, expert consultations, and IVF. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mobility issues. 
Treatment: Personal Care Services (PCS) 24 hours per day, 7 days per week (split shift) for a total of 168 hours. 
The insurer denied Personal Care Services (PCS) 24 hours per day, 7 days per week (split shift) for a total of 168 hours. 
The health plan's determination is upheld. 

This is a female patient with a history of hypertension, hyperlipidemia, lumbar disc disease with history of spinal surgery, neuropathy, osteoarthritis, urinary incontinence, recurrent urinary tract infection (UTI), osteopenia, history of falls with back and foot injuries, recurrent foot fractures, colon fistula, and gastroesophageal reflux disease (GERD). She lives alone. She has one son who lives nearby and visits on the weekends. 

The Personal Care Services 24 hours per day, 7 days per week (split shift) is not medically necessary. 
Split-shift care requires proof that a PCA (personal care assistant) would be unable to receive 5 hours of uninterrupted rest per 24 hours. While the patient requires hands-on assistance for many activities of daily living (ADL) and Instrumental activities of daily living (IADL), there is no documentation showing that patient currently requires frequent care overnight such that a PCA would be unable to receive 5 hours of uninterrupted rest. There were no night-logs of care required overnight. There was no documentation of physician orders for frequent repositioning. Therefore, there is insufficient evidence of medical necessity for the requested increase in PCA hours. Additional hours are not provided when tasks are not being performed and for safety monitoring and supervision only.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay
The determination is upheld.

This is a male patient who presented to the emergency department (ED) after a 15-minute episode of chest, back and left arm pain. His medical history was remarkable for type 2 diabetes, hypertension, hyperlipidemia, coronary artery disease, myocardial infarction and percutaneous coronary intervention. His physical exam was remarkable for chest wall tenderness. An electrocardiogram showed sinus rhythm without acute changes. A chest x-ray showed no acute pathology. His serum troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. The patient was treated with acetaminophen and was admitted to the hospital. A beta-blocker was prescribed along with his home medications. A cardiac catheterization was performed and showed nonobstructive disease. The patient was discharged. The medical necessity for an inpatient admission is at issue.
 Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient, with known coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline
for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3:

Diagnosis: pelvic venous disease.

Treatment: endovascular occlusion of the ovarian and/or internal veins

The insurer denied coverage for endovascular occlusion of the ovarian and/or internal veins

The denial is upheld

The insurer has denied coverage for endovascular occlusion of the ovarian and/or internal veins. 

Pelvic congestion syndrome (PCS), also known as chronic pelvic pain syndrome or pelvic venous incompetence, is caused by utero-ovarian varices. PCS is defined by engorged pelvic veins of more than 10 millimeters (mm) diameter on selective transuterine venography in multiparous, premenopausal women with a history of chronic, noncyclic pelvic pain for more than six months.

Two randomized clinical trials suggest that medical treatment with gonadotropin-releasing hormone agonists or synthetic progestins effectively decrease pain associated with pelvic congestion:

Other treatments for pelvic congestion syndrome, which have not been subjected to randomized clinical trials, include:

1)Hysterectomy and bilateral salpingo-oophorectomy.
2)Embolization of the ovarian veins with or without the internal iliac veins.
3)Sclerotherapy.
4)Surgical ligation of the ovarian vein. 

Efficacy of these treatments is supported only by observational data and case reports. 

Evidence in the published peer-reviewed medical literature investigating the use of embolization for pelvic congestion syndrome (PCS) exists primarily in the form of small case series and cohort studies with mixed results. 

The optimal diagnostic approach for PCS-related pelvic pain remains unclear, and controlled trials comparing medical and interventional treatments are urgently needed for PCS-associated pelvic pain. 

Additional well-designed randomized controlled trials are needed to evaluate the safety and effectiveness of embolization therapy as a treatment for PCS.

The procedure 37241 x 1, closing of blood vessels in the pelvis.  is not considered more beneficial for this patient's diagnosis.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

Endovascular occlusion of the ovarian and/or internal veins does not need approval from the appropriate regulatory bodies for this diagnosis. 

Due to lack of scientific evidence of health improvement, it is unknown if this patient is a good candidate for endovascular occlusion of the ovarian and/or internal veins.

Endovascular occlusion of the ovarian and/or internal veins is not the best available treatment for this patient at this time.

The adverse risks are increased over standard treatment/services.

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of (37241) endovascular occlusion of the ovarian and/or internal veins 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.