Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Issue under review: Methylprednisolone acetate

Determination:
The health plan denied methylprednisolone acetate. The health plan's denial is upheld.

The patient is an adult male with lumbar radicular pain.

There is a request for an interlaminar epidural injection with fluoroscopic guidance.

There is pain management listing indicating the patient had prior procedures of a lumbar epidural steroid injection.  

A note indicates the patient had recurrent radicular leg pain.  He feels the first and third injection was more efficient.  Overall, he notes about two months of relief with the injections, but his pain has returned.  Physical examination indicated overall no ataxia, no unsteadiness.  He had normal conventional walking.  Normal muscle, bulk, and tone with an assessment of greater than two years of persistent left lower back and leg pain.  Most recent imaging revealed multilevel spondylosis with moderate-to-severe central canal foraminal stenosis at L4-5 and L5-S1.  He has had epidural injections with "excellent relief" lasting about two to three months and now returns with recurrent pain.

Note indicates ongoing back pain.  The patient returned for a repeat lumbar epidural.  His pain is located in the left lower back area.  He describes it is aching and sharp, occurring intermittently.  Physical exam documented normal bulk and tone.  Overall normal integument to palpation.  Normal cranial nerves with assessment of spinal stenosis in lumbar region with neurogenic claudication. 

ASRA 2015 Interventional Pain Guidelines and ASIPP Interventional Pain Guidelines as well as ISIS 2015 Interventional Pain Guidelines support that the epidural steroid injection is supported for patients who have physical findings of neuropathy demonstrated by abnormal motor, sensory, or reflex changes in a dermatomal distribution that has been unresponsive to six weeks or longer conservative management and in whom there is corroboration by EMG (electromyelogram) or imaging.  Repeat epidural injections are supported when there is at least 50% improvement for a period of four to six weeks.  

The available medical records provided for review support the patient has ongoing back pain, but does not document physical examination findings consistent with radiculopathy. In reference to the epidural steroid injection, while the available medical records report "excellent pain relief for two to three months", there is no specific quantification as to the degree of relief and support that the patient achieved at least a 50% reduction for a specified period.  As such, based on the medical records provided for review, the available medical records do not support performance of epidural steroid injection for the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Issue under review: Methylprednisolone acetate
The health plan denied methylprednisolone acetate.
The health plan's denial is overturned.

The patient is an adult male with history of chronic low back pain radiating into the Left buttocks and Left lower extremity with no associated weakness, numbness or tingling.

MRI lumbar spine of early 2018 showed diffuse lumbar spondylosis with moderate-severe stenosis at L3-L4, L4-L5 and L5-S1 levels with left foraminal stenosis at L5-S1. He had conservative management that included chiropractic manipulations, acupuncture, OTC (over-the-counter) NSAIDs (nonsteroidal antiinflammatory drugs), Tylenol, etc.

For the year prior year, he had three Interlaminar epidural steroid injections at L4-L5.

The health plan should cover the L4-L5 Interlaminar epidural Steroid Injections , in which Methylprednisone was used, as this was the third interlaminar epidural steroid injection, and not the fifth, as erroneously stated by the health insurance. The record provided support this.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Inpatient Stay
Decision:  Upheld

Summary:
The patient is a female with a past medical history significant for HTN (hypertension), dyslipidemia, CAD (coronary artery disease), s/p (status post) NSTEMI (non ST elevation myocardial infarction) in early 2019, diagnosed with LAD (left anterior descending) and RCA (right coronary artery) disease, initially offered CABG (coronary artery bypass graft), but subsequently deferred due to seizure. She underwent PCI (percutaneous coronary intervention) of LAD for an elective staged PCI of RCA. 

This patient was admitted for an elective cardiac catheterization, and a planned staged PCI of RCA was performed. There were no peri-procedural complications. Usually no acute inpatient admission is required post PCI, unless there is evidence of a bleeding or ischemic complication, peri-procedural MI (myocardial infarction), hemodynamic or electric instability. None of these complications were documented for this patient, and she was discharged home the next day. There was no evidence of acute MI, hemodynamic instability or malignant arrhythmia. The patient did not require any vasoactive drips or intravenous medications, which would necessitate inpatient stay. Thus the medical record does not support medical necessity for acute inpatient care, and the services could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: for Gocovri 137mg cap ER 24H (Amantadine Extended Release)
The insurer denied for Gocovri 137mg cap ER 24H (Amantadine Extended Release).
The denial was overturned.  

