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

Diagnosis: Sepsis
Treatment: Full Hospital Admission
The insurer denied: Full Hospital Admission
The denial is: Upheld.

The patient is a male born by spontaneous vaginal delivery at 39.4 weeks. His birth weight was 3715 grams, and Apgar scores were 9 at both one and five-minutes of age.
The neonate was admitted to the Neonatal Intensive Care Unit (NICU) for observation of sepsis in the setting of maternal chorioamnionitis. Rupture of maternal membranes was 6 hours prior to delivery. The mother had a temperature of 38.5 Celsius (C) within one hour after delivery. No antibiotics were administered prior to delivery.
The infant was hemodynamically stable, breathing unassisted room air and on full ad lib oral feedings of breast milk or Similac Total Care formula. A blood culture was obtained on admission and no antibiotics were initiated. The neonate was noted to be well appearing. A Complete Blood Count (CBC) was ordered to be obtained at 6 hours and 24 hours of life. The Early Onset Sepsis (EOS) score was 1.17 at birth. Monitoring for jaundice and routine newborn infant care were provided. A Hematology Consult was performed by telephone as father's genetic testing showed Factor XI positivity (heterozygous Hemophilia C +) and outpatient circumcision was planned.
The infant's blood type was A negative, and the maternal blood type was O positive. Direct Coombs was negative. The blood culture remained no growth at 48 hours and the final report.
Diagnoses included: newborn affected by chorioamnionitis, heart murmur of newborn and single liveborn infant delivered vaginally.
The infant was discharged to home with his parents. Appropriate follow-up was arranged.
The subject under review is the medical necessity for the full hospital admission.

The health plan's determination is upheld.

No, the requested health service/treatment of full hospital admission in the Neonatal Intensive-Care Unit (NICU) is not medically necessary for this patient.
Although the patient required monitoring for sepsis, care could have been provided at a lower level of care status. The patient was hemodynamically stable, breathing unassisted room air, feeding ad lib, and received routine newborn care while being observed for signs of sepsis. No antibiotics were initiated. Appropriate screening laboratory tests were obtained.
Although the neonate met criteria for admission because of maternal chorioamnionitis, the neonate was hemodynamically stable, breathing unassisted room air, feeding ad lib on demand, and being observed for possible sepsis. A blood culture was obtained, but no antibiotics were initiated.
Because the infant was hemodynamically stable, did not have antibiotic treatment, and needed observation, the intensity of care was not medically necessary for care in the NICU. NICU level services require that the neonate exhibits serious problems including respiratory distress, blood pressure problems, or instability of vital signs (heart rate/respiratory rate). Because the neonate was well appearing and did not exhibit any serious problems, NICU level of care was not medically necessary for any of the dates of service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vertebral Fracture
Treatment: Personal Care Aide Level 2: 8 hours per day - 7 day(s) per week; Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week - a total of 140 hours per week 
The insurer denied: Personal Care Aide Level 2: 8 hours per day - 7 day(s) per week; Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week - a total of 140 hours per week.
The denial is overturned.

The patient is a female with medical history notable for spinal stenosis and recent vertebral fracture. The patient is currently approved for 6 hours per day, 5 days per week and 5 hours per day, 2 days per week (total 40 hours per week). The patient and her care team requested an increase to 8 hours per day - 7 day(s) per week; and 12 hours per day - 7 day(s) per week (a total of 140 hours per week). This request was denied by the health plan, and this denial is the subject under review.

The requested Personal Care Aide Level 2: 8 hours per day - 7 day(s) per week; Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week - a total of 140 hours per week is medically necessary for this patient.

The patient requires hands on assistance for all instrumental activities of daily living (IADLs) and activities of daily living (ADLs). She has declined from a functional perspective over the past year. The most recent UAS (Uniform Assessment System) does not reflect her recent vertebral fracture and worsening of her chronic low back pain, which likely has worsened her mobility. She has incontinence and relies on others for changing and for transfer to the toilet for scheduled voiding. She requires assistance with bed mobility, and this is more important in the setting of her recent fracture and DVT (deep vein thrombosis). The patient's needs are expected to occur throughout the day and night at unscheduled times, and thus she requires an increase to the requested number of hours to properly address her functional needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, hyperlipidemia, diabetes, and a CVA (cerebrovascular accident)
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male for whom an inpatient hospitalization is under review. The patient has a pertinent history of hypertension, hyperlipidemia, diabetes, and a CVA (cerebrovascular accident). He presented with chest pain. It was related to exertion.
The patient was in no acute distress. A chest x-ray was unremarkable. The ECG (electrocardiogram) was not acute. He had known LVEF (left ventricle ejection fraction) of 60-65%. There was report of multiple ED (emergency department) visits for chest pain and occasional cocaine use. Troponins were negative. The patient subsequently signed out against medical advice.

