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

Diagnosis: Seizure.
Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is upheld.

This case involves a male who presented to the emergency department via ambulance for possible seizure/syncopal episode. The patient's mother reported that the patient was sitting in a chair when he stared off and became limp. She attempted to wake him. However, he was unresponsive. She reported 2 similar episodes in the past. Electroencephalograms had not detected seizure activity. The patient was admitted with a diagnosis of seizure versus syncope. Cardiology and neurology consultations were completed. An electrocardiogram was normal. An electroencephalogram and magnetic resonance imaging of the brain were negative. The patient was discharged with plans for outpatient follow-up with neurology.

Per the referenced sources, admission for seizures is indicated when there is hemodynamic instability, complex febrile seizures, for status epilepticus, when there is a brain disorder that requires monitoring or intervention available only at inpatient level of care, for altered mental status that is severe or persistent, and for recurrent seizures that are observed during emergency department or observation care. In this case, the patient presented to the emergency department via ambulance for possible seizure/syncopal episode. Per the appealer, "the patient presented with acute, witnessed seizure-like activity. There was concern for acute recurrence and possible absence seizures. Given that patient had 2 similar prior episodes and incomplete neurologic work-up, the patient required close inpatient monitoring and timely cardiac and neurological work-up. The treatment/testing the patient received could not have been done in the outpatient setting." Although the patient's mother reported 2 previous episodes, the documentation did not identify recurrent seizures that occurred in the emergency department or during observation.  

The documentation did not identify hemodynamic instability or persistent altered mental status. The patient's treatments/evaluation could have been completed at a lower level of care. 

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

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

Diagnosis: Dental Problems. 
Treatment: Root Canal, Core Buildup and Crown for Tooth #14. 

The insurer denied Root Canal, Core Buildup and Crown for Tooth #14. The health plan's determination is overturned. 

The patient is a female who presents for evaluation and treatment of tooth # (number) 14. Provided for review are previous letters of appeal and denial, a narrative from the provider explaining the oral hygiene practices of the patient, full mouth radiographic images, multiple pages of claim forms with codes, periodontal indices, and health plan language. 

The Root Canal, Core Buildup and Crown for Tooth #14 are all medically necessary for the patient. 
Teeth that need root canal therapy are medically necessary to have the treatment when the pulp has been affected as is the case for this tooth. Teeth that have lost extensive amounts of the natural crown require buildup and crown coverage to avoid fracture of the tooth and to return the tooth to the original structure and function, as is the case for this patient. The treatment is medically necessary and supported by the documentation provided.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Atrial Fibrillation.
Treatment: Formulary exception for Eliquis (apixaban).
The insurer denied the Formulary exception for Eliquis (apixaban).
The denial is overturned.

The patient is a male with paroxysmal atrial fibrillation. The request is for Eliquis.

The patient has risk factors for CAD (coronary artery disease) and CVA (cerebrovascular accident), including hypertension, hyperlipidemia, and family history. His echocardiogram is consistent with diagnosis of non valvular atrial fibrillation. He has elevated HAS-BLED (hypertension, abnormal renal and liver function, stroke, bleeding, labile INR, elderly, drugs or alcohol) and CHA2DS2-VASc (congestive heart failure, hypertension, age > [greater than] = 75, diabetes mellitus, prior stroke or TIA (transient ischemic attack) or thromboembolism, vascular disease, age 65-74, sex category) scores. He is presently taking Eliquis.

Yes, the health plan should cover the Formulary exception for Eliquis (apixaban).
Xarelto is as effective as Eliquis, but it has higher risk of adverse events. This patient is at increased risk of bleeding events.

The request for Eliquis was based on a safety profile that favors Eliquis over Xarelto. In addition to the article quoted in the appeal letter, the preference for Eliquis was supported by other articles, guidelines, and community practice.

There is strong evidence that the medication apixaban (Eliquis) is preferable to rivaroxaban (Xarelto) for stroke prevention in patients with atrial fibrillation (AF), with both reduced rates of severe bleeding complications as well as strokes. Apixaban was also associated with better safety in terms of decreased incidence of intracranial hemorrhage or GI (gastrointestinal) bleeding compared with rivaroxaban (12.9 vs 21.9 per 1,000 person-years, HR [hazard ratio] 0.58, 95% CI [confidence interval] 0.52-0.66).

