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

Diagnosis: Alzheimer's disease.
Treatment: Home health care.
The insurer denied  Consumer Directed Personal Assistance Service (CDPAS): 168 Hours per Week.
The health plan's determination is upheld.

The patient is a female with past medical history of Alzheimer's dementia, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), diabetes mellitus type 2, depression, osteoporosis, pulmonary sarcoidosis, tremor, peripheral vascular disease, and sleep apnea who was hospitalized with subsequent rehabilitation stay with COVID-19 infection and pneumonia. The patient underwent an assessment tool via telephone assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, and shopping while maximum assistance with tasks of managing medication, phone use, equipment management, and bathing. The patient was assessed at extensive assistance with tasks of transportation, dressing upper/lower body, transfer toilet, and toilet use while limited assistance with tasks of personal hygiene, walking, locomotion, and bed mobility. With the task of eating the patient was assessed at supervision only. 

Consumer Directed Personal Assistance Service (CDPAS): 168 Hours per Week are not medically necessary for this patient..

There is documentation of cognitive decline of the patient since a recent hospitalization; however, the occupational and physical therapy notes as well as the note from the physician at rehabilitation document that the patient requires 24 x 7 supervision and remains independent with mobility, ambulation, eating, and bathroom needs. The patient does not have unscheduled or unpredictable needs. The requested increase in CDPAS services is solely for safety and supervision. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Consumer Directed Personal Assistance Service (CDPAS): 168 Hours per Week are not medically necessary for this patient. The hours stipulated by the health plan are adequate to meet the patient's needs at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of Breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with history of hypertension, coronary artery disease (CAD), ischemic cardiomyopathy and chronic combined systolic and diastolic congestive heart failure (CHF) - known left ventricular ejection fraction (LVEF) of 30% (percent).  The patient presented with acute on chronic combined systolic and diastolic congestive heart failure (CHF). His symptoms included shortness of breath and leg swelling. Labs showed elevated brain natriuretic peptide (BNP) of 1541 and troponin of 0.06. Transthoracic echocardiogram (TTE) showed left ventricular ejection fraction of 31% and large pleural effusion. Cardiac catheterization showed patent stents. The patient was treated with intravenous (IV) Lasix, bi-level positive airway pressure (BiPaP) and guideline directed medical therapy. 

The health plan denied coverage of the inpatient admission on the basis that it was not medically necessary. The health plan posits that the patient could have been treated at an observation level of care. The treating facility appealed this decision, contending that the admission was medically necessary.

Yes, the proposed inpatient admission was medically necessary.
The full inpatient admission to manage decompensated systolic and diastolic congestive heart failure (CHF) with intravenous diuretics and bi-level positive airway pressure (BiPaP) was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient presented with acute on chronic combined systolic and diastolic congestive heart failure (CHF). His symptoms included shortness of breath and leg swelling.  This patient presentation chest a x-ray showing pulmonary edema and was deemed to have decompensated New York Heart Association (NYHA) Class IV congestive heart failure (CHF) symptoms. The medical literature demonstrates reduced readmission for managing acute decompensated heart failure patients as inpatient with full admission.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Verruca Vulgaris. 
Treatment: Cidofovir 3% topical cream. 

The insurer denied coverage for cidofovir 3% topical cream. 

The denial is upheld. 

The patient is a female with verruca vulgaris who has failed therapy with liquid nitrogen.  The requested medication is cidofovir 3% topical cream. 

Based on the submitted documentation, Cidofovir cream is not medically necessary. There is no documentation provided to show that the patient has a contraindication to commonly used treatments for verruca vulgaris, including topical imiquimod, topical cantharidin, and intralesional candida antigen. Candida antigen and imiquimod are well documented to treat verruca and are available treatment options that are within the standard of care. The requested medication is unlikely to be more effective or have a lower side-effect profile than available formulary alternatives commonly used in the treatment of warts. The appeal is upheld based on the information provided and the documentation submitted. 

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

The insurer's denial of coverage for Formulary Exception for cidofovir dihydrate compound is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heartburn
Treatment: Esophagogastroduodenoscopy
The insurer denied Esophagogastroduodenoscopy. 

The health plan's determination is upheld. 

The patient is a female. She presented with increasingly frequent and severe persistent heartburn; she was not on any medical therapy. Esophagogastroduodenoscopy showed a small area of nodular mucosa at the gastroesophageal junction, a small sessile polyp in the gastric fundus, mild erosions in the gastric body, mild gastritis in the gastric antrum, and normal duodenum; biopsies showed mild chronic inactive carditis in the gastroesophageal junction, mild chronic inactive gastritis, fundic gland polyp, and reactive duodenal changes. Under review is the medical necessity of the esophagogastroduodenoscopy.

