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

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Wegovy. 
The denial was overturned. 

This is a female diagnosed with obesity. She was recommended for Wegovy by her provider. She has a history of pre-diabetes and hyperlipidemia (HLD). Her body mass index (BMI) was 34.26 and weight was 105.2 kilograms (kg). She has been following a strict diet and exercise plan but has been unable to lose a sufficient amount of weight and keep it off. She has tried and failed Contrave as she was unable to tolerate it. Per her provider, Xenical is not appropriate as she has pre-diabetes.
At issue is the medical necessity of Wegovy.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Wegovy is medically necessary for this patient.
Wegovy is a glucagon-like peptide-1 receptor (GLP1R) agonist [1] that is United States Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity. [2, 3, 4] Recent studies published in peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity. [5, 6, 7] This medication is now available for the treatment of obesity in the form of Wegovy. The patient has obesity and prediabetes. Given the fact that the patient has prediabetes, a GLP-1 receptor agonist is the best option. This medication is FDA approved for obesity and for patients such as this patient. The request is consistent with generally accepted standards of medical practice. Other obesity medications are inferior and inappropriate given the patient's comorbidities.
Therefore, the requested Wegovy is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot Disorder. 
Treatment: Skilled Nursing Facility. 
The insurer denied Continued Skilled Nursing Facility Care. 
The denial was upheld. 

The patient is a female with a history of diabetes, obesity, lymphedema, and a left foot wound treated previously with artificial skin grafts times (x) 2 and planning to have a third artificial skin graft. The patient was previously treated with daily dressing changes and wound checks.
The patient was admitted to the Skilled Nursing Facility for wound care, which consisted of daily dressing changes. Her wound vacuum-assisted closure (VAC) was discontinued. She was scheduled for a third Theraskin application, which was managed by the Wound Center. Bilateral lower extremity range of motion was normal. The strength was normal in the upper extremities and strength was 3/5-4 plus (+)/5 in the lower extremities.
She was hemodynamically stable and afebrile. Her blood sugar was well controlled, and her oxygen saturation was normal on room air. She had refused all vaccinations and was a do not resuscitate (DNR). Her pain level was 0. She ambulated with a walker. She was independent with eating, required minimal assistance with toileting, independent with sit to stand transfers, was able to propel her wheelchair 10 feet with contact guard assistance, ambulated greater than (>) 150 feet with bilateral crutches and standby assistance, and required minimum to moderate assistance with dressing.
At issue is the medical necessity of Continued Skilled Nursing Facility Care. 

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Continued Skilled Nursing Facility Care was not medically necessary for this patient.
The patient did not have a continued need for physical therapy services that could not be provided outside of a skilled nursing facility, did not have a need for continued occupational therapy services that could not be provided outside of a skilled nursing facility and did not have skilled needs provided by a medical professional such as a physician or a nurse such as complicated wound care. She required daily dressing changes and this type of care is not considered medically complicated or complex. She was independent with eating, required minimal assistance with toileting, independent with sit to stand transfers, was able to propel her wheelchair 10 feet with contact guard assistance, ambulated > 150 feet with bilateral crutches and standby assistance, and required minimum to moderate assistance with dressing. Per the documentation, the care the patient was receiving does not require an inpatient skilled nursing facility. 
Therefore, continued inpatient skilled nursing facility care is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems- Congestive Heart Failure (CHF).
Treatment: Durable Medical Equipment (DME)-Wearable defibrillator.

The health plan denied the Durable Medical Equipment (DME)-Wearable defibrillator.  The reviewer has upheld in whole the health plan's determination.

The patient underwent multiple surgeries as a child for D-transposition of the great arteries, including a Mustard procedure (atrial switch). His medical history was also remarkable for atrial fibrillation, transient ischemic attack and nonischemic cardiomyopathy. By echocardiogram, his left ventricular ejection fraction was 24% (per cent). He was on medical therapy with a beta-adrenergic receptor blocker. The patient had been previously evaluated by an electrophysiologist, and an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death was recommended. The patient had been told that the risk for complications from this procedure were increased due to his complex anatomy and was hesitant to proceed with device implantation.

