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

This is a patient with stomach cancer. He was treated with neoadjuvant chemotherapy followed by surgery. He was recommended adjuvant radiation therapy (RT) using proton beam. At issue is whether this is medically necessary.
The health plan's determination is upheld. The proton beam therapy is not in accordance with generally accepted standards of medical practice in the United States. The standard of care (SOC) for adjuvant radiation for gastric cancer is photon based intensity modulated radiation therapy (IMRT), which is in accordance with generally accepted standards of medical practice in the United States
Proton beam therapy is used in following conditions.
The use of proton beam radiation may improve outcomes when the following conditions apply:
1) Conventional treatment modalities do not provide adequate local tumor control;
2) Evidence shows that local tumor response depends on the dose of radiation delivered; and
3) Delivery of adequate radiation doses to the tumor is limited by the proximity of vital radiosensitive tissues or structures.
The attending physician has not provided dose volume histogram (DVH) comparison of IMRT versus proton beam therapy. There is no published data supporting superior clinical outcomes of proton beam over IMRT. The American Society for Radiation Oncology (ASTRO)'s Emerging Technology Committee concluded that current data do not provide sufficient evidence to recommend proton beam therapy (PBT) outside of clinical trials in lung cancer, head and neck cancer, gastrointestinal (GI) malignancies (with the exception of hepatocellular carcinoma) and pediatric non-central nervous system (CNS) malignancies.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems - Teeth Spacing Problem

Dental/Orthodontic Procedure

The patient is a young female with a skeletal Class I occlusion, moderate maxillary spacing and moderate mandibular spacing. She has a single tooth crossbite at upper left cuspid and lower left cuspid with bimaxillary protrusion. The proposed treatment is braces for 18-24 months. The health plan has denied braces as not medically necessary.

The health plan's determination is upheld. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 11 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 mm or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Inflammatory Bowel Disease
Pharmacy/Prescription Drug

This is a patient with a history of very early onset inflammatory bowel disease. The  disease was very severe and led to hospital admission. The patient was initially treated with conventional therapy including mesalamine and sulfasalazine but did not respond well. The patient  was then started on Remicade which resulted in significant improvement. Remicade infusion was then denied by the health plan as the patient`s age is less than 6 years which is the cut-off for approval. The requested service is continuation of Remicade. At issue is the medical necessity of the Remicade.
The health plan's determination is overturned. Remicade 10 mg per kg is medically necessary for this patient.
This patient  has a very special variety of inflammatory bowel disease, very early onset inflammatory bowel disease (VEO-IBD), which differs in several ways from typical later-onset Crohn's disease or ulcerative colitis. Remicade has been shown in peer reviewed literature to be an effective treatment for pediatric inflammatory bowel disease. The clinical practice guidelines recommend using Remicade for treating severe cases of Crohn`s disease and ulcerative colitis when conventional therapy fails. Young children with diffuse intestinal inflammation tend to have very severe disease that cannot be expected to respond to immunomodulators like azathioprine, 6-Mercaptopurine (MP) and methotrexate, and sometimes do not respond well even to the newer biologics. This patient has already tried and failed conventional therapies such as mesalamine and sulfasalazine. Escalation to Remicade was appropriate.
The requested dose (10 mg per kg) is higher than the Food and Drug Administration (FDA) approved dose (5 mg per kg). However, it is considered appropriate for this patient due to the severity of the disease and the presence of low serum albumin. Low albumin level suggests protein-losing enteropathy (the loss of serum proteins by weeping into the intestinal lumen) caused by the severe intestinal inflammation. Because infliximab would also be lost into the lumen along with serum proteins, it is standard practice for pediatric gastroenterology physicians to use the higher 10 mg/kg doses, especially with diffuse disease, as this patient  clearly does have.
This patient  has already started on Remicade and responded well. Discontinuation of this treatment is likely to lead to severe disease complication and significant morbidity. Therefore, the use of Remicade at the requested dose in this patient  is medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal
Secondary: Back Pain
Treatment: Pharmacy/Prescription Drugs 

