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

Diagnosis: Heart failure.

Treatment: Hospital admission.

The insurer denied coverage for hospital admission.

The denial is overturned.

This is an adult patient that presented to the hospital complaining of worsening shortness of breath, lower extremity swelling and orthopnea. Past medical history was significant for heart failure with reduced ejection fraction (LVEF 15% (percent)), diabetes mellitus and hypertension. Upon arrival to the hospital vital signs were stable (Blood pressure 133/81, and Pulse 88). Oxygen saturation on room air was 95%. A physical exam revealed bilateral rales and pedal edema. A 12-lead electrocardiogram revealed sinus rhythm with left bundle branch block. Serum blood testing revealed an elevated B-type natriuretic peptide (BNP) of 1261 nanograms per liter (ng/L). A Chest x-ray demonstrated a left retrocardiac opacity representing atelectasis or pneumonia. Recent cardiac catheterization revealed diffuse atherosclerosis of the right coronary artery. The patient was treated with intravenous diuretics and admitted to the hospital for work up and treatment. An echocardiogram confirmed a depressed left ventricle ejection fraction of 20% with no significant valvular abnormalities. Cardiac magnetic resonance imaging (MRI) demonstrated no significant scarring or infiltrative myocardial disease. Guideline directed medical therapy was initiated and the patient was discharged after transition to oral diuretic therapy.

The patient presented with complaints of dyspnea and orthopnea. Upon presentation, physical exam and laboratory testing confirmed fluid overload due to systolic congestive heart failure.  The patient required treatment with intravenous diuretic therapy and was ultimately discharged on oral guideline directed medical therapy.  Failure to admit and treat this patient would have resulted in excess morbidity or even mortality. Patients with chronic congestive heart failure have a high risk of adverse outcomes warranting a higher level of care. In one study, patients presenting with congestive heart failure and an elevated BNP level were found to have an increased morbidity and mortality in the subsequent 90 days. Inpatient hospital admission was medically necessary.

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. The insurer's denial of coverage for the full hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Hematuria
Treatment: Oncology (Urothelial), mRNA (messenger ribonucleic acid), gene expression profiling (code 0012M)
The insurer denied coverage for Oncology (Urothelial), mRNA, gene expression profiling (code 0012M).
The denial is upheld.

This adult patient had a negative cystoscopy for bladder cancer. There is interest in the CxBladder test.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

This test is approved by Clinical Laboratory Improvement Amendments (CLIA) and not the Food and Drug Administration (FDA).

This patient is not a good candidate for Oncology (Urothelial), messenger ribonucleic acid (mRNA), gene expression profiling (code 0012M).

Oncology (Urothelial), mRNA gene expression profiling (code 0012M) rendered is not the best available treatment for this patient at this time.

There are no adverse risks increased over standard treatment/services.

The requested services is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The National Comprehensive Cancer Network (NCCN) does not recommend the Cxbladder test with level of evidence 2a or better which is the usual level of evidence required for carrier approval. A recent publication and a recent evidence-based review of this study suggested further study was warranted. This test is undergoing ongoing clinical study.

There are no randomized or controlled trials demonstrating a net positive benefit on healthcare outcomes at this time.

This testing is not more beneficial than cystoscopy with cytology which is the best available treatment.

In summary, the denial of Oncology (Urothelial), mRNA, gene expression profiling (code 0012M)  and coverage for the requested service should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Other/History of falls due to dizziness. 
Treatment: Home Health Care/Consumer Directed Personal Assistance services, a total of 25 hours per week.
The health plan denied the requested Consumer Directed Personal Assistance services, a total of 25 hours per week as not medically necessary. 

This is a case review for a female patient with a medical history notable for a history of falls and schizophrenia. The patient is approved for 22 hours per week of Consumer Directed Personal Assistance Services (CDPAS). The patient and her care team have requested an increase to 25 hours per week. No medical records or letters of support were provided for this review.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented to person and time only with periods of forgetfulness noted. For instrumental activities of daily living (IADLs), the patient requires maximal assistance for meal preparation, housework, finances, medications, and shopping. For activities of daily living (ADLs), the patient requires limited assistance for bathing, dressing lower body, walking, and locomotion. All other ADLs are independent or supervision only. The patient is able to "do ADLs herself some good days but not willing to do/refuse ADLs in some bad days." It is also noted that the patient's "spouse assists during non CDPAS hours/days when he is home." The patient is frequently incontinent of urine and infrequently incontinent of stool. The patient uses 2-3 pull ups per day for incontinence care. A task tool associated with the assessment recommended 26.49 hours per week to address her personal care needs. Care was allotted on weekdays only with 0 hours per week on the weekends due to informal support. 