Based on the documentation provided the LifeVest wearable cardioverter defibrillator was not medically necessary. This patient has a nonischemic cardiomyopathy and a severely depressed left ventricular ejection fraction (LVEF). Subset analyses of patients from the large multi-center randomized DEFINITE trial evaluating the use of ICDs in nonischemic cardiomyopathy for the primary prevention of sudden cardiac death have shown that even patients with recently diagnosed cardiomyopathy are at risk for serious ventricular arrhythmias. Accordingly, many physicians prescribe the LifeVest WCD as a "bridge" to potential ICD implantation in newly diagnosed patients. Unlike the ICD, however, one of the largest barriers to the overall effectiveness of the WCD is lack of compliance. Even fully compliant patients cannot wear the device 24/7, as it must be removed for bathing. Thus, the recommendation is for ICD implantation after 90 days of optimal medical therapy. This man's LVEF was noted to be severely depressed. He was more than 90 days post-diagnosis and was on maximally tolerated medical therapy. He would have been eligible for an ICD at that time. The WCD is not intended as a replacement for an ICD but, rather, as a "bridge" to potential ICD implantation for patients, who are at risk for malignant arrhythmias but not immediately eligible for an ICD. Unlike with the ICD, there are no data, that long-term use of the WCD improves cardiovascular outcomes. The records provided indicate that the patient elected to delay ICD implantation due to concerns regarding potential procedural complications. They do not indicate that there was a medical reason for use of the WCD rather than an ICD.
Appeal type: Medical necessity
Decision: Upheld

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

The patient presented to the hospital emergency department (ED) with upper abdominal pain and vomiting that was progressive and severe. She had a past medical history of asthma. At the time of presentation, the patient was without a fever and her vital signs showed a heart rate of 64 beats/minute and blood pressure of 122/64 millimeters of mercury (mmHg). She was tender in the upper abdomen. The white blood cell count (WBC) count was slightly elevated at 12.3 thousand (K). The complete metabolic panel identified a normal aspartate aminotransferase (AST) and alanine aminotransferase (ALT). The bilirubin was normal. An ultrasound was also performed that confirmed a tender and edematous gallbladder with stones.
She was initially treated with intravenous (IV) fluid and antiemetics. Surgical consultation was obtained. The patient underwent a laparoscopic cholecystectomy. She tolerated oral intake following surgery. She remained stable following surgery and overnight. She was discharged from the inpatient setting with instructions for outpatient surgical follow up.
At issue is the medical necessity of an inpatient stay.
An inpatient stay was not medically necessary. This patient presented to the ED with abdominal pain. Evaluation identified gallstones and cholecystitis. She was hemodynamically stable at the time of presentation. The WBC count was slightly elevated. The patient had no significant comorbid health conditions that required an inpatient designation. She was treated with surgical therapy (laparoscopic cholecystectomy). The patient remained hemodynamically stable during the period of monitoring overnight. A lower level of care would have allowed for overnight monitoring, provision of antibiotics, surgery, confirmation of clinical stability, and diet advancement.
There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Leiomyoma of uterus
Treatment: Radiofrequency surgery
The insurer denied Radiofrequency surgery.
The determination is overturned.

The patient has symptomatic fibroids, heavy menstrual bleeding and anemia, and is requesting non-invasive uterine conserving therapy after failing medical management with oral contraceptive pills.
After counseling which included a consult for uterine artery embolization, the patient was offered and accepted an outpatient transcervical radiofrequency fibroid ablation. At issue is whether that procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes, the proposed health service or treatment radiofrequency surgery is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The Sonata system is a relatively new Food and Drug Administration (FDA) approved device that allows for radiofrequency ablation (RFA) of fibroids via the transcervical approach.
For a patient who has failed medical management and is seeking uterine conserving intervention, historical options were limited to open or laparoscopic myomectomy and uterine artery embolization. Laparoscopic RFA preceded the transcervical approach and has also become a more recent addition for consideration.
RFA efficacy and safety are well-established. It is the route of approach that seems to be the basis on which this procedure was denied. Transvaginal RFA is far superior to laparoscopic RFA or myomectomy as it can be safely performed as an outpatient without general anesthesia. It is also superior to uterine artery embolization which has a well established higher rate of future surgical intervention for persistent symptoms following the procedure with significantly lower rates at 1, 3, and 5 years.
There are dozens of academic articles that show the efficacy and safety of transvaginal RFA. It is endorsed as a well established option that should be made available to patients both by the American College of Obstetricians and Gynecologists (ACOG) and well respected experts at leading academic medical centers.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health. 
Treatment: Home Health Care. 
The insurer denied consumer directed personal care assistance services. 
The denial is upheld.

