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

Diagnosis: Central Nervous System
Secondary: Alzheimer
Treatment: Home Health Care
The patient has a past medical history of cachexia, contractures, multiple falls, dementia, hyperlipidemia, hypothyroidism, decubitus ulcer of the heel and communication deficits who resides at  home with the spouse. The patient had multiple falls and was hospitalized , subsequently transferred to rehab but returned to acute care after niece called 911 when visiting rehab and was hospitalized with severe hypernatremia. The patient had a request for 24 hour care in split shift/7 days a week to total 168 hours  when leaving the hospital. There was a HELPS and Uniform Assessment System (UAS)-New York provided.  The patient's physician wrote a letter requesting 24 hour care in split shift/7 days a week to total 168 hours per week. The provider noted the patient was home bound, required Hoyer lift for transfers, was mainly bed bound and required total care for activities of daily living (ADL's). The provider requested positioning every 2 hours to prevent skin breakdown in the setting of bilateral lower extremity contractures. The provider felt the patient was more at risk for skin breakdown and pressure ulcers due to poor nutrition. The current aide slept in the kitchen and awoke every 2 hours to reposition the patient. The health plan determination of medical necessity is overturned in whole. The patient has a complex medical history including dementia, cachexia, contractures and multiple falls, who has had a significant decline in physical health following hospitalization with prolonged rehabilitation stay and subsequent prolonged rehospitalization. There was a request for an increase in PCA services to 24 hours per day in split shifts/7 days per week by the treating provider as the patient required positioning every 2 hours to prevent skin breakdown and pressure ulcers. The patient was at higher risk for pressure ulcer given her contractures and poor nutritional status. The patient's husband was not able to provide the care noted in the assessments due to his own frailty and medical issues.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Ulcerative colitis
 
Treatment: Mesalamine DR 1.2 GM tablet

The insurer denied coverage for Mesalamine DR 1.2 GM tablet. The denial is upheld. 

This patient is a male who requested the non-formulary medication mesalamine. Oral 5-ASA formulations differ in the mode of delivery. Although the systemic absorption and efficacy are comparable to sulfasalazine, the 5-ASAs are better tolerated with fewer side effects.

There was no documentation  submitted to indicate that the patient has (1) tried and failed ALL formulary options and/or (2) has a documented contraindication to these formulary options or (3) that the formulary drugs have been ineffective. There is no documentation to indicate the requested drug would be more effective than the formulary options.

There does not appear to be any difference in efficacy or safety between the various formulations of oral 5-ASAs. The choice of oral 5-ASA for treatment of inflammatory bowel disease should be based on the "indication (e.g., induction or maintenance of remission in ulcerative colitis), disease location, patient preference, ability to comply with the prescribed dosing regimen, and availability of the drug" in addition to clinical response and symptom control. In the case of failed therapy, alternatives can be tried until the clinical response is hopefully achieved.

Based on the above, the insurer denial of Formulary Exception for Mesalamine DR 1.2 GM is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's disease.
Treatment:  Increase in personal care services to 12 hours a day, 7 days a week.
The insurer denied the increase in PCA service hours.  The denial was overturned.

The patient has a past medical history of Alzheimer's dementia, frequent falls, urinary incontinence and coronary artery disease who had personal care assistant (PCA) services approved at 8 hours/day, 7 days/week to total 56 hours per week.  The patient lives with her son, who works until the evening hours.  The patient's psychiatrist requested an increase in PCA service hours, due to the patient's worsening dementia with noted needs with help getting in/out of bed, ambulating, eating, toileting, personal hygiene and taking her medications.  The patient's evening aide documented the patient's needs.  The patient required assistance with toileting around 5:00 PM, taking medicine at 7:30 PM, and help with bedtime cares at 8:00 PM.  The patient's psychiatrist and neurologist wrote letters noting the patient needed 12 hours/day, 7 days/week to total 84 hours/week to meet her needs due to her progressive dementia.  They noted the patient needed help with unscheduled tasks, transferring, meal preparation, personal care, instrumental activities of daily living (IADLs) and taking medication.  The patient has been prescribed quetiapine to take in the evening prior to bedtime.  The patient had an assessment tool performed, and it noted the need for total assistance with managing finances and maximal assistance with shopping, medication management, ordinary housework and meal preparation.  The patient was assessed to require extensive assistance with bathing, dressing of lower extremity and phone use and limited assistance with dressing upper extremity and toilet use.  Supervision was recommended for personal hygiene, locomotion and eating.  There was a final adverse determination from the health plan denying coverage of the requested PCA services 12 hours/day, 7 days/week to total 84 hour/week. 