At issue is the medical necessity for the requested health service/treatment of Consumer Directed Personal Assistance services, a total of 25 hours per week. 

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

The requested health service/treatment of Consumer Directed Personal Assistance services, a total of 25 hours per week, is medically necessary for this patient.
There is no documentation of unmet personal care needs for the patient. However, the UAS task tool does recommend 26.5 hours per week to address her personal care needs. If the patient and her family are appealing this decision and state they need additional care for unmet needs, it is reasonable to provide to them within the limits suggested by the UAS. She lives with other family members, but they are not always home, and the allowance of hours on weekdays only should account for any informal support being provided by family members during night hours and weekends.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Limited neck mobility, environmental allergies, conductive hearing loss on the left accompanied by external ear abnormalities and some behavioral and attention issues, heart murmur, stage II chronic kidney disease.
Treatment: Panel testing [XomeDxPlus Trio: Whole Exome Sequencing (WES) with Mitochondrial Genome Sequencing and Deletion Analysis (genetic test, procedure code(s) 81415, 81416, 81460)
The insurer denied: Panel testing [XomeDxPlus Trio: Whole Exome Sequencing (WES) with Mitochondrial Genome Sequencing and Deletion Analysis (genetic test, procedure code(s) 81415, 81416, 81460)
The denial is overturned.

This school-aged male has limited mobility of his neck. X-rays of his neck were non-diagnostic. He is active in karate, soccer, and skiing. He is cognitively normal. He has been tested for branchiootorenal syndrome, but the DNA (deoxyribonucleic)
results were normal. He has decreased conductive hearing on the left but normal hearing on the right. He has left external ear atresia. He also has congenital absence of the right kidney, congenital hydronephrosis and stage II chronic kidney disease. Echocardiogram was normal. The patient's provider has requested whole exome sequencing to better define his diagnosis and prognosis.

The health plan should cover the proposed treatment of Panel testing [XomeDxPlus Trio: Whole Exome Sequencing (WES) with Mitochondrial Genome Sequencing and Deletion Analysis (genetic test, procedure code(s) 81415, 81416, 81460).

This patient meets criteria for whole exome sequencing. His multiple anomalies are not specific to a well-known or delineated genetic syndrome, these were noted before one year of age. The results of the WES (Whole Exome Sequencing) testing may establish a clinical diagnosis that may lead to changes in management. Comprehensive genetic counseling has been performed. Therefore WES (Whole Exome Sequencing)
should be covered, it is considered medically appropriate, and it is well supported by the authoritative, peer-reviewed, published medical literature cited below.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Limited neck mobility, environmental allergies, conductive hearing loss on the left accompanied by external ear abnormalities and some behavioral and attention issues, heart murmur, stage II chronic kidney disease
Treatment: Panel testing [XomeDxPlus Trio: Whole Exome
Sequencing (WES) with Mitochondrial Genome Sequencing and Deletion Analysis (genetic test, procedure code(s) 81415, 81416, 81460)
The insurer denied: Panel testing [XomeDxPlus Trio: Whole Exome Sequencing (WES) with Mitochondrial Genome Sequencing and Deletion Analysis (genetic test, procedure code(s) 81415, 81416, 81460)
The denial is overturned.

The patient is a school-aged child with known concern for genetic abnormalities. The patient has physical abnormalities, and other structural pathologies that are concerning for an underlying genetic pathology with other co morbidities that will require follow up and preventive care.

The health plan should cover the proposed treatment of Panel testing [XomeDxPlus Trio: Whole Exome Sequencing (WES) with Mitochondrial Genome Sequencing and Deletion Analysis (genetic test, procedure code(s) 81415, 81416, 81460).

The requested genetic test, that is used to assess for any other pathologies, is considered medically appropriate as it is needed to prevent other pathologies from developing. Additionally, it assists in developing the preventive care plan needed for this patient to have a healthy and appropriate medical plan. The patient is followed by a specialist in the field, and after the current work up, it has been determined by a geneticist that the next step is the requested testing. It is considered medically appropriate to obtain this test as per current literature and current specialty guidelines to create an appropriate plan to further assess the patient in this manner. The denial is overturned as further pathologies may be associated with this patient and not all genetic pathologies present in clear or direct patterns. The requested health service of Panel testing [XomeDxPlus Trio: Whole Exome Sequencing (WES) with Mitochondrial Genome Sequencing and Deletion Analysis (genetic test, procedure code(s) 81415, 81416, 81460) would be more beneficial than any standard treatment for the patient's condition or disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Elevated blood pressure
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned.