The Inpatient Hospital Admission was not medically necessary.

This patient presented with chest pain and remained stable. There was no CHF (congestive heart failure), respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, another serious cause for chest pain, such as a PE (pulmonary embolism) or aortic dissection. There was no need for prolonged IV (intravenous) medications or oxygen support, need for invasive hemodynamic monitoring, need for vasopressor or mechanical cardiac support. There was no introduction of high-risk medications requiring ongoing in-hospital monitoring or supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal ECG (electrocardiogram). In the setting of this case an acute inpatient level hospitalization, compared to for example observation or outpatient, has not been established as standard of care towards improved cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: vaginal bleeding.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female who was seen for heavy vaginal bleeding, ovarian cyst, and significant anemia and transferred to an affiliated hospital presumably where she would have access to an inpatients pediatric service. She was admitted as an inpatient status with the "anticipation of a 2-midnight length of stay."
The patient was transfused with 2 units of packed red blood cells (PRBC) and gyn (gynecology) consult was acquired. On the day of admission, the gyn consult determined that the patient's ovarian cyst was of minor concern and could be followed up on as an outpatient and that the bleeding could be managed with oral progesterone therapy.

The inpatient stay was not medically necessary for this patient. The same care could have been just as effectively rendered at a lower level of care. Inpatient admission for two midnights may have been anticipated, but in fact, was not required. On the morning after admission, the patient's blood count was still low and she received two addition units of blood, but her bleeding had significantly slowed to the point that she had not changed her pad overnight. She was stable during the period of observation and discharged home.
According to the Milliman Care Guidelines (MCG) for Anemia (M-35), clinical indications for (inpatient) admission for anemia include hemodynamic instability, active bleeding, altered mental status, cardiac arrhythmias, severe thrombocytopenia, acute renal failure, and signs of cardiac ischemia. In this case, the patient did not have these conditions and was hemodynamically stable.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal Bleeding
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with a past medical history (PMH) of hemorrhoids who was admitted with complaints of (c/o) a several week history of rectal bleeding associated with lightheadedness. His vital signs were unremarkable. The physical exam notable for no apparent distress (NAD). Lab work was notable for a hemoglobin of 8. Imaging studies included a chest x-ray (CXR) which showed no acute cardiopulmonary process, a computed tomography (CT) abdomen/pelvis (A/P) angiography which showed no active gastrointestinal (GI) bleed. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with symptomatic anemia and treated with hemoglobin monitoring, type and screen, intravenous fluids (IVF), packed red blood cells (PRBC) transfusion, intravenous (IV) iron, and gastroenterology (GI) consultation. The patient was initially scheduled to have an esophagogastroduodenoscopy (EGD) /colonoscopy, but was cancelled and deferred to outpatient. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o lightheadedness associated with anemia. The patient was found to have a low hemoglobin associated with a history of intermittent bright red blood per rectum (BRBPR) secondary to his known hemorrhoids and the CT A/P angiography showed no active GI bleed. The patient received one unit of packed red blood cells (PRBCs), symptomatically improved, and was discharged home in stable condition. The patient did not have hemodynamic instability, persistent orthostasis, evidence of active bleeding in the ED (such as frequent episodes of hematemesis, melena, or BRBPR), coagulopathy, or known esophageal varices. In addition, the patient was deemed appropriate for outpatient EGD/colonoscopy by GI. This patient could have been safely observed and received diagnostic work-up, consultation and transfusion at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Lumbar decompression
The insurer denied coverage for lumbar decompression.
The denial is overturned.

This adult woman has chronic low back pain and bilateral sacroiliitis. She takes Lyrica, Hydrocodone, and oxycodone. She has had physical therapy. Her magnetic resonance imaging (MRI) shows multi-level degenerative disc disease, facet hypertrophy and spinal stenosis. The request is for the minimally invasive lumbar decompression (MILD) procedure.

