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

Diagnosis: Cutaneous T-cell lymphoma (CTCL)
Treatment is outpatient procedure (96900X10) Skin Phototherapy services
The insurer denied coverage for outpatient procedure (96900X10) Skin Phototherapy services.
The denial is overturned. 

The patient who has a past medical history significant for renal transplantation who is being treated with mycophenolate and tacrolimus. The patient was diagnosed by skin biopsy with patch stage Mycosis fungoides. The available records indicate that the patient has early-stage Cutaneous T-cell lymphoma (CTCL). The patient was previously treated only with topical steroids. The request is for ultra-violet (UV) light therapy for early-stage Mycosis Fungoides/CTCL.  

Based on the evidence-based literature, phototherapy is medically necessary. Phototherapy has been used first-line for decades for the management of cutaneous T-cell lymphomas including mycosis fungoides, especially those that have widespread involvement.  

Aydogan et al. writes in "Efficacy of Low Dose Ultraviolet A1 Phototherapy for Parapsoriasis/Early-Stage Mycosis Fungoides", "Mycosis fungoides (MF) and parapsoriasis (PP) are major dermatologic conditions for which phototherapy continues to be a successful and valuable treatment option. UVA (ultra-violet A) 1 phototherapy is effective in the management of cutaneous T-cell mediated diseases...UVA1 therapy seems to be an effective, safe, and well tolerated treatment option for patients with PP/early-stage MF" (1).  

Hernandez et al. writes, "Psoralen with UVA is a safe and effective treatment for early-stage MF" (2).  

Olsen et al writes in "Guidelines for phototherapy of mycosis fungoides and Sezary syndrome: A consensus statement of the United States Cutaneous Lymphoma Consortium" that "Ultraviolet light (UVL) is a long-established treatment for mycosis fungoides (MF) and Sezary syndrome (SS), subtypes of cutaneous T-cell lymphoma (CTCL). Treatments have traditionally included broadband, narrowband ultraviolet B light (UVB) and psoralen plus ultraviolet A light photochemotherapy (PUVA), but more recently, treatment options have expanded to include UVA1 and excimer laser. UVL is used either as monotherapy or as an adjuvant to systemic therapy, demonstrating efficacy in many cases that equal or surpass systemic medications" (3).  

Phototherapy is medically necessary according to current guidelines, the standard of care, and evidence-based literature.  
Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the outpatient procedure (96900X10) Skin Phototherapy services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment: Skilled nursing services
The insurer denied coverage for skilled nursing services.
The denial is overturned.

This case involves a male diagnosed with infantile spasm, ketogenic diet, and Lennox-Gastaut syndrome who is being recommended for skilled nursing services. The record stated the patient was suffering from multiple seizures a day. The primary care physician was requesting skilled nursing services to supervise and adjust the patient's medications accordingly. The physician indicated that lack of nursing care may result in adverse consequences including hospitalization. The document indicated the physician was requesting 20 hours of skilled nursing per week to ensure the patient's care and safety. The intention was for the skilled nurse to administer antiseizure medication, monitor for spasms/seizures and safety while the patient eats, and sleeps, and assist with medically prescribed ketogenic diet. The document noted that the patient required a high level of skilled care as it is difficult for his mother to complete and requires many daily medications. Due to his dietary needs, the patient also required blood glucose and ketones to be taken every other day to monitor for possible negative effects of the diet. The report stated that the patient was experiencing different types of spasms and seizures on a daily basis that could require intervention or transfer to a higher level of care. He needed someone with him who can watch him and assess for safety.  

Aside from bathing and feeding, the administration of medications and monitoring for spasms and seizures would fall within the criteria of skilled nursing services.

Current medical literature notes that primary indication for skilled nursing can include patients who have pulmonary issues, cardiac issues, central nervous system issues, gastrointestinal problems, and when they are at end-of-life. The information provided for the review noted the patient suffered from seizures requiring medications for controlling symptoms along with a specialized diet. While bathing and feeding are not a covered service given that the patient does not require enteral feeding, administering antiseizure medication and monitoring for various spasms and seizures would be reasonable given that the family has two other children requiring care, which may prevent adequate monitoring of the patient, potentially placing the patient at an increased risk should he have an episode requiring immediate care. After a review of the provided documentation, it was determined that skilled nursing services at 20 hours/week to ensure the care and safety of the patient is supported. As such, the request for skilled nursing services is medically necessary.