The health plan's determination is overturned.

The patient has a diagnosis of Alzheimer's dementia with progression of symptoms, as noted by her neurologist and psychiatrist.  Her medical providers have documented the progressive nature and worsening of her dementia with increased needs for personal care.  The patient needs help with unscheduled and scheduled tasks.  The patient has personal care needs outside of the currently provided PCA hours, as she needs assistance with preparing and eating her dinner, personal care tasks for bedtime and help with taking her evening medications.  The level of assistance on the assessment tool completed a few months ago is lower than indicated by her multiple providers.  There is documentation by a previous care aide regarding the patient's need for help with activities of daily living (ADLs) and IADLs in the hours outside of her current PCA service hours.
Appeal type: Medical necessity
Decision: Overturned

Digestive system/gastrointestinal
inpatient hospital

Diagnosis: GI Bleed Treatment: Inpatient hospital stay. The insurer denied the inpatient hospital stay. The health plan's determination is overturned. 

The patient is a man who presented to the hospital. He had a history of asthma, coronary artery disease (CAD), cardiac bypass surgery, heart failure, depression and upper GI (gastrointestinal) bleed. He presented with two days of vomiting blood, nausea and chest pain. He denied fevers, chills, syncope and shortness of breath. He also had a history of alcohol abuse and was intoxicated. 

The inpatient hospital admission was medically necessary. The patient was being treated aggressively for suspected acute GI bleed and rhabdomyolysis. In addition, there was concern for alcohol withdrawal and benzodiazepines were considered for treatment of withdrawal symptoms. The patient's presentation involved multiple organ systems and he was at increased risk for an adverse event due to his conditions. A patient with this level of complexity requires an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System/Gastrointestinal
Treatment:  Inpatient Hospital
The insurer denied the inpatient admission.  The denial was upheld.

The patient is a female with medical history of hypertension, diabetes mellitus complicated by neuropathy, chronic kidney disease, coronary artery disease with myocardial infarction status post stent placement, chronic obstructive pulmonary disease, asthma, and pulmonary hypertension.  She presented to the emergency department with hematochezia, abdominal pain, chest pain, and wheezing.  She had onset of diffuse abdominal pain and hematochezia, followed by sharp, non-radiating left chest pain, paresthesias of the left arm, dyspnea, and wheezing.  In the emergency department, she had nausea and 7-8 episodes of vomiting.  She was admitted to the hospital. 

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  In this case, the patient presented with hematochezia, consistent with lower gastrointestinal bleeding.  However, there was no sustained tachycardia or hypotension, and no significant visible ongoing gastrointestinal bleeding.  The patient had close monitoring, which was warranted, as bleeding can be severe and sudden in onset.  However, she did not require a blood transfusion or inpatient colonoscopy.  Myocardial infarction was ruled out, and there was no evidence of decompensated heart failure.  The Acute kidney injury was uncomplicated, and was addressed with decrease in diuretics [8].  All of the measures that were undertaken, including monitoring, labs, and specialist consultations, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

This is infant male was brought to the emergency room by his mother due to intermittent fever first noted 2 weeks prior to presentation but was more frequent over the past week. The patient also had nasal congestion for the past few weeks and his mother said he had been frequently congested since birth. Mother took the patient to PMD on the day of presentation and was told if symptoms persist to have patient evaluated in the emergency room. The patient had decreased oral (PO) intake for three days prior to admission and then on the day of presentation only made one wet diaper and had taken only two ounces of formula. His mother endorsed three episodes of vomiting the week prior to admission as well as 3 to 4 loose stools on the day prior to admission. 

In the emergency room IV placement was difficult and ultimately unsuccessful. While in the emergency room the patient had 4 ounces of formula and 8 ounces of Pedialyte. He had 2 wet diapers. Laboratory studies were done that revealed white blood cell (WBC) of 27,000. The patient was admitted to the pediatric floor for treatment of fevers, PO intolerance secondary to viral illnesses. On a respiratory panel, the patient was positive for adenovirus, hypoxia response element (HRE), and parainfluenza virus. At issue is the medical necessity of the inpatient admission. The health plan's determination is overturned. The inpatient admission was medically necessary.

