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

Diagnosis: Abnormal Pap Smears. 

Treatment: Procedural terminology (CPT) code 57460 colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix. 

The insurer denied coverage for current procedural terminology (CPT) code 57460 colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix. 

The denial is upheld. 

The patient is a female with a history of abnormal pap smears. Her latest pap smear was reported as atypical squamous cells of undetermined significance with high-risk Human papillomavirus (HPV). A colposcopy was performed. Cervical biopsy consistent with Low grade squamous intraepithelial lesion (LSIL). 

The provider wants to proceed with a LEEP procedure. The (LEEP) is being done at a surgical center because the patient does not want to be awake nor have local anesthesia in the office. 

Review of the submitted records dating back to 2015 do not provide any rationale that the LEEP procedure would require a surgery center. The literature clearly supports this being done in an office center. The doctor does not indicate that his office does not have the requisite facility to safely perform the procedure. Lastly, ACOG states "In most cases, LEEP is done in the office of an ob-gyn. The procedure takes a few minutes." 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for the cervical procedure to be done at an ambulatory surgical center instead of in the office is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, dementia, and hypertension

Treatment: 7 days per week, 24 hours per day; continuous care by more than 1 person; 168 hours per week, personal care worker (PCW) services

The insurer denied coverage for 7 days per week, 24 hours per day; continuous care by more than 1 person; 168 hours per week, personal care worker (PCW) services

The denial is overturned

This is a female patient with chronic medical problems including progressive Alzheimer's dementia.  She lives in a private residence with a personal care worker (PCW).  The insurer had initially approved PCW services for 7 days/week, 24 hours/day; continuous care by more than 1 person; totaling 168 hours/week.  However, the insurer reduced the PCW from 7 days per week, 24 hours per day; totaling 168 hours/week to 91 hours/week, which is currently under appeal.   

According to the Uniform Assessment System (UAS) report , the patient's cognitive status is impaired (and declining), "Decisions consistently poor or unsafe; cues/supervision required at all times."  Her treating physician described her cognitive ability as "severely impaired."  She requires extensive to maximal assistance for bathing, personal hygiene, and toilet transfer/use.  She is incontinent of bowel and bladder.  The combination of her severe cognitive deficits limited functional capacity, progressive decline and necessity for 24-hour supervision support the insurer's original approval of 7 days per week, 24 hours per day continuous care by more than 1 person; 168 hours per week, personal care worker (PCW) services; allowing the patient to continue living safely at home.  

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).  

From a physical medicine and rehabilitation perspective, the requested 7 days per week, 24 hours per day; continuous care by more than 1 person; 168 hours per week, personal care worker (PCW) services are medically necessary for this patient.  

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

The insurer's denial of coverage for 7 days per week, 24 hours per day; continuous care by more than 1 person; 168 hours per week, personal care worker (PCW) services is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Ozempic
The insurer denied Ozempic.
The determination is upheld.

The patient has a history of obesity, hypogonadism, depression, anal fistula, sleep difficulties, and human immunodeficiency virus (HIV). He is requesting coverage for Ozempic. It was denied by the plan as he does not have diabetes. There is no evidence that the patient suffers from diabetes. In a video visit, it was noted that the patient lost 15 pounds with a combination of exercise and medication changes.
At issue is the medical necessity of Ozempic.

No, the requested health service/treatment of Ozempic was not medically necessary for this patient.
Based on the information provided, the medical necessity of Ozempic cannot be substantiated. Although Ozempic is Food and Drug Administration (FDA) approved for the treatment of obesity, and can be effective, the patient does not have diabetes. It has not been proven that Ozempic is superior to all other weight loss management options available to this patient that include behavioral modification, medications, and surgery. Therefore, based on the standard of care, and the peer reviewed literature cited in the references, Ozempic is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Humira. 
The denial is overturned.

The patient is a female patient who has severe ulcerative colitis. She has previously tried and failed aminosalicylates (5-ASA) agents, steroids, an anti-TNF (tumor necrosis factor) agent (infliximab) and a Janus Kinase inhibitor (JAK) (tofacitinib). Because of her medically refractory ulcerative colitis, with extra intestinal manifestations (erythema nodosum and arthritis) the attending gastroenterologist would like to start Humira in combination with Entyvio to treat her severe ulcerative colitis. The subject under review is the medical necessity for Humira.