The patient is permanently disabled with the diagnoses of lumbar radiculopathy, pain in the right knee, and right hip, cervical radiculopathy, pain in left hip, pain in left leg, and pain in right leg. Patient has trialed multiple medications, such as tramadol, morphine sulfate extended-release, fentanyl patches, as well as oxycodone 40 milligrams (mg) extended-release, which caused an adverse reaction and gave no pain relief. The patient's pain ranges from 5-7 out of 10. Patient has chronic intractable pain. Per the provider the patient's use of oxymorphone 20 mg extended-release will keep pain stable and allow the patient to function with activities of daily living (ADLs). The health plan's determination is upheld in whole. 
The patient has chronic intractable pain. The patient's provider is requesting oxymorphone. The formulary alternatives that should be trialed and failed are generic Exalgo as well as tramadol extended release. There was no documentation that this patient has tried and failed the generic Exalgo as well as tramadol extended release.  These medications are the same class of medications as the requested agent and may lead to a similar outcome. There is no rationale as to why the formulary alternative agents cannot be trialed. Overall, the requested oxymorphone is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a male with a history of (h/o) Hepatitis C, multiple atrial arrhythmias status/post (s/p) ablations, s/p ablation, with 7 to 8 second pauses for which a a pacemaker is required. The leadless type is under review.

The health plan's determination is upheld. The Single Chamber Leadless Implantable Transcatheter Pacing System is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
A leadless pacemaker has been developed to potentially decrease pocket and lead complications and malfunctions known to occur with current implanted pacemakers. They do not require a surgical incision, are placed percutaneously, and are currently capable of only single chamber pacing. There are no head to head trials comparing a leadless system to a transvenous one. A leadless system may be considered when transvenous placement is not medically possible (i.e. no vascular access). Overall, they are not established as standard of care compared to transvenous pacing for an individual with no contraindication to placement of a transvenous pacemaker, as in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a man with a history of atrial fibrillation, chronic Hepatitis C infection and cirrhosis. He underwent catheter ablation for atrial fibrillation. Ambulatory monitoring showed episodes of atrial tachycardia with pauses of up to 7.5 seconds. The patient underwent catheter ablation of atrial tachycardia. Ambulatory monitoring showed episodes of atrial tachycardia with pauses of seven and eight seconds upon tachycardia termination. These episodes were associated with near syncope. Coverage for implantation of a leadless permanent pacemaker is at issue.

The health plan's determination is overturned. This man's history of cirrhosis places him at substantial risk for bacterial infections, which can be overwhelming in immunocompromised patients. For this reason, a leadless system would be expected to decrease his risk of an infectious complication. In addition, the medical record indicates that a repeat catheter ablation attempt might be necessary. Pharmacologic control of post-ablation atrial tachycardias is often unsuccessful and this patient has not tolerated antiarrhythmic drugs. A repeat ablation attempt would require placement of multiple catheters in the right heart, with the attendant risk of dislodging permanent pacemaker leads if a transvenous system were to be used. For these reasons, the single chamber leadless pacemaker that has been recommended would likely be safer and more beneficial in this instance than a standard transvenous system.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a male physician with a history of paroxysmal atrial fibrillation, status/post (s/p) catheter ablation and redo ablation for atrial tachycardia. Outpatient event monitors showed episodes of atrial fibrillation with post-conversion pauses of up to 7-8 seconds. These episodes correlated with symptoms of near syncope. Placement of a leadless pacemaker was recommended.

The health plan's determination is upheld. The leadless pacemaker is not likely to be more beneficial than standard dual chamber pacemaker placement for this patient with paroxysmal atrial fibrillation and post-conversion pauses. The Micra leadless pacemaker is an FDA approved device, and has been shown to be safe and effective in short-term follow-up. However, the majority of patients have been those with permanent atrial fibrillation. Also, the long-term effects of the single chamber, leadless pacemaker are uncertain, with regard to incidence of atrial fibrillation. In other clinical trials asynchronous ventricular pacing in patients with underlying sinus rhythm has been shown to increase incidence of atrial fibrillation, among other adverse effects. It is uncertain if asynchronous ventricular pacing with Micra would have similar effects.
Appeal type: Medical necessity
Decision: Upheld

Heart Disease
Durable Medical Equipment (DME) (including Wearable Defibrillators)

The patient is a man with a history of hypertension, diabetes, and chronic kidney disease. He was admitted to the hospital with pneumonia and congestive heart failure, His course was complicated by respiratory failure and cardiac arrest due to pulseless electrical activity. An echocardiogram showed a left ventricular ejection fraction (LVEF) of 20%. His LVEF had been 50-55%. Upon hospital discharge, a LIfeVest wearable cardioverter defibrillator (WCD) was prescribed. A visit note showed the patient was being treated with metoprolol, isosorbide and hydralazine for management of his congestive heart failure. The note indicates that a cardiac catheterization had been performed and the patient had no obstructive disease. He was wearing the WCD at the time of the visit. No subsequent records were provided. Coverage for use of the WCD  is at issue.