The patient presented with a high fever and poor PO intake. He was also noted to have WBC of 27,000 and a fever of 103.5 in the ER. He was noted to have decreased urine output and high urine specific gravity (SG) of 1.023 on admission. Although he tolerated PO in the ER, he was s/p a course of antibiotics with elevated WBC. Admission for IV antibiotics pending cultures and monitoring for signs and symptoms of sepsis would be prudent and acceptable care.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has medical history significant for progressive neurologic decline with prominent lower extremity spasticity, cerebellar atrophy, with axonal and sensorimotor neuropathy. The patient is followed by a neurologist who has ordered whole exome sequencing (WES) for further evaluation.  The health plan's determination is overturned.
The exome sequence analysis is likely to be more beneficial than any standard testing for the patient's condition.
 Exome Sequencing is a comprehensive test which identifies changes in a patient's deoxyribonucleic acid (DNA) that are causative or related to their medical concerns. In contrast to current sequencing tests that analyze one gene or small groups of related genes, exome sequencing will analyze the exons or coding regions of over 20,000 genes. Errors that occur in DNA sequences that then lead to genetic disorders are located in the exons. Therefore, sequencing the exome is an effective method of analyzing a patient's DNA to discover the genetic cause of diseases or disabilities. 
It is widely understood that neurodevelopmental disorders (NDDs) are often very complex clinical scenarios form a genetic perspective and are attributable to single-gene mutations at more than 1000 different loci within the genome. 
The use of WES has been readily endorsed by the American College of Medical Genetics and Genomics, which states that "WES should be considered in the clinical diagnostic assessment of a phenotypically affected individual when: The phenotype or family history data strongly implicate a genetic etiology, but the phenotype does not correspond with a specific disorder for which a genetic test targeting a specific gene is available on a clinical basis; A patient presents with a defined genetic disorder that demonstrates a high degree of genetic heterogeneity, making WES or WGS analysis of multiple genes simultaneously a more practical approach; A patient presents with a likely genetic disorder but specific genetic tests available for that phenotype have failed to arrive at a diagnosis." (American College of Medical Genetics and Genomics (ACMG) Policy Statement.). As noted above, the patient in this case readily meets these criteria.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has progressive neurological decline with prominent lower extremity spasticity, cerebellar atrophy, axonal, sensorimotor neuropathy. Despite extensive prior genetics and neurological evaluations and tests a definitive diagnosis has not been established. The attending physician (AP) ordered whole exome sequencing (WES). The health plan's determination is overturned.

The whole exome sequencing (WES) test analyzes the protein coding portion of the human genome and is offered by a number of Clinical Laboratory Improvements Amendments (CLIA)-certified diagnostic laboratories. The results of the tests will likely identify the underlying genetic causes of this patient's disorder and may offer an opportunity for targeted treatment. Furthermore, WES is in a wide use by clinical geneticists and is current standard of care for patients with similar complex genetic syndromes of unknown causes. Despite extensive genetic clinical and molecular evaluations no definitive diagnosis was established for this patient. The disease is presumed to have genetic etiology based on the clinical symptoms. The WES has the potential to identify a mutation a gene responsible for this patient's disease. Without a specific diagnosis it is not possible to predict what the best treatment options for this patient is, which is why the WES test is appropriate. Once a specific genetic diagnosis is established, the next step in the management of this patient would be is to determine what would be the best treatment options for his condition.

In conclusion, once a specific genetic diagnosis is established for this patient then it can be determined what the best treatment options are. Therefore, the testing for this patient in this case is likely to be more beneficial than any standard treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has progressive neurological decline with prominent lower extremity spasticity, cerebellar atrophy, axonal sensorimotor neuropathy who had a previous genetic workup including a 49-gene panel specific to this condition which was unrevealing. The treating physician ordered Whole Exome Sequencing (WES) to further test for etiology of the patient's condition. The subject under review is whether this testing is likely to be more beneficial for this patient than any standard treatment for the patient's condition. The health plan's determination is overturned.

Exome sequence analysis is likely to be more beneficial than any standard treatment for the patient's condition. Genetic diagnosis in the patient has not been established. Finding a type and variant that could contribute to the patient's neurodegenerative disease would be crucial for the patient's management, prognosis and recurrence risks. Furthermore, several areas of possible health concerns may not be addressed if the patient's doctors don't know where to look (in case if renal or other organ system are involved) and therefore potentially life-threatening complications may not be prevented. WES can be used to identify the underlying molecular basis of a genetic disorder in an affected individual.1 WES can test the largest number of genes than any other genetic test because it uses next-generation sequencing (NGS) technology that allows all genes to be sequenced simultaneously and therefore saves time.2 WES tests entire coding deoxyribonucleic acid (DNA) with approximately 20,000 genes and parental samples are tested to help with interpretation of the results. Multiple studies have demonstrated over the past 6 years (since WES was first developed in 2009) its vast power to identify disease-associated genetic variants across a diverse spectrum of human diseases which directly affects treatment.3-4 WES has been very effective as a clinical tool. Since the patient's presentation is nonspecific, WES would be the most effective method with the highest yield, and bypass multiple tests that would have lower yields. WES would indeed be more beneficial for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Fibroid tumors in uterus
Issue under review: Sonata procedure

Determination:
The health plan should not cover the Sonata procedure.

