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

Diagnosis: Severe left knee osteoarthritis

Treatment: Inpatient hospitalization

The insurer is denied coverage for inpatient hospitalization.

The denial is upheld. 

This male patient has a history of hyperlipidemia, hypertension, obesity, Duane syndrome of the left eye, severe left knee osteoarthritis, tuberculosis, and right total hip arthroplasty.

The medical records demonstrate the patient underwent a non-complicated left total knee arthroplasty with limited comorbidities. His American Society of Anesthesiologists (ASA) score was 2. His surgery was approximately 2 hours with limited blood loss. There was no use of a drain. Post operatively his vital signs were stable. There were no signs of infection. There were no problems with his wound. His hematocrit was stable at 31. He was able to tolerate oral pain medication with effective regional block (visual analog scale [VAS] 3). He was able to walk 60 feet with physical therapy services. He did not require treatment for associated medical conditions. There were no extenuating circumstances to substantiate the admission and level of service as provided.

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 the inpatient hospitalization is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Community Acquired Pneumonia (CAP).

Treatment inpatient hospitalization

The insurer denied coverage for inpatient hospitalization

The denial is upheld

This patient with history a of hypertension (HTN), Renal Cancer, hyperlipidemia (HLD), and Barrett's esophagus presented to the emergency department (ED) with a 5 day history of fever, headache and cough. Fever was accompanied with night sweats and the patient reported temperature to 103.2F (Fahrenheit) at home. The patient had gone to urgent care and was referred to emergency department (ED).

Vital signs at presentation: Temperature (T) 39.2C (102.56F), Heart Rate (HR) 87, Respiratory Rate (RR) 18, Blood Pressure (BP) 139/85, and oxygen (O2) saturations 97% (percent) on room air. The patient looked ill but was in no acute distress (NAD). Physical exam was unremarkable. Lungs were clear.

White blood cell count (WBC) was 9.1K (thousand), hemoglobin (Hb) 15.8, electrolytes were within normal limits (WNL) blood urea nitrogen (BUN) / Creatinine were within normal limits.

Chest x-rays (CXR) revealed patchy left lower lobe (LLL) infiltrates. C-reactive protein (CRP) was elevated. Procalcitonin was 0.45. Lactate 1.2

The patient was diagnosed with community acquired pneumonia (CAP). Other differential diagnosis included temporal arteritis. The patient underwent a computed tomography (CT) of head and neck. There was no evidence of intercranial pathology or temporal arteritis noted.

The patient was pan cultured and viral studies were sent. The patient was seen by Infectious Diseases who recommended the patient be treated with Rocephin and Doxycycline. The patient remained stable after admission. The patient was afebrile HR 71, RR, 16 BP 136/56, and O2 saturations 95%. Some rales were noted at lung base. Neurologic exam: patient awake and alert, exam was non focal neurological exam. WBC was 6.4K, electrolytes were normal except for potassium (K+) at 3.1.

The patient was continued on Rocephin and Doxycycline. The patient remained stable and was switched to oral (PO) antibiotics - Doxycycline. The patient was discharged home.

This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated.  Observation could be for up to 48 hours. The patient's Pneumonia was mild with CURB 65 score (confusion, urea, respiratory rate, blood pressure) of Zero and a low pneumonia severity index (PSI).

The patient was not hypoxic. There were patchy infiltrates noted on CXR. There was no evidence of pneumothorax or pleural effusion. WBC was normal. The patient was stable to be discharged home on oral antibiotics after a period in observation.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Breast Cancer.
Treatment: Herceptin (J9355).
The insurer denied the Herceptin (J9355).
The denial is upheld. 

The patient is a female with metastatic human epidermal growth factor receptor II (HER2) positive (+) breast cancer.  The attending physician (AP) has been using with Herceptin (brand), Pejeta and Navelbine.  This was denied because the policy requires formulary preferred products.

No, the proposed Herceptin is not medically necessary.

Biosimilars are considered therapeutically equivalent to branded counterparts and are available on the formulary.  The National Comprehensive Cancer Network (NCCN) fully supports the use of trastuzumab biosimilar agents in place of brand Herceptin.  The use of biosimilar agents offers an alternative option on the formulary over Herceptin with equivalent therapeutic efficacy.  The attending physician (AP) can use a biosimilar as these have equivalent therapeutic efficacy.  Therefore, Herceptin is not medically necessary as a biosimilar on the formulary may be considered.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atherosclerotic Heart Disease
Treatment:  Praluent 75mg/ml SC SOAJ, Pre-service
The insurer denied the Praluent 75mg/ml SC SOAJ, Pre-service
The denial is upheld. 