There are two prospective randomized controlled trials (1,2) that support this procedure.
Staats, et al (1) conducted the MiDAS ENCORE study which was approved by the Centers for Medicare & Medicaid Services (CMS) as a Coverage with Evidence Development study for the purpose of providing level I evidence to support the safety and effectiveness of the MILD procedure. This randomized controlled trial assessed outcomes of the MILD procedure compared with epidural steroid injections (ESIs) in subjects with lumbar spinal stenosis (LSS) and neurogenic claudication symptoms, with verified Ligamentum Flavum Hypertrophy as a contributing factor. Study follow-up intervals occurred at 6 months and 1 year for the randomized phase of the study, and subjects in the MILD treatment group were followed at 2 years. Study design and 6-month and 1-year follow-up comparative results between MILD and ESI were previously reported. This is a report of 2-year clinical outcomes of patients treated with the MILD procedure in the MiDAS ENCORE study which were statistically significant improvement in pain and disability scores.

Deer, et al (2) also conducted a randomized controlled trial and reported the one-year results of this Level-1 study which demonstrated the superiority of MILD+ (plus) Conservative Medical Management (CMM) over CMM alone for patients with lumbar spinal stenosis who were suffering from neurogenic claudication secondary to hypertrophic ligamentum flavum. Use of the validated Walking Tolerance Test to objectively measure increased ability to walk without severe symptoms provided evidence of statistically significantly better outcomes for MILD+CMM than for CMM alone. With no reported device or procedure-related adverse events, the long-standing safety profile of the MILD procedure was reaffirmed. MILD is a safe, durable, minimally invasive procedure that has been shown to be effective as an early interventional therapy for patients suffering from symptomatic lumbar spinal stenosis.

This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.

The carrier's denial of coverage for lumbar decompression should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pregnancy.
Treatment:  Code 0247U obstetrics (preterm birth), insulin like growth factor binding protein 4 (IBP4), sex hormone-binding globulin (SHBG), quantitative measurement by LC-MS/MS, utilizing maternal serum, combined with clinical data, reported as predictive-risk stratification for spontaneous preterm birth.

The insurer denied coverage for code 0247U obstetrics (preterm birth), insulin like growth factor binding protein 4 (IBP4), sex hormone-binding globulin (SHBG), quantitative measurement by LC-MS (liquid chromatography-mass spectrometry
)/MS, utilizing maternal serum, combined with clinical data, reported as predictive-risk stratification for spontaneous preterm birth.  The denial is upheld.
 
A test (PreTRM Test) for two serum proteins, insulin-like growth factor-binding protein 4 and sex hormone-binding globulin, is available for clinical use to predict preterm labor. In a study to develop and validate a mass spectrometry-based serum test to predict spontaneous preterm delivery in asymptomatic pregnant women, the test had sensitivity and specificity of 0.75 and 0.74, respectively, for predicting preterm labor <37 weeks. According to society guidelines, it is recommended not moving forward with serum screening for pre-term birth (PTB) until such screening has been adequately tested and validated.

In its latest Practice Bulletin (see ref.) American College of Obstetricians and Gynecologists (ACOG) does not recommend testing patients with no history of preterm labor or who are not at high risk of preterm labor. ACOG does not recommend using the PreTRM test. According to ACOG, the assessment of the cervical length in the second trimester has been shown to identify women at increased risk for preterm birth.

Note that this patient was not at any risk for preterm labor. She has no history of preterm labor. There was no information of preterm labor or shortened cervix during this pregnancy. In addition there are no guidelines or recommendations about how to manage patients with abnormal Pre TRM tests. In summary, the Pre TRM test for this enrollee is not considered an effective diagnostic tool and is not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for charge code 0247U obstetrics (preterm birth), insulin like growth factor binding protein 4 (IBP4), sex hormone-binding globulin (SHBG), quantitative measurement by LC-MS/MS, utilizing maternal serum, combined with clinical data, reported as predictive-risk stratification for spontaneous preterm birth is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Outpatient Procedure (Lumbar Spinal Codes 22842 and 22853).

The insurer denied Outpatient Procedure (Lumbar Spinal Codes 22842 and 22853).  The denial is upheld.

The patient is a female with primarily low back pain, although she does have some radiating bilateral leg pain. Past surgical history (PSH) is significant for prior spinal cord stimulator placement and removal. The patient has a prior history of tobacco use, but documentation shows she has quit smoking. Physical exam is notable for decreased and painful lumbar range of motion (especially extension) and tenderness in the lower lumbar spine. X-rays show mild scoliosis and advanced decreased disc height lumbar (L)2/3 and moderate disc height loss L3/4. Magnetic resonance imaging (MRI) shows modic changes at L2/3 level. Foraminal and central stenosis at L2/3 and L3/4 due to degenerative changes documented in the clinical notes but the radiology report states no central stenosis at either level and only mild foraminal stenosis. Prior treatments include non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, activity modification, physical therapy (PT), narcotics, muscle relaxers, home exercise program (HEP), spinal cord stimulator. The patient continues to experience symptoms that affect her activities of daily living. She was recommended L2-4 transforaminal lumbar interbody fusions (TLIFs). This was denied by her health plan as not medically necessary due to lack of implant name for concern that Food and Drug Administration (FDA) approved implants are utilized. Addended note documents that the cage is Medtronic Crescent cage and pedicle screws are Nuvasive. 