In addition, multiple studies have shown the safety profile of a DOAC (directly acting oral anticoagulant) is superior to that of warfarin. While warfarin is on the formulary, it is recognized by the plan that a DOAC (directly acting oral anticoagulant) is available. For the reasons that Xarelto is available as a preferred medication, Eliquis should also be available, and is the preferred medication compared to warfarin. Eliquis has a safety profile that is better than warfarin, and it is likely to be more effective.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-Atrial fibrillation.
Treatment: Pharmacy/Prescription Drugs-Eliquis.
The health plan denied the non formulary prescription drug Eliquis.
The reviewer has overturned in whole the health plan's determination.

The patient has atrial fibrillation. She has been treated with Eliquis (apixaban) 5 milligrams (mg) twice daily for several years. It was recommended that Eliquis be continued instead of changing to Xarelto (rivaroxaban) or warfarin, formulary agents, due to greater efficacy in stroke prevention.

Both Xarelto and Eliquis are approved for stroke prevention in patients with nonvalvular atrial fibrillation, supported by multi center, randomized controlled clinical trials comparing each agent to warfarin. While warfarin is as effective, these agents are preferable to warfarin as they don't require frequent monitoring of international normalized ratio (INR) and have less food and drug interactions.
With respect to Xarelto versus Eliquis, however, both are factor X a inhibitors, Food and Drug Administration (FDA) approved for stroke prevention in nonvalvular atrial fibrillation in 2011. There are newer data, however, from large studies indicating a potential superiority of Eliquis compared to Xarelto. There was a retrospective study (reference 1 below) of over 580,000 patients comparing Xarelto with Eliquis which showed a lower incidence of major ischemic or hemorrhagic events (16.1 per 1000 patient-years versus 13.4 per 1000 patient-years), which was statistically significant. There is also data supporting use of Eliquis with regard to bleeding risk in a study of over 6,000 patients (reference 2 below) which showed significantly higher major bleeding risk with Xarelto compared to Eliquis. For these reasons, the formulary drugs, warfarin and Xarelto will not be as effective as Eliquis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Saxenda. 
The denial is upheld.

This is a female with pre-diabetes and obesity with body mass index of 35.8 kilograms per square meter (kg/m2). Request for continuation of Saxenda is under review. The prior request was denied as the patient was not actively engaged in a comprehensive medical weight loss program and the Saxenda is being used in combination with phentermine.  The patient is back to being monitored in a comprehensive medical weight loss program with a dietician, health coach, medical doctor, and nurse practitioner. She is taking phentermine, Saxenda, and topiramate.

The health plan's determination is upheld.

The request for Saxenda is not medically necessary for this patient.
This request is for Saxenda for the treatment of obesity in combination with phentermine. In a randomized controlled trial, the addition of phentermine to Saxenda did not induce further weight loss as compared to Saxenda alone [1]. Therefore, no, the requested Saxenda 3 milligrams (mg) pen injection is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dilated aortic root and bicuspid aortic valve. 
Treatment: Myocardial strain imaging. 

The insurer denied the Myocardial strain imaging. 
The determination is upheld. 

The patient has hyperlipidemia, previous tobacco use, and bicuspid aortic valve and presented for a routine office visit/ annual physical. An echocardiogram (ECHO) was ordered to evaluate the aortic root history of  dilated aortic root and bicuspid aortic valve. Myocardial strain imaging was ordered. At issue is the medical necessity of heart muscle strain imaging. 

Myocardial strain imaging is not medically necessary. 

There are no national guidelines for myocardial strain imaging, as this is a fairly new technology. However, per the American College of Cardiology (ACC) review by Matiasz R, et al.  the main area where strain imaging is used is in predicting chemotherapeutic agent myocardial toxicity - development of chemotherapy-induced heart failure. That is not the situation for this patient, who is being evaluated for valve and aortic disease due to a congenital abnormality. 

While there are some data supporting its use for detection of cardiotoxicity related to chemotherapy, it is not currently the standard of care for the evaluation of left ventricular function and the technique requires further study. Therefore, it is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth. 
Treatment: Genetic Testing. 

The insurer denied Genetic Panel Testing. 
The denial is upheld. 

The patient is a pregnant female who had Natera genetic testing. There are no documented antepartum conditions nor family history of inherited diseases. No prenatal office visits were provided. There is a question of the medical necessity of the testing for 81408 (Duchenne muscular dystrophy) and 81243 (Fragile X). Testing was negative. The subject under review is the medical necessity for the Genetic Panel Testing. 

The requested health service/treatment of Genetic Panel Testing is not medically necessary for this patient. 