The esophagogastroduodenoscopy is not medically necessary based on the submitted documentation. Clinical guidelines (including the American College of Gastroenterology guidelines for the treatment of gastroesophageal reflux disease, and guidelines for dyspepsia) recommend endoscopy for investigation of upper gastrointestinal symptoms when those symptoms are refractory to proton pump inhibitor taken properly for 4-8 weeks without response. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that endoscopy is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful. Current medical literature continues to support these recommendations.
In this case, there is no documented proton pump inhibitor therapy for at least 4 weeks before the endoscopy. For these reasons, the esophagogastroduodenoscopy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dyspepsia
Treatment: Esophagogastroduodenoscopy (EGD)
The insurer denied Esophagogastroduodenoscopy (EGD). 
The health plan's determination is upheld. 

The patient is a female with heartburn and functional dyspepsia. There are limited clinical records provided. The patient is taking pantoprazole as indicated from the endoscopy report. The patient underwent an esophagogastroduodenoscopy (EGD) for the evaluation of her heartburn and dyspepsia. The endoscopic and biopsy results were consistent with chronic gastritis. No metaplasia, dysplasia or H (Helicobacter) pylori were identified.

An Esophagogastroduodenoscopy (EGD) was not medically necessary for this patient.
Based on the guidelines [1], for patients lacking worrisome symptoms, the recommendation is to first test non-invasively for H pylori with either the stool antigen or urea breath test. If this testing is negative, the next step is an empiric trial of proton pump inhibitor (PPI) therapy for 4-8 weeks. If this is unhelpful sequential trials for symptom relief with a TCA (tricyclic antidepressant) followed by a promotility drug are recommended. If this is unhelpful than upper endoscopy is recommended. In standard practice in the US (Unites States), upper endoscopy is usually pursued after negative H pylori testing and failure to respond to a PPI. None of this is documented in the records provided for review.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Cancer Screening. 
The insurer denied Gene profiling. 
The denial is upheld.

This is a male with prior abnormal prostate biopsy. Initial biopsy was done for elevated prostate-specific antigen (PSA). ExSome Dx testing was recommended as part of his continued diagnostic workup. The subject under review is whether the testing is likely to be more beneficial than any standard treatment for the patient's condition.

Current literature does not endorse this test as beneficial to long term health care outcomes.
Current American Urological Association (AUA) guidelines state, "While the benefits of PSA-based prostate cancer screening have been evaluated in randomized-controlled trials, the literature supporting the efficacy of digital rectal exam (DRE), PSA derivatives and isoforms (e.g. free PSA, -2proPSA, prostate health index, hK2, PSA velocity or PSA doubling time) and novel urinary markers and biomarkers (e.g. prostate cancer antigen 3 [PCA3]) for screening with the goal of reducing prostate cancer mortality provide limited evidence to draw conclusions. While some data suggest use of these secondary screening tools may reduce unnecessary biopsies (i.e., reduce harms) while maintaining the ability to detect aggressive prostate cancer (i.e., maintain the benefits of PSA screening), more research is needed to confirm this."
National Comprehensive Cancer Network (NCCN) guidelines note that biomarkers for the diagnosis of prostate cancer have not been subjected to randomized controlled studies and have been marketed with significant industry influence.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Cancer Screening. 
The insurer denied Gene profiling. 
The denial is upheld.

The patient is a male with a diagnosis of fluctuating prostate-specific antigen (PSA). Prostate biopsies showed atypic. Exosome Gene paneling is being considered. The subject under review is whether the testing is likely to be more beneficial than any standard treatment for the patient's condition.

The proposed testing is not likely to be more beneficial than any standard treatment for the patient's condition.
The National Comprehensive Cancer Network (NCCN) Guideline for early detection of prostate cancer, 2019 states, "Biomarkers that improve the specificity of detection are not, as yet, mandated as first-line screening tests in conjunction with serum PSA. However, there are may be some patients who meet PSA standards for consideration of prostate biopsy, but for whom the patient and/or the physician wish to further define the probability of high-grade cancer. The panel recommends consideration of percent free PSA (percentage [%] of PSA), Prostate Health Index (PHI), 4Kscore, or ExoDx Prostate Test (EPI) in patients with PSA levels greater than (>)3 nanograms per milliliter (ng/mL) who have not yet had a biopsy. %free PSA, Prostate Health Index (PHI), 4Kscore, EPI, Prostate Cancer 3 (PCA3), and ConfirmMDx may also be considered for men who have had at least one prior negative biopsy and are thought to be at higher risk. Results of biomarker assays can be complex and should be interpreted with caution."
European Association of Urology (EAU) Guidelines for prostate cancer 2019 states, "Multiple tools are now available to determine the need for a biopsy to establish the diagnosis of a prostate cancer (PCa), including imaging by magnetic resonance imaging (MRI), if available. New biological markers such as TMPRSS2-ERG fusion, prostate cancer antigen 3 (PCA3) or kallikreins as incorporated in the Phi or 4Kscore tests have been shown to add sensitivity and specificity on top of PSA, potentially avoiding unnecessary biopsies and lowering over-diagnosis. At this time there is too limited data to implement these markers into routine screening programmes. In men with an elevated risk of PCa with a prior negative biopsy, additional information may be gained by the Progensa-PCA3 and SelectMDX DRE urine tests, the serum 4Kscore and PHI tests or a tissue-based epigenetic test (ConfirmMDx)."
American Urological Association (AUA) Guidelines for Early Detection of Prostate Cancer, Published 2013; Reviewed and Validity Confirmed 2018 does not comment on Exosome test. screening men for prostate cancer.
Hence, use of Exosome Gene paneling score is not considered a clinically appropriate and generally accepted standard of care in routine screening for prostate cancer in men. As such based, the requested test would not be more beneficial for the patient than other standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Cancer Screening. 
The insurer denied Gene profiling. 
The denial is upheld.