The health plan's determination is upheld. Based on the records provided, the WCD was not medically necessary.Depressed left ventricular systolic function is a risk factor for, and powerful predictor of, sudden arrhythmic death. Consequently, implantation of an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death is a widespread practice, proven to be beneficial to heart failure patients with a variety of cardiac diagnoses. Current guidelines support ICD implantation in patients, such as this man, with nonischemic cardiomyopathy, and left ventricular ejection fractions of 35% or less. However, due to the possibility that left ventricular function may improve with time and/or treatment, it is recommended that device implantation be delayed for at least 90 days following the initial diagnosis of nonischemic cardiomyopathy. If, after 90 days of optimal medical therapy, the LVEF remains less than or equal to 35%, ICD implantation is then recommended. However, subset analyses of patients from the large multi-center randomized DEFINITE trial evaluating the use of ICDs in nonischemic cardiomyopathy for the primary prevention of sudden cardiac death have shown that even patients with recently diagnosed cardiomyopathy are at risk for serious ventricular arrhythmias. Accordingly, many physicians prescribe the LifeVest WCD as a "bridge" to potential ICD implantation in newly diagnosed patients. The efficacy of the WCD in detecting and terminating serious ventricular arrhythmias compares favorably to that of the implanted device.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-small cell lung cancer
Issue under review: Genetic testing

Determination:
The Genetic testing was not medically necessary.

The patient is an adult female with metastatic EGFR-mutated NSCLC (non-small cell lung cancer).  She was initially diagnosed in 2018. She was placed on Iressa and progressed earlier this year.  Her AP performed Guardant 360 testing at this time.

There is no evidence that the Guardant 360 testing is of clinical benefit.  The SHIVA study has shown that the use of NGS (next generation sequencing) panel testing does not improve clinical outcomes in advanced cancer conditions.  While the NCCN supports the use of NGS panel testing for evaluation of NSCLC in a first line setting, following failure of EGFR TKI (Tyrosine Kinase Inhibitor) therapy in EGFR-mutated disease, the NCCN only recognizes performance of T790M testing.  Therefore, the proposed Guardant 360 testing performed following failure of Iressa does not conform to accepted standards of practice and would not be considered necessary care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency room with a 3 day history of dizziness and a 2 week history of intermittent headaches. The dizziness was provoked by movement. The patient did not endorse falls or self-injury due to dizziness or gait impairment. The headache was diffuse. In the emergency room, the patient was noted to have some horizontal nystagmus and wide-based gait. A computed tomography (CT) scan of the head was unremarkable. An electrocardiogram (EKG) and laboratory studies were unremarkable. The emergency department (ED) provided noted that the presentation was "reassuring for a peripheral pathology like benign paroxysmal postural vertigo (BPPV)" or benign paroxysmal peripheral vertigo. However, he was admitted to rule out cerebral ischemia. A magnetic resonance imaging (MRI) scan of the brain was later performed that was negative. There was no evidence of stroke. The patient was discharged home in good condition. The health plans determination is upheld.
A CT scan of the brain was performed in the emergency room and was negative for an acute stroke. Acute stroke can often been seen on a CT scan within 8 hours from symptom onset. As such, the likelihood of stroke was low given a negative CT scan and a 3 day to 2 week history of symptoms. Neurology examination was significant for nystagmus and wide-based gait. The emergency room provider stated that the presentation was most consistent with benign paroxysmal position vertigo. This diagnosis does not typically require hospital admission or further inpatient testing. However, the patient was admitted to rule out stroke. An MRI of the brain was performed that did not show stroke. Symptoms were attributed to headache and vertigo. The patient was subsequently discharged home.  

Acute inpatient admission is not medically necessary. The patient could have had an MRI of the brain at a lower level of care to rule out ischemic stroke. He did not have focal neurologic signs or symptoms. He did not have an abnormal EKG, laboratory, or diagnostic studies. He did not require rehabilitation on discharge. All of the above services could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Acute gastroenteritis
 
Treatment:  Inpatient admission

The insurer denied coverage for inpatient admission.  The denial reversed.