The patient is a female with an elevated blood pressure of 172/107 one week after her cesarean section delivery in the postpartum period. She was admitted. She was provided medication for her high blood pressure and magnesium for her diagnosis of preeclampsia and seizure prophylaxis. She was provided multiple medications to control her blood pressure. The highest recorded value 200/120. Labs were ordered and monitored. She was discharged against medical advice (AMA) and she was provided labetalol and nifedipine.

Inpatient Hospital Admission is medically necessary for this patient.
The patient had gestational hypertension throughout her pregnancy with a severely elevated blood pressure in clinic. She was provided medication and sent to the hospital. The patient had a diagnosis of severe preeclampsia and admitted to the hospital for monitoring of disease progression. Severe preeclampsia was diagnosed with blood pressure criteria, highest in severe range of 200/120 and given the diagnosis of hypertensive crisis. Magnesium was started for seizure prophylaxis. Once magnesium is started for intravenous medication, toxicity should be closely monitored and it is standard of care to perform this as an inpatient. Toxicity can show in neurological manifestations and is considered an emergency. The patient also was not hemodynamically stable and was in hypertensive crisis. She was discharged that day; however, only secondary to her against medical advice (AMA) status.
Acute inpatient monitoring for signs of HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome and magnesium toxicity is standard of care. In addition, her blood pressure was severely elevated and difficult to control which requires inpatient monitoring to prevent hypertensive crisis. Stroke and cardiac concerns are prominent with a blood pressure that high. Careful cardiac monitoring is required. Therefore, the inpatient admission was medically necessary and standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Services
The insurer denied: Inpatient Hospital Services
The denial is: Overturned

The patient is a female with a past medical history significant for hypertension and migraine who presented to the hospital with left-sided chest pain. The pain was located under the left breast. The patient described the pain as sharp, and constant, with radiation to the left shoulder, 8/10 in intensity. By the time the patient was seen by the admitting physician, the intensity of the chest pain decreased to 3/10. The pain was exacerbated by taking a deep breath. The patient also complained of a frontal headache but denied fever, chills, dizziness, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, numbness, weakness, and lower extremity edema with tingling.

The patient was admitted to the hospital with left-sided chest pain, which was thought to be atypical. The admitting physician admitted the patient with the goal to rule out acute coronary syndrome and treat a hypertensive emergency. The patient received treatment with antihypertensive medications. It was also mentioned that the patient's pro brain natriuretic peptide (BNP) was 1611. An echocardiogram was performed and demonstrated a normal ejection fraction with no significant valvular disease. There was moderate pulmonary hypertension and dilated inferior vena cava (IVC).
In the hospital, the patient was seen by a cardiologist who was consulted for a hypertensive emergency. The cardiologist recommended the continuation of treatment with antihypertensive medications and continuous cardiac monitoring.
The patient stated that she could not stay in the hospital any longer, therefore, was discharged on the day of admission.
The subject under review is the medical necessity for the inpatient hospital services.

The health plan's determination is overturned.

The inpatient hospital services were medically necessary for this patient. The patient presented with a true hypertensive emergency, which according to the nationally accepted standards of care, is a legitimate reason for admission at the acute inpatient level.
Even though the hospital stay was short, it did not change the fact that the patient had a true hypertensive emergency, which is an indication for admission at the acute inpatient level of care.
The patient presented with severely elevated blood pressure that was associated with pulmonary edema seen in the imaging studies.
In addition, the pro BNP was severely elevated, suggestive of acute congestive heart failure (CHF).
Taking into consideration all these facts, the inpatient hospital services were completely justified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right sided hemiplegia.
Treatment: Increase in Consumer Directed Personal Assistance Services (CDPAS) from 28 hours to 56 hours per week. 
The health plan denied the increase in CDPAS from 28 hours to 56 hours per week as not medically necessary.
The health plan's determination is overturned.