The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for skilled nursing services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension and coronary artery disease
Treatment: Inpatient Stay.
The insurer denied the inpatient stay.
The determination is upheld.

The patient is a male with a past medical history of hypertension and coronary arterial disease who was seen by the cardiologist. The patient had a nuclear stress test which came back with a report suggestive of ischemia. He was referred to the hospital for an outpatient coronary angiography. On the day of the procedure the patient's physical exam was unremarkable and his vital signs were stable. The patient underwent the coronary angiography without any complications. The procedure report was reviewed in length and showed no intra or postprocedural complications. The patient tolerated the procedure well. The patient was then sent to the medical floor.

The patient's chart was reviewed in detail and based on the latest high quality evidence available as well as current standards of care the patient could have been managed safely and effectively at a lower level of care. The procedure report was reviewed and there were no intra or post-procedural adverse events. The patient tolerated the procedure well and his vital signs remained stable. The patient remained hemodynamically stable and no unexpected events happened throughout his hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System Lymphoma
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of lymphoma. He previously completed chemotherapy and developed right groin numbness. An outpatient positron emission tomography (PET) scan demonstrated a right temporal brain lesion and prior to presentation he also experienced numbness in his right index finger and right foot. He was admitted for an "expedited workup" of central nervous system (CNS) lymphoma.
The patient underwent magnetic resonance (MR) imaging and a lumbar puncture that demonstrated lymphoma. He subsequently underwent Ommaya placement with methotrexate. The patient was discharged. Inpatient care is under review for medical necessity.
The services provided during this period are typically provided at a lower level of care and do not require inpatient care. The patient was hemodynamically stable without deficits that would require acute surgical intervention, intensive nursing care, or other services for which inpatient care is necessary. The services rendered were either supportive (such as intravenous (IV) fluids) or diagnostic (MR imaging and lumbar puncture). Support for inpatient care is not present in the peer-reviewed literature, National Comprehensive Cancer Network (NCCN) Guidelines, nor by the authors of UpToDate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right foot cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient is an adult with past medical history significant for diabetes mellitus and peripheral arterial disease who presented to the emergency room with complaints of pain and swelling to the right foot and leg. 

Vitals on presentation included: Temperature 97.2 Fahrenheit, Blood Pressure 140/77, Pulse 104, Respiratory Rate 18, oxygen (O2) saturation 100% on Room Air. Laboratory results included the following: white blood cell (WBC) count 9.4, hemoglobin 13.9, hematocrit 41.9, creatinine 0.81, glucose 181.

The patient was started empirically on intravenous antibiotics (vancomycin and Unasyn) for right foot cellulitis. Vascular Surgery consulted and recommended arterial duplex studies. The patient however, refused any vascular interventions and foot x-rays and remained afebrile, and hemodynamically stable. He signed out of the hospital against medical advice (AMA).

According to documentation, the patient presented to the emergency department with right foot infection. Otherwise, the patient was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC. The patient had no evidence of a disseminated infection, and no surgical intervention was required. Based on the above findings, the patient did not fulfill criteria for acute hospitalization. 

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

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

Diagnosis: Class III malocclusion 
Treatment: braces/monthly visits
The insurer denied braces/monthly visits. The health plan's determination is overturned.

The patient in question is a female with a crossbite of anterior teeth 7 and 10. She presents with a skeletal Class III malocclusion with spacing in the maxilla and the mandible. She is treatment planned for Braces and Monthly Visits to address the crowding and crossbite. This is the subject of this review.

Braces and monthly visits are medically necessary for this patient. This patient presents with an anterior crossbite on teeth 7 and 10, as well as severe spacing. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. It appears the lower anterior teeth are migrating labially in the arch.
If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Durable medical equipment (continuous glucose monitoring device - K0553x6 and K0554x1)
The insurer denied: Durable medical equipment (continuous glucose monitoring device - K0553x6 and K0554x1)
The denial is overturned.