The patient is a male who had an ExoDx Prostate (Intelliscore) assay performed on a specimen from Prostate biopsies from 2018 and 2020 had atypia. He has a history of prostatitis with variable prostate-specific antigen (PSA) levels between 3-12. The subject under review is whether the Gene profiling is likely to be more beneficial than any standard treatment for the patient's condition.

No, the requested testing is not likely to be more beneficial than any standard treatment or treatments for the patient's condition.
This testing is not endorsed as standard of care by National Comprehensive Cancer Network (NCCN) based on an absence of clear data supporting improvement in long-term clinical outcomes. Use may be considered but is not required to meet standard of care.
Periodic repeat prostate biopsies are considered to be appropriate for a history of atypia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes mellitus type 2

Treatment: E0784, external ambulatory infusion pump, insulin

The insurer denied coverage for E0784, external ambulatory infusion pump, insulin

The denial is upheld

This is a female with a history of diabetes mellitus type 2. The request is for a Tandem T Slim insulin pump. The coverage was previously denied because this is a new pump - a replacement insulin pump may be covered if the patient's current pump cannot meet her needs. There must be documentation from the pump supplier showing that the pump cannot be adjusted to work better for her needs. Per an office note, she was using an old Medtronic pump with Libre sensor. A1c (glycated hemoglobin) was 9.5. She is on 500 units. Per pump download she had 1 hypoglycemic event to 54. She is 79% above goal. She is frustrated with new Medtronic pump and sensor and is unable to use automode. She is unable to use automode due to closed loop function of the pump. Provider recommended a Tandem T Slim insulin pump with Control IQ (intelligence quotient) technology to control diabetes. Per provider appeal letter, the patient has uncontrolled diabetes. Her last measured hemoglobin A1c (HbA1c) was 9.4% which is above the American Diabetes Association standards. The HbA1c has increased since she started using her Medtronic pump. Her current therapy regimen and insulin delivery is failing to meet her diabetes and overall health needs. She needs a Tandem T Slim insulin pump with Control IQ technology to meet her needs. The patient's blood sugar can range from 50 to 350 and poses long term risks. The pump and sensor will reduce hypoglycemia and burden of diabetes.

As discussed in the American Diabetic Association (ADA) 2021 standards of care, automated continuous glucose monitor (CGM)-insulin pump loop systems may reduce A1C levels and improve time in range (Brown et al. 2019, Kaur et al. 2019, Sherr et al. 2020, Lal et al. 2019, Kovatchev et al. 2020) and may decrease risk of exercise-related hypoglycemia among other glycemic parameters (Sherr et al. 2013, Broughton 2021) but noted that success is dependent on the patient's capability to safely and effectively use this system.

Review of the records show the patient's glucose is hyperglycemic the majority of the time, particularly after meals, and rarely hypoglycemia. This implies inadequate bolusing and inadequate basal rates which can be easily manipulated on pump settings without requiring closed loop technology. The patient has the Libre continuous glucose monitor, Medtronic pump with Libre sensor. Although the requested system, Tandem T Slim insulin pump with Control IQ is one of the new closed loop systems that connects an insulin pump, CGM, and a controller algorithm, there is no evidence she has failed her current insulin pump as her current system has not been optimized.

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

The insurer's denial of coverage for E0784, external ambulatory infusion pump, insulin is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered Mental Status

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld.