The patient is an adult female with irregular bleeding and pelvic pain.  She had an exam which was unremarkable.  Ultrasound revealed a normal sized uterus measuring 6.7 x 6.7 x 5.0 cm with 1 intramural posterior fibroid measuring 2.9 x 3.1 cm and a subserosal fibroid measuring 1.9 x 1.6 cm.  The plan is for the Sonata procedure.  

Although the trials look at data out to three years, RFVTA of uterine fibroids is still undergoing investigation to assess its long term efficacy and safety. The longest study recommends use for small sized and non pedunculated fibroids.  Further studies are needed to determine the long-term efficacy of this procedure and to evaluate the efficacy and safety of this procedure relative to other treatments for uterine fibroids.  

In summary, there are no long term data to support use of this procedure as being effective and safe long term in patients with symptomatic uterine myomas.  This procedure is also not endorsed by the American College of Obstetrics and Gynecology who provides the guidelines for OB/GYNs in the United States.  Therefore this is not considered a standard of medical practice at this time and should not be covered by the health plan.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Fibroid tumors in uterus
Issue under review: Sonata procedure

Determination:
The health plan should not cover the Sonata procedure.

The patient is an adult menopausal female with complaint of pelvic pain. Ultrasound showed two fibroids: An intramural myoma 3 cm in size and a subserosal myoma less than 2 cm in size. 

The patient is requesting coverage for transcervical Radiofrequency Ablation of Uterine Fibroids, transcervical radiofrequency ablation for the treatment of uterine fibroids using the Gynesonics Sonata TM System.

It is unclear what is causing this patient's discomfort. She has 2 small myomas that are unlikely to be causing any pain. 

Indication for management of fibroids are:
Interference with fertility NOT MET
Heavy bleeding NOT MET
Pelvic pain due to mass effect. NOT MET, as both the location and the size of the fibroids are unlikely to be causing any mass effect and therefore any pain.

There is inadequate and poor quality evidence to permit scientific conclusions regarding the use of the Sonata system. While the Sonata system is FDA-approved for the management of fibroids, the information provided is insufficient to approve the procedure, as it is unclear what is causing this patient's complaint, and the published studies are inconsistent in the reporting of outcomes, such as fibroid size, location and associated symptoms. There are no adequate studies documenting the safety of this procedure in patients interested in future conceptions. 

The gold standard for a uterine sparing procedure is a myomectomy, which can easily be accomplished laparoscopically given the small size and location of these two fibroids.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ectopic pregnancy, abdominal pain
Treatment: Inpatient admission
The treatment was not medically necessary.  

The patient is a G5P0040 female who presented at seven weeks three days with abdominal pain.  The patient had a known history of ectopic pregnancy being medically managed with methotrexate and a prior history of ectopic pregnancy status post right salpingectomy.  On transvaginal ultrasound the day prior to admission, a cystic adnexal mass was seen separate from the ovary and suggestive of ectopic pregnancy.  

The patient was hemodynamically stable with a hemoglobin (Hgb) of 12.4.  She was admitted to the hospital for observation but then proceeded to the operating room the following day where a laparoscopic left salpingectomy was performed.  The patient was discharged the day of surgery.  No evidence was presented that the postoperative period was complicated.  

There was a short period, less than one day of observation, following which the decision was made to perform an uncomplicated laparoscopy and salpingectomy.  There was no evidence of postoperative complications and the patient was discharged home the day of surgery.  In the absence of complications, laparoscopic salpingectomy does not require inpatient hospitalization or prolonged postoperative stay in the hospital.  Therefore the proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Full braces

The proposed full braces are medically necessary. 

Tooth #27, the lower right canine is in crossbite. When an anterior tooth is in crossbite with gingival attachment loss, this is an "automatic qualifier" for benefits according to the handicapping index. The patient is in need of orthodontic treatment to correct the problem.