The requested health service/treatment of Humira is medically necessary for this patient. Ulcerative colitis (UC) is a chronic disease of the gastrointestinal (GI) tract that is characterized by mucosal inflammation in the colon. Anti-TNF therapy should be initiated in patients with acute severe refractory to corticosteroids ulcerative colitis and in patients with moderate-to-severe ulcerative colitis who are not responsive to conventional treatment with aminosalicylates, corticosteroids and immune modulators. Another systematic review with meta-analysis evaluated the effect of both dual biologic therapy and combination biologic with small molecule therapy in patients with refractory IBD(Inflammatory bowel disease). Although various combination therapies were included in this study, 48% of patients were treated with an anti-TNF agent plus vedolizumab, 7% with an anti-TNF agent plus ustekinumab, and 19% with vedolizumab plus ustekinumab. Although the efficacies of the various combination therapies were not delineated for each drug combination, the study did note that clinical response, clinical remission, endoscopic response, and endoscopic remission were more likely in patients treated with dual therapy because of concomitant extraintestinal manifestations than in patients who simply had refractory intestinal disease. Both of these recent systematic reviews concluded that dual biologic therapy poses a potential therapeutic option for patients with refractory disease or those with extraluminal manifestations not controlled on a single agent.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypothyroidism. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This case involves a female diagnosed with hypothyroidism.  The patient was admitted to the hospital regarding dizziness, tinnitus, diaphoresis, and tachycardia.  The patient has a past medical history of hypertension.  The patient works as a teacher in a school and was in her usual state of health before going to work where she suddenly started having ringing sensation in the right ear with a whooshing and humming noise.  There was associated spinning sensation, nausea, and vomiting.  The patient received a saline flush in her nostrils in school which did not help.  Dizziness worsened with any motion and there were muffled sounds in the right ear.  There was shortness of breath during vertigo spells.  The patient looked weak and tired and was always closing her eyes.  The examination documented the inability to hear fingers rubbing on the right side.  Motor and sensory examinations were intact.  Gait was deferred.  CT (computed tomography) of the head was unremarkable.  There was no central pulmonary embolism on CT.  The patient was admitted.  Later, the patient was discharged. 

The hospitalization does not meet the MCG (Milliman Care Guidelines) criteria.  A CVA (cerebrovascular accident) was excluded in the ER (emergency room), with a likely diagnosis of vertigo caused by a peripheral vestibular etiology.  There were no signs of infection.  There were no objective signs or subjective symptoms to suggest a CVA/ VBI (vertebrobasilar Insufficiency).  Therefore, the request is not supported, and the prior determination is upheld. 

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

The insurer's denial of coverage for an inpatient is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Genetic Diseases/Other/ Hypogonadotropic Hypogonadism
Treatment: Lab Work/Blood Tests
The health plan denied the requested Genome sequence analysis testing as experimental/investigational. 
The health plan's determination is overturned.

The patient is a male with multiple health issues and congenital anomalies including hypogonadotropic hypogonadism, muscle weakness, obesity, history of cleft lip status post repair and left post axial polydactyly status post removal.
This patient had extensive previous genetic workup including metabolic labs, chromosomal microarray, fluorescence in situ hybridization (FISH)/22q11 and fragile X genetic testing and all of these tests did not find a cause for clinical presentation. There is family history of consanguinity which increases risk for autosomal recessive conditions. There is no current treatment plan documented in the medical records.
At issue is whether the proposed health service or treatment of Genome sequence analysis testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

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

The patient already had extensive genetic workup done which did not reveal a cause for his overall clinical presentation. Further testing including whole exome/genome sequencing has a higher diagnostic yield when previous testing failed to give a diagnosis. Also, the patient has multiple health issues and more than one congenital anomaly, raising the possibility of having a genetic condition and this is another indication for sending whole exome/genome sequencing. Finding a clinical diagnosis would help determine further specific management and treatment based on diagnosis such as hormone replacement, and screening for other health issues such as cardiomyopathy.
Whole exome/genome sequencing is not investigational based on recent clinical studies and publications and based on this patient's medical records and previous inconclusive genetic testing.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Genetic Diseases/Other/ Hypogonadotropic Hypogonadism
Treatment: Lab Work/Blood Tests
The health plan denied the requested Genome sequence analysis testing as experimental/investigational. 
The health plan's determination is overturned.

The patient is a man with attention deficit hyperactivity disorder (ADHD), tall stature, muscle weakness and hypotonia, cleft lip and palate, and micropenis and delayed puberty due to hypogonadotropic hypogonadism. Despite extensive genetic evaluations and multiple tests, a definitive diagnosis has not been established.
At issue is whether the proposed health service or treatment of Genome sequence analysis testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

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

Yes, this patient had standard genetic evaluations and tests, but a definitive diagnosis has not been established. The result of the requested whole exome sequencing (WES) test will allow a definitive diagnosis to be established and will provide information about the optimal treatment and management regimens and the anticipated future medical problems for this patient. Furthermore, the results of the requested test will allow accurate genetic counseling of the family, an estimate of the recurrence risks, and identification of other family members at risk of having the disease.
The WES test analyzes the protein coding portion of the human genome and is offered by a number of certified diagnostic laboratories. WES does not need Food and Drug Administration (FDA) approval, as it is a genetic test based on routine molecular techniques, such as deoxyribonucleic acid (DNA) isolation, enrichment, polymerase chain reaction (PCR), and DNA sequencing. 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Genetic Diseases/Other/ Hypogonadotropic Hypogonadism
Treatment: Lab Work/Blood Tests
The health plan denied the requested Genome sequence analysis testing as experimental/investigational. 
The health plan's determination is overturned.