The patient is a female with a history of stroke, hypertension (HTN), asthma, pain in lower leg, mitral valve stenosis, low back pain, gastroesophageal reflux disease (GERD), pacemaker, sleep apnea, anxiety/depression, and hyperlipidemia, who has been receiving physiotherapy and is completely wheelchair bound. There is a request for an increase in her personal assisted services as her physician's letter states she needs assistance with activities of daily living (ADL) such as bathing, cleaning, and grooming.
An assessment on shows that the patient requires max assist with both ADLs and instrumental activities of daily living (IADL). She has right sided hemiplegia. She needs at least one person assist with ambulation and has an unsteady gait. She requires extensive assistance for weight bearing and transferring.
At issue is whether the increase in consumer directed personal assistance services (CDPAS) from 28 hours to 56 hours is medically necessary.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of increase in CDPAS from 28 hours to 56 hours per week is medically necessary for this patient.
The patient is still having hemiplegia after her stroke requiring max assistance with ADLs and IADLs. She requires assistance with transferring and walking. 28 hours per week would not allow her enough assistance and could in fact cause her to be more sedentary, which would further negate any potential physical or psychological recovery after her stroke. Disability is very prevalent after strokes and can last a long time. According to a review article looking at long term disability after cerebrovascular accident (CVA):
"Disability and handicap remain highly prevalent up to 3 years after stroke. Patients' perception of physical health is persistently low, but mental health perception is satisfactory up to 3 years. Due to variable correlations between different health-related quality of life (HRQOL) domains with disability and handicap, it is suggested that disability, handicap, and HRQOL should all be assessed to acquire a broader measure of stroke outcome."
Therefore, the requested health service/treatment of increase in CDPAS from 28 hours to 56 hours per week is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary
Inpatient hospital

Diagnosis: kidney stone
Treatment: inpatient stay
The insurer denied an inpatient stay. The health plan's determination is upheld. 

The patient is a female who was admitted for right sided abdominal pain and nausea. Imaging showed right kidney stone with obstruction. She was started on intravenous (IV) fluid with pain medication and a urology consult was requested. Her diet was advanced, pain improved and she did not need any invasive intervention and was discharged in stable condition. 

The Inpatient admission was not medically necessary. A lower level of care was appropriate.
A systematic review and meta-analysis including 23 randomized controlled trials (2458 patients) found that outpatient therapy in addition of medical expulsive therapy (with alpha blocker) to ESWL in ambulatory settings in patients with renal or ureteral stones improved expulsion rates, reduced time to stone clearance, and reduced pain.
Meta-analyses of randomized controlled studies have found that use of an alpha blocker as an outpatient is associated with shorter times to stone passage and lower risks of surgical intervention.
A multisite prospective study of 2759 adult patients (mean age 41 years) with suspected nephrolithiasis found that most were discharged home from the emergency department, and only 9% required hospitalization.
Analysis of a national database that included over 3.6 million visits to the emergency department for renal or ureteral stones found that only 12% of patients required inpatient admission. This patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Degenerative disc disease
Treatment: Code E0745 neuromuscular stimulator for shock
The insurer denied coverage for Code E0745 neuromuscular stimulator for shock.
The denial is overturned.

This is the case of a patient with a history of anxiety disorder, degenerative disc disease, neck and back pain. The patient's Physical Therapy (PT) note stated that the physical therapy treatment has focused on pain management, manual and mechanical joint decompression via cervical traction, the original 7/10 pain level had reduced in size; but the physician is recommending a transcutaneous electrical nerve stimulation (TENS) for pain relief. The patient's magnetic resonance imaging (MRI) lumbar reading stated multilevel small protrusions at lumbar (L) 2-3, L3-4 and L4-5.

The medical record documents criteria have been met:

The device is beneficial for people with chronic pain. There should be confirmation of duration, medications and a course of PT. There should be evidence of TENS usage for at least one month.

These facts have been confirmed. As benefit was noted, a home unit would be beneficial and should be provided.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for Code E0745 neuromuscular stimulator for shock, is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Parkinson's Disease
Treatment: Ropinirole Extended Release
The insurer denied ropinirole extended release.
The determination is upheld.

The patient was diagnosed in 2019 with Parkinson's disease. Treatment with ropinirole extended release (ER) is the subject of this review. The drug was denied because the patient has not tried and failed pramipexole. The patient has tried and failed ropinirole 1 milligram (mg) three times daily only. At issue is the non-formulary medication ropinirole extended release for the treatment of Parkinson's disease.

The patient has tried and failed ropinirole immediate release. The provider notes that the patient has tried and failed ropinirole and the drug has a wearing-off effect when taken three times daily. The patient has not tried and failed pramipexole. Pramipexole is Food and Drug Administration (FDA) approved for treatment of Parkinson's disease. The member has not tried and failed this drug. There is no reason to believe that this drug would not be effective for the patient as it is literature and compendia supported for the treatment of Parkinson's disease. The patient does not have a contraindication to the use of this medication, and it can be tried and failed prior to the request for the extended release formulation of ropinirole ER. The formulary agents and the requested medication are all dopamine agonists and have the same side-effect profile.