This is a female patient currently diagnosed with idiopathic Parkinson's disease, anxiety, cataract in the left eye, cortical basal degeneration, depression, scoliosis, and sickle cell anemia.  The patient's complaints included issues with mobility/tremor/walking/balance/right leg dystonia/hallucinations.  The patient's current home medications included Sinemet, Gocovri, Neupro, and Folvite.  On exam, the patient exhibited a tremor and abnormal muscle tone.  The medication request form indicated that Gocovri, requested medication was a continuation of care.  The patient has been on Gocovri prior, when she became a new patient in this physician's office.

Based on the review of the medical record and literature, Gocovri is considered medically necessary for this patient.  This patient has a clinical history of idiopathic Parkinson's disease with cortical basal degeneration.  The treating physician notes difficulty with mobility, tremor, gait, balance, dystonia, and hallucinations.  The patient is currently being treated with Sinemet, Gocovri, and Neupro. As per this patient's treating physician, the patient has positive response to treatment with Gocovri from the standpoint of dyskinesia.  As per literature, Gocovri has been demonstrated to reduce the intensity and time duration of episodes of dyskinesia in patients with Parkinson's disease. As noted by Paik, et al. "this new formulation of amantadine allows a more gradual time to peak plasma amantadine concentration and higher drug concentrations in the morning and throughout the day, the time period when levodopa-induced dyskinesia (LID) is the most problematic." This was the case for this patient. The patient has achieved a positive response with Gocovri in terms of controlling episodes of dyskinesia. Therefore, the continuation of Gocovri is medically necessary for this patient.

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

The carrier's denial of coverage for Gocovri 137mg cap ER 24H (Amantadine Extended Release) for treatment of Parkinson's disease should be overturned.  The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Refractory constipation.
Treatment: Linzess Capsule 290MCG.
The insurer denied the Linzess Capsule 290MCG.
The denial is upheld. 

The patient is a female with IBS-C (Irritable bowel syndrome with constipation). She has failed bisacodyl, senna, Miralax, docusate and Amitiza. Her physician is requesting treatment with Linzess. 

No, the health plan should not cover Linzess Capsule 290MCG.

The patient has IBS-C. Per the plan, the patient must have tried and failed the plan preferred Trulance and Motegrity before Linzess can be covered. As the patient has not tried and failed the plan preferred Trulance and Motegrity, and as there is no literature to support that Linzess is more effective than Trulance and Motegrity for the treatment of IBS-C, the health plan should not cover Linzess.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Transsexualism.
Treatment:  Pharmacy/Prescription Drugs (Estradiol Valerate).

The health plan denied the requested drug (Estradiol Valerate).  The health plan's determination is upheld.

The patient is a transgender woman with a past medical history significant for dyslipidemia on Spironolactone 100 mg daily and Estradiol 2mg bid for her hormone therapy without side effect or complaint, with blood work showing an Estradiol level at goal.  The patient wishes to change to Estradiol Valerate intramuscular (IM) treatment due to the patient's individual concern for long term use of oral Estradiol.

The health plan's determination is upheld, in whole.

Estrogen can be administered by oral, transdermal or parenteral route.  The transdermal and parenteral routes can avoid first pass metabolism and may have a lower risk of a thromboembolic event.  The goal of therapy according to the 2017 Endocrine Society guidelines are an Estradiol level between 100-200 pg/ml.  This patient has not had adverse effects from her Estradiol tablets (at least none that were included in the office note available to review).  Her Estradiol level on blood work included in the office note was at goal.  Transdermal Estradiol patch is another option that can be as effective as oral administration.  Personally, I have found it difficult to achieve premenopausal range Estradiol levels with the transdermal route in individuals who have not had an orchiectomy.

Oral Estradiol in this patient will be as effective as IM Estradiol Valerate and may or may not be as effective as transdermal Estradiol, though IM and transdermal administration may be associated with a lower risk of thromboembolic event.