The patient is a with history of CAD (coronary artery disease), status post PCI (percutaneous coronary intervention) of RCA (right coronary artery) and OM1 (obtuse marginal branch 1), as well as HTN (hypertension) and dyslipidemia.

As per the provided records, the patient previously did not tolerate atorvastatin 80 mg (milligrams) and Crestor 40 mg (milligrams). The patient's most recent LDL-C (low-density lipoprotein cholesterol) level is 119 mg/dL (milligrams per deciliter). Praluent injection was requested for management of dyslipidemia.

As per the letter from the insurance plan, there have been no claims paid for any statin medication for the last year. A trial of rosuvastatin 20 mg (milligrams) in combination with ezetimibe 10 mg (milligrams) was offered as a preferred alternative.

No, the requested treatment with Praluent is not medically necessary.

Praluent is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (CVD), who require additional lowering of low density lipoprotein cholesterol (LDL-C).

According to the records provided for review, the patient has a history of CAD (coronary artery disease), status post prior stents, as well as dyslipidemia. The patient had reported intolerance of high dose statins (specifically atorvastatin 80 mg [milligrams] and rosuvastatin 40 mg [milligrams]). There have not been any pharmacy claims for lower dose rosuvastatin. A trial of rosuvastain 20 mg (milligrams) in combination with ezetimibe, as suggested in the denial letter, would be a reasonable preferred alternative in this clinical scenario. Therefore, the medical necessity of Praluent could not be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, normal pressure hydrocephalus and ataxia
Treatment: Increase Home Care/Personal Care Level 2 Services from 35 Hours To 84 Hours Per Week
The insurer denied the Increase Home Care/Personal Care Level 2 Services from 35 Hours To 84 Hours Per Week

The denial is upheld. 

The patient is a female with diagnoses including dementia, normal pressure hydrocephalus and ataxia. The patient lives alone. The appeal is regarding denial of increase Home Care/Personal Care Level 2 Services from 35 hours to 84 hours per week.

The patient's UAS (Uniform Assessment System) evaluation completed shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, and transportation; extensive assistance with stairs; and supervision with bathing, personal hygiene, dressing, walking, locomotion, bed mobility, and eating. She is occasionally incontinent of urine.

A letter from the patient's provider notes the patient has poor cognition secondary to dementia and needs 24 hours supervision. The patient also has ataxia and needs frequent changes due to urinary incontinence. A letter from another provider notes the patient has a progressive cognitive disorder to Alzheimer's disease. The letter notes the patient needs assistance with ADLs (activities of daily living). The letter further notes the patient is unsafe if left home alone, and the patient needs around-the-clock monitoring. A letter from another provider notes the patient needs assistance with ADLs (activities of daily living).

No, the Increase in Home Care/Personal Care Level 2 Services from 35 Hours To 84 Hours Per Week is not medically necessary.
Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This appeal is regarding denial of increase Home Care/Personal Care Level 2 Services from 35 hours to 84 hours per week.

The UAS (Uniform Assessment System) evaluation completed shows the patient needs assistance with meal preparation, housework, managing finances, and shopping, managing medications, transportation, and stairs. She is able to perform other ADLs/IADLs (activities of daily living/instrumental activities of daily living) with supervision. She is occasionally incontinent of urine. Appeal letters note the patient has progressive dementia and needs assistance with ADLs (activities of daily living) as well as supervision. This patient has been approved for personal care service 35 hours per week. This is sufficient to meet this patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living). Personal care service is not indicated for supervision. The proposed increase in personal care service to 84 hours per week is not medically necessary to meet this patient's need for assistance with ADLs (activities of daily living) and personal care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical Spinal Fracture.

Treatment: Inpatient admission.

The insurer is denied coverage for inpatient admission.

The denial is overturned. 

The patient is an adult female patient that was involved in a motor vehicle accident. She sustained a cervical spinal fracture, developed paraplegia, and required cervical spine surgery. The patient was eventually admitted to the hospital. She was transferred back to the acute care hospital due to seizures. 