The patient is a male with past medical history of major depressive disorder, specified abnormal immunological finding in serum, gastroesophageal reflux disease (GERD), tobacco abuse, vitamin D deficiency, hypertriglyceridemia, and tachycardia who requested Consumer Directed Personal Assistance Program (CDPAP) services. The patient underwent an assessment tool assessing him at extensive assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, shopping, transportation, and equipment management while supervision with task of bathing. The patient was assessed at set up only with task of phone use and independent with tasks of stairs, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The assessment noted the patient had memory problems, the patient lived with his mother, the patient's mother was primary caregiver, and the patient had 72 hours of informal care and active monitoring during the last 3 days. The insurer sent final adverse determination notice denying request for CDPAP services. The denial stated the patient was able to perform activities such as toileting and personal hygiene and could walk on his own. The denial also stated the M11Q signed by the patient's doctor reflected chronic and other conditions that do not impact the patient's ability to perform daily activities.

The health plan's determination is upheld in whole.

The consumer directed personal care assistance services (CDPAS) are not medically necessary for this patient.
The patient does not have assistance needs of at least limited assistance with physical maneuvering with more than two activities of daily living. The patient did not require more than 8 hours of assistance with tasks per week. 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, CDPAS services are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Dental Implant Tooth # (number) 22
The insurer denied Dental Implant Tooth #22.
The determination is overturned.

The patient presented for evaluation and treatment of tooth number (#) 22. Provided for review are previous letters of appeal and denial, a narrative from her doctor explaining challenges with chewing function, full mouth panoramic radiographic image, multiple pages of claim forms, intra-oral clinical photos, multiple correspondence between the applicant and the health plan, appeal acknowledgement letters, and clinical notes . At issue is the medical necessity of the planned treatment of extraction of implant placement (6010) for tooth #22.

The requested health service/treatment of surgical placement of implant body in site #22 is medically necessary in order to provide support stability and retention of the denture.

This will reduce the need for a vestibule as well as reduce the compression of the tissue around the tori which would otherwise cause ulceration. The clinical images along with the radiographic images support the clinical notes and assessments. A narrative explains challenges with chewing function.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.

The denial is upheld.

The patient presented after vomiting coffee grounds. He was afebrile and the vital signs were stable. Left upper quadrant (LUQ) abdominal tenderness was present, but there was no rebound or guarding. The hemoglobin was 9.7. After the patient arrived in the ED (emergency department), there was no further vomiting. The hemoglobin was noted to be at his baseline. Proton pump inhibitor (PPI) therapy and Zofran were given. The stool occult blood was negative.

Clinical indications for admission for Upper Gastrointestinal Bleeding (MCG [Milliman Care Guidelines] M180) include hemodynamic instability, ongoing active bleeding, high risk endoscopic features, severe coagulopathy, anemia with signs of cardiac ischemia, and peritoneal signs. The patient did not have these conditions.

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient had vomited some coffee grounds. He was not actively bleeding. Intravenous hydration, PPI therapy, and antiemetics could have been given in the ED with observation status. His hemoglobin remained stable. He did not meet MCG criteria for admission for either Upper Gastrointestinal Bleeding or Undiagnosed Abdominal Pain. 

The health care plan acted reasonably and with sound medical judgement. An inpatient hospital stay was not medically necessary.

The insurer's denial of coverage for the inpatient hospital stay is upheld. Medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer
Treatment: FoundationOne CDx 
The insurer denied the FoundationOne CDx testing. The health plan's determination is overturned. 

The case involves a male patient with metastatic esophageal cancer whose oncologist ordered FoundationOne CDx targeted genomic sequence analysis. Coverage for this service was denied by the patient's health care plan.

The FoundationOne CDx Targeted Genomic Sequence Analysis is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. National Cancer Care Network guidelines suggest next generation sequencing (NGS) evaluation for patients with metastatic esophageal cancer if ample material is available. This testing will provide information that will be "more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease." Such testing will allow for commercially available immunotherapy or targeted therapy options or possible clinical trial options. Without such data, these possible options can not be identified.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer
Treatment: FoundationOne CDx 
The insurer denied the FoundationOne CDx testing. 
The health plan's determination is upheld. 