This is an adult female with type II diabetes. Request for Freestyle Libre II is under review. The prior request was denied because approval on criteria requires the patient is on an insulin treatment plan that requires frequent adjustment of insulin dosing or use of an insulin pump. The provider is appealing this determination because the patient is injecting U-500 insulin three times per day with doses adjusted based on glucose levels and is testing glucose four times per day.  The patient's glycated hemoglobin (A1C) was 11.2% (percent).

The proposed Freestyle Libre II is medically necessary.

This request is for Freestyle Libre II for the management of type II diabetes. This patient is on multiple daily insulin injections and is adjusting her U-500 insulin dose based on pre-meal glucose levels. 

Continuous glucose monitoring has been shown to lower glycated hemoglobin (A1C) in patients with uncontrolled type II diabetes on multiple daily insulin injections (adjusted difference in mean change of glycated hemoglobin [A1C] with use of continuous glucose monitoring, 0.3% [95% CI, 0.5% to 0.0%]; P = 0.022) [1]. 

In a second study of 101 patients with type II diabetes on two or more injections per day, use of the continuous glucose monitoring system significantly improved glycated hemoglobin (A1C) levels. The changes in glycated hemoglobin (HbA1c) were 0.82% versus 0.33% in the intervention group using the continuous glucose monitoring system and control group, respectively (P = 0.005), and 68.6% of the patients in the intervention group using the continuous glucose monitoring system had their glycated hemoglobin (HbA1c) reduced by 0.5% compared with 30.2% in the control group (P < [less than] 0.001), and 39.2% had their glycated hemoglobin (HbA1c) reduced by 1.0% versus 18.6% in the control group without an increased frequency of hypoglycemia [2]. 

Without Freestyle Libre II, this patient will be at increased risk for ongoing hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the proposed Freestyle Libre II is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD)
Treatment: Vyvanse 20 milligrams oral capsules (OR CAPS)
The insurer denied Vyvanse 20 milligrams oral capsules (OR CAPS).
The denial is upheld.

The patient is a male who had a prescription denial for Vyvanse to treat attention deficit hyperactivity disorder (ADHD). Documentation from the health plan states that the patient has ADHD with a history of substance abuse. The patient does not have a documented trial of the preferred health plan agents atomoxetine, or Guanfacine extended release (ER). The prior appeal only stated that the patient had ADHD and would benefit from Vyvanse and did not provide any information about trials of non-stimulant alternatives.

The most recent office visit note from the treating physician was reviewed. It states that the patient does have a history of stimulant use disorder and is currently undergoing counseling. It states that at the time of the visit his urine drug screen was "not that clean."

The subject under review is the medical necessity for Vyvanse 20 milligrams (MG) oral capsules (OR CAPS).

The health plan's determination is upheld.

The requested health service/treatment of Vyvanse 20MG OR CAPS is not medically necessary for this patient. The patient has no documented trial of non-stimulant medications and no rationale as to why the patient cannot undergo a trial. It is concerning that the patient has a history of amphetamine abuse with an initial urine screen that was not clean. The plan alternative recommendations which favor the use of non-stimulant medications to treat an ADHD diagnosis are consistent with good medical judgement given the information provided. Therefore, it would be reasonable to start with a trial of these medications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ear pain - Otitis externa
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
 The denial is overturned

This is a patient with past medical history significant for hypothyroidism and recurrent ear infections who presented to the emergency room with complaints of ear pain for two weeks.  

Vitals on presentation included: T (temperature) 99.8 F (farenheit), BP (blood pressure) -134/74, P (pulse) -78, RR (respiratory rate)-14, O2 sat (oxygen saturation)-99% on RA (room air). Laboratory results included the following: WBC (white blood cell count) -4.8, HGB (hemoglobin)-12.1, HCT (hematocrit)-35.5, creatinine-0.7, and glucose-109.

The patient was admitted for intravenous antibiotics. An outpatient CT (computed tomography) scan showed left malignant otitis externa. Infectious Disease was consulted and started intravenous cefepime. The patient underwent a PICC (peripherally inserted central catheter) line insertion. An ENT (ear nose and throat) physician was consulted but was not able to evaluate the patient prior to discharge. The patient remained afebrile and hemodynamically stable. She was discharged with a PICC line for possible continuation of intravenous antibiotics as an outpatient. 