The patient is a female with axial low back pain. While she has failed conservative treatment to date, lumbar fusion surgery has not been shown to reliably treat axial low back pain. The patient has axial low back pain for which lumbar fusion is not recommended. As per Eck et al., "Based on a number of prospective, randomized trials, comparable outcomes, for patients presenting with 1- or 2-level degenerative disc disease, have been demonstrated following either lumbar fusion or a comprehensive rehabilitation program with a cognitive element." Patient's MRI showed significant muscular atrophy and likely would benefit from a comprehensive rehab program as aforementioned.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Bipolar Disorder
Treatment: Invega Sustenna 156mg/ml (milligrams per milliliter) injection
The insurer denied: Invega Sustenna 156mg/ml injection
The denial is overturned.

The patient is an adult non-binary adult who is in treatment for a severe and persistent mental disorder best characterized as bipolar I disorder with psychotic features and an unspecified eating disorder. The patient is treated with a long-acting injectable formulation, Invega Sustenna at a dose of 156 mg/ml (milligrams per milliliter) together with lithium 900 mg (milligrams) daily and Zyprexa Zydis 10 mg (milligrams) at bedtime with a positive clinical response. The patient participates in outpatient care with injections of the Invega Sustenna as clinically appropriate. Mental status examination showed a groomed and cooperative patient with fluent speech and linear thought processing. Mood was okay with blunted affect and no evidence for delusions or depressive ruminations.

The health plan denied coverage of the request on the basis of plan criteria and policy with requirement for at least 3 trials and failure with formulary alternatives including paliperidone ER (extended release), olanzapine, clozapine, risperidone, ziprasidone, quetiapine and Saphris.

Appeal is on the basis of clinical features and response with use to the injectable formulation of paliperidone, Invega Sustenna.

The health plan should cover the Formulary exception for Invega Sustenna.

None of the formulary alternatives are clinically appropriate, as they are oral formulations and the request is for an injectable formulation of paliperidone, Invega Sustenna. Therefore, the formulary drugs would not be as effective as the requested non-formulary drug and would not be effective, as they are not injectable as necessary in this case. It is not known whether the formulary drugs would result in adverse effects for this patient. This answer is consistent with New York State instruction for this review with regard to a formulary exception. Moreover, and in this regard, a switch from a medication that is effective and well-tolerated to another medication is contraindicated in keeping with prevailing standards of care in this case scenario, and clearly does pose risk to the patient that contraindicates the switch to any of the suggested formulary alternatives. New York State instruction allows for a formulary exception in cases where a contraindication to the use of a formulary alternative is applicable, as in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Small Cell Lung Cancer. 
Treatment: Radiation Therapy, Phase 1:30 Fractions of Intensity Modulated Radiation Therapy (IMRT), (IGRT). 
The insurer denied:  Radiation Therapy, Phase 1:30 Fractions of Intensity Modulated Radiation Therapy (IMRT), (IGRT). 
The denial is overturned. 

The patient is an elderly male with history of limited stage small cell lung cancer. He was recommended to proceed with definitive radiotherapy with curative intent. The request is for approval of 30 fractions of IMRT (intensity-modulated radiation therapy). 

The requested health service is medically necessary. 

The treating provider performed a 3D/IMRT (three dimensional/intensity-modulated radiation therapy) plan comparison, which revealed that the 3DCRT (three-dimensional conformal radiotherapy) plan was unable to provide adequate safety/precision with regard to spinal cord, esophagus, and normal lung tissue exposure. If delivered, the 3DCRT (three-dimensional conformal radiotherapy) plan would result in an unacceptable and unnecessary risk for injury to these surrounding normal tissues. The IMRT (intensity-modulated radiation therapy) plan was able to significantly reduce the risk for high grade toxicity, as the normal tissue exposure was within known safe tolerance limits. IMRT (intensity-modulated radiation therapy) is widely utilized for similar patients who cannot be treated safely/effectively with 3DCRT (three-dimensional conformal radiotherapy). IMRT (intensity-modulated radiation therapy) in the member's setting is supported by the ASTRO (American Society for Radiation Oncology) Model Policy and the NCCN (National Comprehensive Cancer Network) guideline.