The patient is a man who underwent esophageal biopsy which revealed adenocarcinoma. It was human epidermal growth factor receptor 2 (HER2) + (positive). There was evidence of lung and liver metastases. He began FOLFOX/Herceptin. The FoundationOne CDx assay was ordered and is under review.

The FoundationOne CDx targeted genomic sequence analysis is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The National Comprehensive Cancer Network (NCCN) guidelines recommends biomarker testing for Her2 adenocarcinoma. There are no data in randomized controlled clinical trials demonstrating a survival benefit in patients given standard of care systemic therapy based on NCCN guidelines versus (vs). targeted agents based on other biomarkers or mutation analysis. Therefore, the NCCN guidelines do not recommend testing for other biomarkers or mutation analysis.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer
Treatment: FoundationOne CDx 
The insurer denied the FoundationOne CDx testing. 
The health plan's determination is upheld. 

This is a male with newly diagnosed human epidermal growth factor receptor 2 (HER2) + (positive) metastatic adenocarcinoma of the esophagus. The FoundationOne CDx assay was obtained and is under review.

FoundationOne CDx Targeted Genomic Sequence Analysis is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

This service is a laboratory study performed on tissue that has already been removed from the body. It is not a treatment but the results of this assay are intended to be used to guide treatment recommendations. Unfortunately, the use of next generation sequencing gene panels to guide the treatment of patients with metastatic esophageal cancer has not been demonstrated to be of benefit. Several ongoing trials (eg, the National Cancer Institute [NCI] Molecular Analysis for Therapy Choice [MATCH] and the ASCO Targeted Agent and Profiling Utilization Registry [TAPUR] trials) are using next-generation sequencing of multiple genes (gene panel tests) to identify molecular abnormalities in the tumors of patients with refractory cancers that may potentially match molecularly targeted therapies that are either in clinical trials or approved for treatment of other cancer types (NCT02465060 and NCT02693535).

Based on the paucity of supporting data, neither the National Comprehensive Cancer Network (NCCN) nor the authors of UpToDate recommend the use of the Foundation Medicine next generation sequencing (NGS) assay in this clinical scenario. Treatment based on published literature and guideline recommendations has been encouraged.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obsessive Compulsive Disorder (OCD)
Treatment: Repetitive Transcranial Magnetic Stimulation (rTMS).
The health plan denied the requested Repetitive Transcranial Magnetic Stimulation (rTMS).
The health plan's determination is overturned.

The patient is an adult female with obsessive compulsive disorder (OCD) associated with anxiety with severe symptoms and impaired functioning. Symptoms include intrusive thoughts, rituals and excessive time spent cleaning and checking, with concern with germs and dirt. The symptoms of OCD are severe and longstanding. The patient has co-morbid major depressive disorder. There is not substance use disorder in this case and no acute general medical issues.

The patient has received medication trials with selective serotonin reuptake inhibitors (SSRIs), Buspar, Seroquel and Klonopin. She has also received treatment with cognitive-behavioral therapy (CBT) without substantial improvement in symptoms of OCD or functioning. After a course of repetitive transcranial magnetic stimulation (rTMS) targeting depression, the patient's health questionnaire (PHQ-9) decreased from a score of 20 to 1 during transcranial magnetic stimulation therapy. However, the patient's symptoms of anxiety and OCD remained with a general anxiety (GAD-7) score of 16, reflecting severe symptoms. Again, there is no report of other psychiatric conditions or general medical co-morbidity or co-occurring substance use disorder in this case.

The health plan's determination of medical necessity is overturned, in whole.

Yes, the requested health service/treatment of TMS is medically necessary for this patient.

The requested benefit of Repetitive Transcranial Magnetic Stimulation (rTMS) is reasonable, clinically appropriate, medically necessary, and in the patient's best interest. The requested rTMS service is backed by credible scientific study and is consistent with prevailing standards of medical practice for the condition under treatment in this case. This answer is consistent with the scientific literature, referenced below, treatment refractory OCD and co-morbid anxiety disorder.