Currently guidelines recommend testing for Fragile X in patients with a family history of fragile X-related disorders, unexplained mental retardation or developmental delay, autism, or premature ovarian insufficiency. Routine screening is currently not recommended. The patient does not have any of the above disorders nor documentation of these disorders in her family. Therefore, the proposed tests for fragile X (81243) are not recommended at this time and are not medically necessary. 

There are current no recommendations for dystrophin testing for Duchenne/Becker muscular dystrophy in prenatal screening without a prior history of disorder in the affected individual. Therefore, testing Duchenne/Becker muscular atrophy 81408 is not recommended.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Surgical Services.
The insurer denied spinal surgery (facet joint injection). 
The denial is upheld.

The patient is a male with a significant medical history of lumbar (L)4 to sacral (S)1 decompression and fusion. He has low back pain with radiating pain down to bilateral lower extremities. Physical examination is remarkable for positive straight leg raise tests and decreased sensation in the distal lower extremity (LE). Magnetic resonance imaging (MRI) reveals disc bulge, facet osteoarthritis, buckling of ligamentum flavum with significant central canal stenosis at L3-4 level, the stenosis at L3-4 has increased in severity from the prior study. The issue is whether this patient is an appropriate candidate for Intracept procedure according to current clinical studies.

The health plan's determination is upheld.

The Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. The available medical records did not reveal adequate evidence that this patient's pain is from vertebral bodies. This patient has a history of L4 to S1 decompression with adjacent segment disease at L3-4 level. MRI revealed progressively worsening spinal stenosis at L3-4. He has pain in the lower extremities, which is consistent with spinal stenosis and radiculopathy. Current clinical studies supported the efficacy of Intracept procedure for vertebrogenic back pain. However, patients with radiographic evidence of other pain etiologies including severe spinal stenosis, disc bulge, nerve impingement and facet arthrosis were excluded from these studies. 1
Given this patient's spinal stenosis and his symptoms of spinal stenosis and radiculopathy, he is not an appropriate candidate for the Intracept procedure. It is unlikely he will benefit from the Intracept procedure based on his symptoms, MRI findings and current clinical studies.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Surgical Services.
The insurer denied spinal surgery (facet joint injection). 
The denial is upheld.

The patient is a male with complaints of low back pain. The patient has low back pain radiating into bilateral legs. He has had physical therapy as well as prior injections. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated postoperative decompressive laminectomy at lumbar (L) 4-sacral (S)1. There is adjacent segment disease. The patient's medications include anti-inflammatory agents. The physical exam shows tenderness to palpation at the lumbar paraspinals with palpable spasm, positive straight leg raise to the left and right. The subject under review is whether the spinal surgery is likely to be more beneficial than any standard treatment for this patient's condition.

The patient presented with low back pain. The patient is noted to have low back pain with radiation to the bilateral legs, along with positive straight leg raise. This is consistent with a radicular phenomena.
There is a request for Intracept or intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care. As such, the Intracept procedure would not be more beneficial for this patient than standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease.
Treatment; Infliximab Injection (Remicade) .
The insurer denied Infliximab Injection (Remicade). 
The health plan's determination is upheld. 

The patient is a male under management for Crohn's Disease. The patient has been treated for years with Remicade and mercaptopurine. He has done well on Remicade with well-controlled disease.
The patient's prescriber recommended Infliximab (Remicade) for treatment. This was denied by the plan which requires the use of Inflectra (infliximab) unless there has been a failure or treatment or serious side effect with this therapy. 