This physician disagrees with the insurer regarding the patient's reported inability to participate in hours of therapy. The patient was evaluated by the physical therapist at the acute hospital, indicating she could tolerate 3 hours of therapy. Similar opinions were provided by the nurse practitioner and the physical therapist. The patient clearly has functional impairments that should be addressed by a comprehensive inter-disciplinary team that includes physical, occupational and speech therapy. Her blood pressure fluctuations, grade 3-4 pressure ulcers and underlying osteomyelitis requiring intravenous (IV) antibiotics also support the necessity for inpatient physician and skilled nursing care. Acute inpatient rehabilitation is the most appropriate level of care for this patient.

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient in this particular case. Considerations include the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations. All decisions are evidence-based.    

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, inpatient admission was medically necessary.

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Medulloblastoma

Treatment: Ibrance 75 milligram (mg) tab (tablet)

The insurer denied coverage for Ibrance 75 milligram (mg) tab.

The denial is upheld.

According to the available medical record and documents, the patient is a child with a diagnosis of medulloblastoma. The patient was enrolled on Head Start 4 (multi-agent chemotherapy with stem cell rescue) . She received chemotherapy, radiation and underwent craniectomy and resection. She has had recurrence and a sample of her recurrent tumor underwent organotypic slice culture. Palbociclib treatment showed the strongest drug-response by this organotypic slice culture testing. The treating team suggests treatment with Irinotecan, temozolomide and palbociclib/Ibrance. 

Ibrance does not have approval, but this is common for many agents used in pediatric oncology so not necessary and not a reason to withhold supplying this agent if it were otherwise supported by the literature. The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. It is unclear if the patient is a good candidate for Ibrance.  There is limited evidence to support the efficacy of palbociclib in medulloblastoma patients. (ref 1)

While the theoretical argument for treatment with Ibrance is appreciated, the treating team's own records note "Organotypic Slices Culture (experimental biology program) which highlights that this approach is experimental.  While rational in theory, it is unclear if this approach will increase survival for pediatric brain tumor patients or this patient specifically.  The appeal letter did not provide ample peer-reviewed support of this approach, and this reviewer was unable to find sufficient support in a Pubmed search.

The adverse risks are possibly increased over standard treatment/services. The treating team suggests combination treatment with temozolomide and irinotecan. There is limited published evidence regarding the safety of this combination in children.

The Children's Oncology Group recently published the efficacy and safety of temozolomie, irinotecan and bevacizumab for pediatric patients with recurrent medulloblastoma (ref 2). The treating team suggests using palbocilib based on an experimental approach rather than using a published approach with known toxicity profile for this combination therapy.  The literature does not yet support that palbociclib will more likely be successful. 

Ibrance for the treatment of this patient's clinical circumstance is not likely to be more beneficial than any other standard treatments.

Based on the above Ibrance 75 milligram (mg) tab for the treatment of medulloblastoma  is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, stroke. 
Treatment: Increase Personal Care Worker (PCW) Service From 7 Days Per Week 4 Hours Per Day To 7 Days Per Week, 8 Hours Per Day. 

The insurer denied the increase in personal care worker (PCW) service from 7 days per week, 4 hours per day to 7 days per week, 8 hours per day. 
The denial is overturned. 

The patient is a female with a history of coronary artery disease and stroke. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 56 hours/week Personal Assistance Services to offer increased ADL support. 

Yes, the requested increase in personal care worker (PCW) service to 7 days per week, 8 hours per day is medically necessary. 

Although an assessment of the patient's functionality and ability to perform ADLs was completed and noted that the currently approved plan is sufficient to meet the patient's current needs, the patient's advocate relates this reduced schedule leaves her home alone, completely unassisted for at least numerous hours/day. This is problematic, as she currently requires assistance with personal hygiene, dressing, toileting, meal prep and feeding. 

Hence, provision of 56 hours/week Personal Assistance Services can reasonably be expected to be beneficial for the patient, and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the requested 56 hours/week Personal Care Worker is deemed medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Unilateral Coronal Synostosis.

Treatment: Craniodysmorphology Panel.

The insurer denied coverage for craniodysmorphology panel.

The denial is overturned.

According to the medical records, the patient is an infant born with right-sided unicoronal craniosynostosis. She has been scheduled to have surgery for an anterior cranial vault expansion and remodeling due to persistent right plagiocephaly. This was originally diagnosed when she was three months old. She initially had surgery. She does not appear to have any other medical problems. The doctor was also recommending that she have her blood drawn for a craniosyostosis gene panel to look for a genetic cause to "help direct care, which can lead to improved outcomes."