Malignant (necrotizing) external otitis is an invasive infection of the external auditory canal and skull base, which typically occurs in older adult patients with diabetes mellitus. Pseudomonas aeruginosa is the bacterial cause in more than 95 percent of cases; and therefore, antipseudomonal antimicrobials are the mainstay of therapy. According to documentation, the patient failed outpatient intervention with topical antibiotics. Guidelines recommend initiating treatment with intravenous antibiotics. Once a clinical response is established, patients are transitioned to oral antibiotics. Total duration is typically 6-8 weeks. Based on the above findings in a patient with documented failure of outpatient intervention with recurrent infections, hospital admission was medically necessary for intravenous antibiotics. 

Prior determination of the denial of inpatient hospital services is overturned.

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

The insurer's denial of coverage for the hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain. 
Treatment: Spine surgery. 

The insurer denied coverage for pre-service request for spine surgery. 
 
The denial is upheld. 

This female patient has chronic low back pain with spinal stenosis and neurogenic claudication. The pain has not responded to conservative therapy.  The request is the placement of an interspinous spacers (ISS) at L (lumbar) 4-L5. Gala et al (1) reviewed the efficacy of interspinous spacers and found: "ISS may play a role in the treatment of LSS (lumbar spinal stenosis). While ongoing research is still needed to clarify the safety and adverse event profiles of these devices, ISS have been shown to provide at least comparable results to decompression surgery while mitigating the risks associated with open laminectomy. Nevertheless, additional studies need to be performed in order to assess the long-term results for these implants and to document their durability over time." Similarly, Zhang et al (2) noted the short-coming of Interspinous spacer Devices: "For the treatment of LSS, several procedures including decompression, fusion, and IPD (Interspinous Process Decompression) have been reported. However, each method has its own advantages and disadvantages. To date, the golden standard treatment for LSS is still controversial. In this network meta-analysis, our results demonstrate that both decompression and IPD obtain satisfactory clinical effects for LSS. IPD is accompanied with a low incidence of complications, however, its high rate of reoperation should be acknowledged". Finally, Poetscher et al (3) concluded that: Patients submitted to IPD implants had significantly higher rates of reoperation, with lower cost-effectiveness. Future trials should improve in design quality and data reporting, with longer follow-up periods. 

While there are promising results, this approach still needs more study and there is a considerable risk of re-operation. The other approaches have long track records and known complication rates while the complication rates of interspinous spacers is still speculative. 

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

The insurer's denial of coverage for pre-service request for spine surgery is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD)
Treatment: Transoral incisionless fundoplication (TIF)
The insurer denied transoral incisionless fundoplication (TIF).
The determination is overturned.

The patient has gastroesophageal reflux disease (GERD). He has failed proton pump inhibitor therapy for multiple years, as well as pantoprazole 40 milligrams (mg) daily with famotidine 40 mg daily. An esophagogastroduodenoscopy showed unremarkable esophagus, a small hiatal hernia, patchy gastritis, gastric polyps, and unremarkable duodenum; gastroesophageal junction biopsies showed mild chronic inflammation. Esophageal manometry was normal. At issue is the medical necessity of transoral incisionless fundoplication (TIF) for the treatment of GERD.

The requested TIF is medically necessary. The efficacy of TIF using the EsophyX device has been studied in a meta-analysis including 3 randomized controlled trials (including 233 patients at 3 years), with findings of improved esophageal potential hydrogen (pH), decreased proton pump inhibitor utilization, and improved quality of life compared with proton pump inhibitor therapy of sham treatment [1-4]. The American College of Gastroenterology (ACG) guidelines for the treatment of GERD state that "We suggest consideration of transoral incisionless fundoplication (TIF) for patients with troublesome regurgitation or heartburn who do not wish to undergo anti-reflux surgery and who do not have severe reflux esophagitis (LA grade C or D) or hiatal hernias greater than (>) 2 centimeters (cm)." In this case, the patient does not have severe reflux esophagitis or hiatal hernia larger than 2 cm [5]. Additionally, the patient has attempted therapy with a proton pump inhibitor, as recommended by ACG guidelines, without improvement in symptoms and concurrent gastroesophageal junction inflammation on endoscopic biopsies. For these reasons, the use of transoral incisionless fundoplication is supported as medically necessary for the treatment of this patient's GERD.