This patient has had success to date with oral Estradiol, as detailed in the clinic note made available in the report.  She has not had any side effects from the medication that is noted.  According to the Endocrine Society 2017 guidelines for the treatment of Gender Dysphoric/Gener-Incongruent Persons, Ethinyl Estradiol has the most thromboembolic of the estrogens; therefore, that is not recommended for the treatment of transgender women.  This patient is not on Ethinyl Estradiol.  It is thought that perhaps sublingual, transdermal or IM Estradiol, administration routes that can avoid the "first pass effect" and, therefore, may have less thrombogenic risk.  However, with sublingual and IM administration estrogen levels are harder to monitor, due to the rapid peaks.

In an otherwise healthy transgender woman without a personal history of thromboembolic event or an increase in thromboembolic risk, who is tolerating her current hormone regimen without side effect, and given that there is insufficient data to suggest that there is other long term consequences /risk from oral Estradiol, the health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Immunologic Disorders.
Treatment: Lab work/Blood tests.
The health plan denied the testing as not medically necessary. The health plan determination is overturned.


This pediatric patient has been diagnosed with a periodic fever syndrome. The patient has symptoms of fever for 2-7 days at a time for the last 16 months. There is also history of inflamed joints, lymph node swelling, and refusal to walk. A fever syndrome such as Cryopyrin-Associated Autoinflammatory Syndromes (CAPS), hyperimmunoglobulinemia D syndrome (HIDS) is suspected. The panel that the physician ordered is checked for 7 genes.

Yes, the genetic testing is medically necessary for this patient. The exact diagnosis will be important in choosing treatment and stopping the inflammation from occurring in this child. The gene Dx and other panels that are similar are considered standard of care for patients who have recurrent fevers. The exact diagnosis is important because this will affect the treatment that is given. The testing, which is standard of care, is not checking for more genes than necessary. This is an appropriate number of genes to check for periodic fever evaluation.
The genetic testing for autoinflammatory syndromes is medically necessary. Although not all genes are identified, many patients will be diagnosed based on the mutation that they carry. The clinical picture can vary and therefore a diagnosis is not always certain based on clinical features. A definitive diagnosis based on gene testing can give direction in treatment. Colchicine treatment may work well for FMF and biologic agents may work well for TRAPS and CAPS. Determining which gene is affected may help in management and the prevention of long term morbidity such as amyloidosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis
 
Treatment: Adalimumab (Humira)

The insurer denied the Adalimumab (Humira). The denial was reversed.  

This is a male patient with a medical history of ulcerative colitis, irritable bowel. The patient was initially diagnosed with ulcerative colitis several years prior with symptoms of bloody diarrhea.  He has been under the care of a gastroenterologist and has had serial colonoscopies over the past several years. His current medications include Azathioprine 150 milligrams (mg) and Humira 40 mg, and Apriso 4 tablets daily. The patient had a colonoscopy that showed inflammation from the anus to the distal descending colon. His treating physician is seeking to increase his Humira dose to a weekly administration while discontinuing the Apriso tablets.

In patients with severe ulcerative colitis, dose escalation is a commonly utilized method to achieve remission. This can be used in partial response or non-response before the type of biological agent is changed. In this situation, Humira dose was escalated gradually to once in 10 days and now is being requested for once a week. This is an appropriate strategy given the patient presentation and the below referenced literature. 

Adalimumab (Humira) dosed weekly for the treatment of ulcerative colitis is medically necessary for this patient. The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

Based on the above, the medical necessity for Adalimumab (Humira) dosed weekly for the treatment of ulcerative colitis is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Gastrointestinal:Other
Nursing Services (including Private Duty Nursing)

The patient is a female child born with gastroschisis and medical history significant for the following: short gut syndrome status post multiple surgeries as well as bowel transplant complicated by acute rejection, insulin-dependent medication-induced diabetes mellitus, superior vena cava syndrome, moderate persistent asthma, chronic kidney disease stage G3a with resultant hypertension with acute exacerbations, recurrent hyperammonemia with encephalopathy, immunosuppression due to tacrolimus and resulting in recurrent HSV infections, severe skin/wound infections (E coli ESBL, mucormycosis), multiple allergies (anaphylaxis to peanuts, allergies to tree nuts and shellfish, allergies to macrolide antibiotics and benzodiazepines), history of recurrent pericardial effusion that required pericardiocentesis on one occasion, and enuresis. 