The patient is a male with hypogonadotropic hypogonadism, prediabetes, hypotonia, muscle weakness, attention deficit hyperactivity disorder (ADHD), unilateral cleft lip, vesicoureteral reflux, micropenis and small testicles.
At issue is whether the proposed health service or treatment of Genome sequence analysis testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

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

The requested health service/treatment of Whole Exome Sequencing (WES) would be medically necessary for this patient as well as evidence-based and cost effective. Etiology of the patient's multiple medical problems has not been established. Due to complexity of his history, genetic etiology is likely. Finding a genetic mutation that could explain his hypogonadotropic hypogonadism, prediabetes, hypotonia, muscle weakness, ADHD, unilateral cleft lip, vesicoureteral reflux, micropenis and small testicles 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 do not know where to look (in case if other organ systems 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 and cost [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 10 years (since WES was first developed in 2009 and became clinically available in 2012) its vast power to identify disease-associated genetic variants across a diverse spectrum of human diseases which directly affects treatment [3]. WES has been very effective as a clinical tool. Since the patient's presentation is not specific for any disorder, WES would be the most cost-effective method with the highest yield and bypass multiple tests that would have lower yields. WES would indeed be the best option.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease (CAD). 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This case involves a male who has a prior history of hypertension as well as hyperlipidemia, coronary artery disease (CAD), and status post diagnostic cardiac catheterization revealing 100% (percent) total occlusion within the left anterior descending vessel and ischemic cardiomyopathy.  He presented for an elective staged percutaneous coronary intervention.  The documentation indicated he has class II anginal symptoms with no residual CAD.  He underwent the procedure without complication.  The documentation indicated he was admitted and upon examination the following day he was comfortable.  He denied any palpitations, dizziness, chest pain, shortness of breath.  His EKG (electrocardiogram) was unremarkable.  His access site was stable.  It was recommended he be discharged with instruction to follow-up. 

According to reference literature, the requested inpatient admission was not medically necessary.  Typically, a cardiac catheterization or angiography is an ambulatory procedure.  The documentation indicated he presented for an elective staged percutaneous coronary intervention.  The documentation indicated he went through the procedure without complication.  There is no documentation detailing the need for admission versus observation.  As such, the prior denial remains upheld. 

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

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

Diagnosis: Crohn's disease

Treatment code 84999, measurements of serum levels of infliximab and antibodies to infliximab

The insurer denied coverage for code 84999, measurements of serum levels of infliximab and antibodies to infliximab

The denial is overturned

The patient has ulcerative colitis. He has been on Remicade but had a flare in his disease. He then had Remicade level and antibody levels to Remicade checked.

The American Journal of Gastroenterology article titled "Clinical utility of measuring infliximab and human anti-chimeric concentrations in patients with inflammatory bowel disease" concludes that measuring infliximab concentration and antibody levels is clinically useful. Increasing the drug dose may be a good strategy if infliximab levels are subtherapeutic.

Clinical Gastroenterology and Hepatology article titled "Appropriate Therapeutic Monitoring of Biologic Agents for Patients with Inflammatory Bowel Disease" concludes states that consensus was achieved towards the utility of therapeutic drug monitoring of biologics in IBD [inflammatory bowel disease], particularly anti-TNF therapy. For anti-TNF (tumor necrosis factor) therapies, proactive therapeutic drug monitoring was found to be appropriate after induction and at least once during maintenance therapy.

This patient had a flare up from his Crohn's disease. Obtaining infliximab concentration and antibody levels is well established in the medical literature. The health care plan did not act reasonably or with sound medical judgment.

Measurement of serum levels and antibodies to infliximab is medically necessary. The denial is reversed.

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

The insurer's denial of coverage for code 84999, measurements of serum levels of infliximab and antibodies to infliximab is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myo/pericarditis

Treatment:  inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

This is an adult female that presented to the hospital complaining of fevers, chills, dyspnea and chest pain. Chest pain was exacerbated with movement and when supine. Pain improved upon arrival to the hospital. Vital signs were stable with temperature of 99 degrees, blood pressure 133/89, and pulse 92 beats per minute. Physical examination revealed no abnormality. A 12-lead electrocardiogram revealed normal sinus rhythm without ST (interval on EKG [electrocardiogram] or T (interval on EKG) wave abnormalities. Serum blood testing revealed an elevated troponin of 0.834ng/ml (nanogram/milliliter). CT (computed tomography) scan of the chest revealed no pulmonary embolism and no pericardial effusion. Echocardiogram revealed normal wall motion, an LVEF (left ventricular ejection fraction) of 65% (percent) and no pericardial effusion. The patient was admitted for observation and treatment. 

This patient presented with typical symptoms of myo/pericarditis and had an elevated serum troponin. Acute myo/pericarditis can be complicated by pericardial effusion, as well as atrial and ventricular arrhythmia and may be complicated by cardiac tamponade (Reference 1,2,3). Inpatient admission was medically necessary for diagnostic testing and treatment. In conclusion, this patient could not have been managed at a lower level of care. Inpatient 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 an inpatient admission is overturned. Medical necessity is substantiated.