This patient is a male child who presented to the emergency department with bilious vomiting.  Per his parents, the patient had vomited every 20 minutes, and the last several episodes were streaked with blood and greenish.  The patient was given Zofran and intravenous fluids in the ED.  An ultrasound revealed no evidence of intussusception.  An x-ray showed the bowel gas pattern was non-obstructive.  The patient was admitted for acute gastroenteritis following evaluation by the Pediatric team.  He received continuous IV fluids and was discharged.  The insurer has denied coverage for the inpatient admission.

In this case, the patient presented with intractable vomiting, diarrhea, and signs of mild to moderate dehydration.  The following rationale is offered in support of the determination:  1) A Practice Parameter issued by the American Academy of Pediatrics pertaining has recommended that patients with acute gastroenteritis with mild to moderate dehydration be treated with oral rehydration, 2) While oral rehydration is preferred, in children who fail oral rehydration, administration of rehydration fluids intravenously is effective and should be recommended, 3) According to 2014 guidelines for the management of acute gastroenteritis in children, indications of hospitalization for acute gastroenteritis in this population include shock, severe dehydration, neurological abnormalities (lethargy, seizures, etc.), intractable or bilious vomiting, failure of oral rehydration, and/or suspected surgical condition, and 4) This child presented with tachycardia, decreased oral tolerance, and inability to tolerate fluids by mouth (PO). He was trialed on IV fluid boluses x 2 to induce urine output, as well as oral Zofran without successful oral tolerance.

Based on the guidelines and practice parameters described, the medical team's decision to admit was warranted.  The health plan did not act reasonably and with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Numbness of left arm and leg
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a female with a history of diabetes mellitus, hypertension and right breast cancer, s/p (status post) mastectomy and chemo radiation. She presented to the ER for further evaluation/management of left arm and leg paresthesia's. 

The patient's intake vitals were afebrile, hemodynamically stable. Her examination was non focal with no significant abnormalities noted including no evidence of acute neurologic deficits. Laboratory and ECG (electrocardiogram) testing were also within normal limits (WNL), with no significant abnormalities noted. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received supportive care with IV fluids and continued cardiac monitoring, along with continuation of her outpatient regimen of medications. She responded well to the prescribed therapies and was subsequently discharged in stable condition. An appeal review requested for potential approval of inpatient admission. 

The patient's intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Her examination was non focal with no significant abnormalities noted, including no evidence of acute neurologic deficits. Head CT, laboratory and ECG testing were also within normal limits, with no significant abnormalities noted, including no evidence of end organ damage. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.
Appeal type: Medical necessity
Decision: Upheld

Other
Inpatient hospital

This is a female who presented to the emergency department with fever, chills, abdominal pain and diarrhea. On presentation, the patient had a temperature of 98.9, pulse rate of 84, blood pressure of 136/76, respiratory rate 20, and oxygen saturation 98% on room air. Bloodwork was notable for white blood cell (WBC) 9.5, hemoglobin 14.2, and hematocrit 44.5, platelet count 274,000, sodium 141, potassium 4.1, chloride 105, and bicarbonate 25, total bilirubin 0.5, alkaline phosphatase 103, aspartate aminotransferase (AST) 26, alanine aminotransferase (ALT) 21 and albumin 4.5. A computed tomography (CT) abdomen/pelvis revealed diffuse thickening and inflammation of the large bowel most prominently the transverse colon suggestive of colitis. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration and antibiotic therapy. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. On presentation, the patient was hemodynamically stable without fever, tachycardia or hypotension. Bloodwork revealed no evidence of anemia, leukocytosis or significant electrolyte derangements. A CT abdomen/pelvis revealed diffuse thickening and inflammation of the large bowel most prominently the transverse colon suggestive of colitis. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration and antibiotic therapy. Gastroenterology service consulted. The patient remained hemodynamically stable and did not develop complications related to colitis in the way of toxic megacolon, perforation, abscess/phlegmon development, sepsis or the need for surgical intervention.
Based on the Milliman Care Guidelines (MCG), the patient did not have suspected severe infection, severe abdominal tenderness, toxic megacolon, hemodynamic instability, severe or persistent vomiting or dehydration, hemolytic uremic syndrome, absent bowel sounds, signs of intestinal obstruction, or require parenteral nutrition. Therefore, an inpatient admission was not medically necessary.