The health plan's determination is overturned. The Additional Private Duty Nursing Hours: Request for 12 Hours per Day/7 Days per Week is medically necessary for this patient. This medically fragile female child has numerous medical problems as a result of and in addition to her gastroschisis as detailed above. Virtually every organ system has been affected, and she requires constant supervision and intervention to maintain health and prevent complications and morbidity. This is particularly important when she is at school because there is no one there to check her blood sugar and administer insulin. She is not aware when she is dangerously hypoglycemic and she is still a child, so she is unable to manage this independently. At home, she is the eldest of three children. Her mother is a single parent, and even though her father is actively involved, he is not in the home to participate in management of the home and all of the children. With appropriate private duty nursing services during the school day (9 hours Mon-Fri), several hours after school while the mother is involved with the two younger siblings, and on the weekend to allow the mother to manage both family and household responsibilities, problems can be addressed skillfully and immediately to prevent hospitalization and allow this child to reach her functional potential. The requested private duty nursing hours (12 hours daily 7 days a week) are medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of diabetes, hyperlipidemia, hypertension, coronary artery disease and myocardial infarction. He was evaluated for exertional dyspnea. An echocardiogram showed a decline in his left ventricular ejection fraction to 30-35%. Cardiac catheterization was scheduled. When the patient presented to the hospital he denied cardiac symptoms. His blood pressure was 169/74 millimeters of mercury (mmHg) with a heart rate of 63 beats/minute (bpm). His room air oxygen saturation was 99%. His physical exam was unremarkable and an electrocardiogram showed no acute changes. Coronary angiography was performed and showed a significant lesion in the mid left circumflex artery that was treated with two stents; the procedure was uncomplicated. Post-procedure the patient was admitted to the hospital. 

The health plan's determination is upheld. 

This patient presented for elective coronary angiography. At the time of presentation, he denied cardiac symptoms. He was hemodynamically stable, without signs of decompensated heart failure. He had no acute electrocardiographic changes. While some period of observation immediately following coronary angiography and percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. Per the recommendations, the majority of other patients can be observed overnight for a period of less than 24 hours, and do not require an inpatient admission. Moreover, the EPOS (Elective percutaneous coronary intervention [PCI] in Outpatient Study), a large randomized trial involving 800 patients who underwent elective PCI via a femoral arterial approach, found that same-day discharge after elective PCI is feasible and safe in the majority of patients and does not lead to additional complications, as compared to an overnight stay. These results were confirmed by a more recent retrospective study by Nacimento et al. Accordingly, the care this patient received could have been provided at a lower level of care and an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Autism Spectrum Disorder
Speech Therapy

This is a patient diagnosed with Autism Spectrum Disorder (ASD). He also presents with food aversion and oral motor weakness. According to a provided medical report, the patient actively participates, interacts well with family and friends, and eats solid foods at regular mealtimes. The documentation states that the patient has been in private speech therapy for years but has not been receiving speech therapy services through his school since late 2019.The documentation also states the need for ongoing speech therapy. At issue is whether the requested services are medically necessary for the patient.

The health plan's determination is upheld.

Language deficiencies (as in the case of the autism) can have a significant impact on several domains including the academic, social, and emotional states of the patient. Speech and language intervention has been shown clinically to be extremely effective when provided as early as possible along with intensive instruction. (1) Specifically, individuals diagnosed with autism who receive language therapy have been shown to exhibit improved functional communication abilities, which in turn, improve their social abilities, academic abilities, as well as the individual's overall quality of life.
However, no documentation was provided by a speech-language pathologist, on behalf of the patient, indicating his current speech and language functioning level. Furthermore, there is no clear information of the daily impact experienced by the patient. Additional information was requested and a speech therapy initial evaluation from 2018 was provided, but there are no speech therapy records provided from 2019.
In general, services for autism spectrum disorder (ASD) are considered medically necessary when developmental delays or persistent deficits in social communication and social interaction across multiple contexts have been identified when the evaluation is performed by a qualified and certified speech-language pathologist.
Since there is no information relative to the patient's social communication deficits or how his oral motor weakness significantly impacts the intelligibility of his speech, a level of medical necessity cannot be professionally supported.
As a result, the requested health/service treatment of speech therapy evaluation visits are not medically necessary for this patient.