This case involves a female who has a history of congestive heart failure, coronary artery disease, CVA (cerebral vascular accident), diabetes, end-stage renal disease, hypertension, obesity, seizures and gastroesophageal reflux disease. She presented to the emergency department with complaints of worsening fatigue, weakness and feeling ill. She stated she missed a dialysis session due to feeling ill. She also had complaints of slurred speech. She stated she started having symptoms the morning prior. She had normal range of motion in all 4 extremities on physical exam. She was lethargic; however, oriented to person and place. She was conversational and appropriate. There was no facial droop. There was positive slurred speech. The recommendation was made for additional laboratory diagnostic studies. The documentation indicated that they were unable to get IV (intravenous) access despite multiple attempts by 2 nurses and ultrasound IV attempts by a physician. The CT (computed tomography) scan did not reveal any acute findings. A chest x-ray showed mild pulmonary congestion with mild to moderate cardiomegaly slightly increased from the prior study. The physician indicated she was admitted for further evaluation and treatment. She did continue with treatment to include diabetic monitoring in addition to dietary changes. She denies any further significant adverse events and therefore, she was discharged with instructions to follow-up given the period of stability.

The patient was monitored from the standpoint of diabetes with diabetic monitoring with recommendations for dietary changes. Care provided, including diagnostic imaging and testing, medical management and specialty consultation could have been provided in the ED (emergency department) and at an observation level of care. Therefore, the decision is upheld and the inpatient admission was not medically necessary.  

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

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

Diagnosis: Severe fistulizing Crohn's disease. 
Treatment: Hyperbaric Oxygen Therapy. 

The insurer denied Hyperbaric Oxygen Therapy.  The denial is overturned.

The patient is male whose provider is requesting hyperbaric oxygen therapy to treat severe fistulizing Crohn's disease. He has previously tried and failed steroids, an anti-tumor necrosis factor (TNF) agent (infliximab) and an interleukin (IL)12-23 inhibitory (ustekinumab). He is currently on an anti-integrin inhibitor (vedolizumab). He has ongoing inflammation at his stoma and active colitis. Therefore, the attending gastroenterologist would like to use hyperbaric oxygen (HBO) therapy to treat his severe fistulizing Crohn's disease. The subject under review is the medical necessity for the HBO therapy.

The health plan's determination is overturned in whole.

The requested health service/treatment of Outpatient services (hyperbaric oxygen) is medically necessary for this patient. This patient has medically refractory Crohn's disease and hyperbaric oxygen therapy has been shown in some studies to promote fistula healing.

Crohn's disease (CD) and ulcerative colitis (UC) are immune-mediated inflammatory conditions characterized by relapsing intestinal inflammation. Management of CD and UC is usually pharmacological, based on steroids, immunomodulators, and biological agents. The aim of medical therapy in inflammatory bowel disease (IBD) is the achievement of clinical remission and mucosal healing. Even with optimal medical therapy strategies, patients may experience disease progression with perianal, intestinal, and extraintestinal complications. These immune and nonimmune complications may present as open wounds such as perianal fistulizing Crohn's disease (pCD), enterocutaneous fistulas (ECF), or pyoderma gangrenosum (PG), an important extraintestinal manifestation of the disease. The pCD represents a difficult phenotype of the disease that can require intensive medical therapy, wound care, and surgical intervention.

A proportion of CD patients with pCD, ECF, and PG may develop persistent nonhealing wounds, which represent a clinical challenge. Many associated factors such as hypoxia, alterations in local microbiota, different proinflammatory responses, and dysfunctional tissue remodeling may play an important role in the pathogenesis of these complications. These dysfunctions can be reversed with therapeutic inhalation of 100% oxygen at supra-atmospheric pressures, also known as hyperbaric oxygen therapy (HBOT). HBOT for refractory CD complications is not a new therapeutic strategy and is used in therapeutic algorithms for more than a decade.
Appeal type: Formulary Exception
Decision: Overturned

The patient has a history of hypertension, diabetes, nonischemic cardiomyopathy, atrial fibrillation (AF) and catheter ablation for AF. The patient was previously treated with Xarelto rivaroxaban (Xarelto), which caused body aches, bleeding gums, and abdominal pain. The patient has been taking apixaban (Eliquis) and tolerating it well. Coverage for apixaban is at issue. The insurer denied the Eliquis. The determination is overturned.
The formulary alternatives include warfarin, a vitamin K antagonist, and rivaroxaban (Xarelto) which, like apixaban (Eliquis), is a direct oral anticoagulant (DOAC). Warfarin would be expected to be less safe and less effective in this instance as compared to apixaban. Data from multiple randomized controlled trials have shown that use of DOACs, as compared to warfarin, for thromboprophylaxis in atrial fibrillation has been associated with fewer ischemic events and fewer severe bleeding episodes. This patient did not tolerate rivaroxaban, the only formulary DOAC. The patient has tolerated apixaban. Therefore, in this case, both formulary alternatives would be expected to be less effective and to have more adverse effects. Current guidelines do not specify the use of one DOAC over another in this situation. Moreover, the medical literature does not suggest that transitioning from one DOAC to another is associated with a significant increase in the risk for adverse events.