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

Regardless of the genetic and nongenetic factors underlying the disease pathogenesis, patients with a craniosynostosis need a multidisciplinary approach and close collaboration between pediatricians, neurosurgeons, psychologists, imaging specialists, geneticists, and laboratory diagnosticians. The identification of the genetic defect, although very important for disease prognosis and treatment decisions (e.g., in the case of early surgical intervention), also allows to identify the persons' genetic risks and to give proper genetic counseling for the patients' families (3)."      

Genetic sequencing panels do not have Food and Drug Administration (FDA) approval for specific diagnoses. The technology itself can be used for a large number of diagnoses, known or previously unknown. Technical and clinical performance of the genetic test is supported by published peer-reviewed medical literature." Guidelines from the American College of Medical Genetics and Genomics have been established (4).     

As she has coronal craniosynostosis, this patient a good candidate for a craniodysmorphology panel.  This panel would be one part of a workup to find a possible reason for craniosynostosis. The surgical treatment that is also going to be performed can help correct some of the problems from the craniosynostosis. These work side-by-side but should not be considered to be replacements for each other.     

This is solely a blood test, so there are no adverse risks for this service.     

This testing is beneficial along with her other craniosynostosis team evaluations and her surgery. As stated by Kutkowska-Kazmierczakn A. et al..,                                                    

The carrier's denial of craniodysmorphology panel should be overturned. 

The patient a good candidate for a craniodysmorphology panel and it is the best available testing for this patient at this time. The requested service is likely to be more beneficial than any of the standard testing for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Unilateral Coronal Synostosis.

Treatment: Craniodysmorphology Panel.

The insurer denied coverage for craniodysmorphology panel.

The denial is upheld.

This infant has a history of right unilateral coronal craniosynostosis.  The documentation indicated the patient is scheduled to have an anterior cranial vault remodeling/expansion reconstructive surgery to enlarge her cranial fossa and allow her brain more ventricle.  The documentation indicated the physician scheduled to perform the procedure has ordered genetic testing at the time of surgery It is noted the patient underwent craniotomy.  The documentation detailed there were no complications.  The request has been made for genetic testing.

There is no significant literature to support the need for such genetic testing when evaluating for craniosynostosis. The diagnostic utility of existing panels for nonsyndromic craniosynostosis; however, is extremely low.

These tests have not been approved by regulatory bodies as standard of care. This patient has a likely non-syndromic craniosynostosis.

This can help with providing prognosis once diagnosis is established and confirmed. The diagnostic yield is very low. Recent genetic studies have identified several novel genes and pathways that cause nonsyndromic craniosynostosis, providing genetic evidence linking the causes of syndromic and nonsyndromic craniosynostoses, and allowing for genotype-based prediction of risk of recurrence in some nonsyndromic families.

There is no known harm in obtaining the test.

The panel is not the best available treatment for this patient at this time. The requested service is not likely to be more beneficial than any of the standard testing for this patient. The procedure offers no direct benefit or harm to the patient. The results could assist with informing the prognosis of known entities. It is not considered to be a standard of care and the information serves as more of an academic rather than practical or intervenable test.
The carrier's denial of craniodysmorphology panel should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Unilateral Coronal Synostosis.

Treatment: Craniodysmorphology Panel.

The insurer denied coverage for craniodysmorphology panel.

The denial is overturned.

The patient has unilateral coronal synostosis, and per the recommendations of Timberlake and Persing, genetic counseling is indicated to inform the family of the risks of passing on the gene to future offspring. 

According to a review by Timberlake and Persing: "Recent genetic studies have identified several novel genes and pathways that cause nonsyndromic craniosynostosis, providing genetic evidence linking the causes of syndromic and nonsyndromic craniosynostoses, and allowing for genotype-based prediction of risk of recurrence in some nonsyndromic families. Based on analysis of exome sequence data from 384 families, the authors provide recommendations for a new genetic testing protocol for children with nonsyndromic craniosynostosis, which include testing nonsyndromic cases of sagittal, metopic, and coronal craniosynostosis."  Genetic testing will allow for more accurate genetic counseling for this patient's family given their child is diagnosed with unilateral coronal synostosis. 

The patient has unilateral coronal synostosis, and per the recommendations of Timberlake and Persing, genetic counseling is indicated to inform the family of the risks of passing on the gene to future offspring. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. The patient a good candidate for a craniodysmorphology panel and is the best available testing for this patient, at this time. The requested service is likely to be more beneficial than any of the standard testing for this patient.

The panel is the only intervention that will allow for accurate familial genetic counseling about the future risks of craniosynostosis. There are no adverse risks.

The carrier's denial of craniodysmorphology panel should be overturned.