Infliximab Injection (Remicade) is not medically necessary for this patient.
Infliximab is known as CT-P13 In one study, 111 patients with Crohn's were randomly assigned to initiate CT-P13 and 109 to initiate infliximab. CDAI-70 (Crohn's Disease Activity Index) response rates at week 6 were similar for CT-P13 and infliximab, thereby establishing non-inferiority. The NOR-SWITCH trial showed that switching from infliximab originator to CT-P13 was not inferior to continued treatment with infliximab originator according to a prespecified non-inferiority margin of 15%. Randomized trails beyond these studies are lacking but the data from trials and clinical experience are consistent suggesting that switching to a biosimilar drug should be safe and effective for the patient.
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 has a past medical history (PMH) of Wegener's granulomatosis on steroids and was admitted with complaints of (c/o) abdominal pain associated with nausea and vomiting and back pain after a fall. The vital signs were notable for a pulse of 100. The physical exam was notable for oral thrush, left dacryocystitis, and abdominal tenderness. Lab work was notable for evidence of a urinary tract infection (UTI). A chest x-ray (CXR) showed patchy bilateral airspace opacities suspicious for pneumonia. An electrocardiogram (EKG) showed sinus tachycardia. The patient was diagnosed with pain likely secondary to a fall and treated with pain control, antibiotics, and a radiologic work-up. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
The hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the ED(emergency room) with c/o abdominal pain associated with nausea and vomiting and back pain after a fall. The patient did not have associated high-risk features, such as renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability. In addition, the patient did not have a bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, the tachycardia improved, and she did not have an acute kidney injury, pyelonephritis, ascending infection, toxic appearance, or unstable vital signs. Although there was a suggestion of possible pneumonia on the admission CXR, the patient's CURB-65 [confusion, urea, respiratory rate, blood pressure, age greater than or equal to 65] score was zero and was considered low-risk. The patient presented with musculoskeletal pain after a fall, was treated and responded to physical therapy (PT), antibiotics, and pain control, and these interventions could have been safely and appropriately provided at a lower level of care.
Per the Milliman Care Guidelines (MCG) for Abdominal Pain, Undiagnosed, the patient did not have hemodynamic instability, severe pain requiring acute inpatient treatment, peritoneal signs, need for prolonged nothing by mouth (NPO), suspected toxic megacolon, bacteremia, or need for inpatient procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Skilled Nursing Facility. 
The insurer denied skilled nursing facility stay. 
The denial is upheld.

The patient is a male with alcohol dependence and gait instability. The patient had past medical history of hypertension, chronic obstructive pulmonary disease (COPD) Rosacea, insomnia, ascites. He was admitted for alcohol detoxification and noted to have gait instability. The patient was admitted for rehabilitation. The subject under review is the medical necessity for the skilled nursing facility stay.

The health plan's determination is upheld.

The requested Skilled nursing facility stay is not medically necessary for this patient. The patient has alcohol dependence and gait instability and was admitted to the Skilled Nursing Facility. He completed his detox program and was placed on a swing bed for physical therapy (PT) / occupational therapy (OT) due to his debility.

During his stay, he was independent with transfers and toileting. He ambulated without an assistive device to the bathroom and back to bed independently. He was independent with activities of daily living. He was asleep or refused therapy sessions. He returned to baseline. There was no documentation in the medical records provided of debility that rendered care at a lower level status unsafe, cognitive, or physical inability to manage care, or an unsafe home environment. Daily skilled nursing or rehabilitation services are medically necessary at least 5 days per week when there is the expectation that the patient will improve materially in a reasonable and generally predictable period of time. There was no expectation that he would improve materially as he was at baseline initially in this case. His treatment with physical therapy and occupational therapy could be performed at a lower level of care status and the Skilled Nursing Facility setting was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional-Diabetes
Treatment: Diabetic Equipment, Supplies and Self-Management Education-Insulin Pump
The health plan denied the insulin pump as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient has a history of type 1 diabetes and has been on insulin pump therapy. She has a history of diabetic ketoacidosis and diabetic neuropathy. 

The requested Insulin pump is medically necessary for this patient. The patient has a past medical history significant for uncontrolled type 1 diabetes mellitus complicated by peripheral neuropathy and frequent diabetic ketoacidosis (DKA). When comparing insulin pump use versus multiple daily injections, insulin pumps have shown to lower average glucose concentrations, decrease glucose variability, reduce HbA1c and incidence of hypoglycemia. (1,2) As per the American Diabetes Association guidelines, insulin pumps are considered necessary especially if patients have a history of frequent hypoglycemia and have extreme insulin sensitivity. (3) Now there are insulin pumps that have automated (hybrid) closed-loop systems that allows the pump to infuse basal insulin automatically that is determined by an algorithm based on the results of the glucose readings derived from a continuous glucose monitor. One study has shown the hybrid-closed loop system to decrease HbA1c levels from 7.7% to 7.1% and 7.3% to 6.8% in adolescents and adults, respectively (4). In a meta-analysis of trials comparing the use of this hybrid-closed loop therapy in non-pregnant patients with type 1 diabetes, the proportion of time spent in normal glycemic levels was significant higher with the hybrid-closed loop therapy. (5) Moreover, the incidence of severe hypoglycemia is significantly reduced.
Given this patient's poorly controlled Type 1 Diabetes and her outdated/damaged insulin pump, the tandem pump is medically necessary for this patient given this patient's glucose variability. 
There is evidence that the patient's pump is damaged, has cracks, and is illegible to the patient. The patient's pump is also out of warranty and damaged and in need of repair.