Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Recurrent pregnancy loss. 

Treatment: Tests for inherited thrombophilia disorders, described by codes 81241, 81240, 85306, 85303 and 85300. 

The insurer denied coverage for the tests for inherited thrombophilia disorders, described by codes 81241, 81240, 85306, 85303 and 85300. 

The denial is upheld. 

This is a female patient with a history of recurrent pregnancy loss. The patient's results of genetic testing showed that she was a carrier for biotinidase deficiency, cystic fibrosis and Usher syndrome, type lll; the patient's husband was a carrier for factor Xl deficiency, familial Mediterranean fever, and primary hyperoxaluria, type 3. 

There is a large and contradictory body of literature on the association between maternal inherited thrombophilia and recurrent spontaneous abortion, fetal loss, and stillbirth. 

The American College of Obstetricians and Gynecologists states that tests for thrombophilia conditions are not required as part of the evaluation of recurrent pregnancy loss; but may be considered in cases of otherwise unexplained fetal death in the second or third trimesters. The literature states that the role of thrombophilia in recurrent pregnancy loss is a controversial subject of current research interests. Tests for factor V Leiden, the prothrombin G20210A mutations, or deficiencies of protein C, protein S, or antithrombin III should be considered in cases of otherwise unexplained fetal death in the second or third trimesters. However, the role of these heritable thrombophilia conditions in recurrent early pregnancy loss is uncertain at present, and tests for these thrombophilia conditions are not required as part of the evaluation. Whether antithrombotic treatment improves subsequent pregnancy outcomes in women with evidence of thrombophilia is uncertain. 

Based on the above and the American Society for Reproductive Medicine (ASRM) recommendation, this patient is not a good candidate for tests for inherited thrombophilia disorders, described by codes 81241, 81240, 85306, 85303 and 85300. The tests for inherited thrombophilia disorders, described by codes 81241, 81240, 85306, 85303 and 85300 are not the best available treatment for this patient at this time. Therefore, the thrombophilia panel ordered on this patient is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of tests for inherited thrombophilia disorders, described by codes 81241, 81240, 85306, 85303 and 85300 should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Type 1
Treatment: Inpatient Stay 
The health plan denied the requested inpatient management program.
The health plan's determination is overturned.

The patient is a male who has been diagnosed with type 1 diabetes for few years. He is being followed at a facility. His diabetes control has been poor. He was on insulin pump in the past but decided to take a break from the pump and is now on subcutaneous (SQ) insulin injections. He is also on continuous glucose monitor but does not use blood sugar data to use correction scale. He is also frequently missing food coverage. His clinical course is also complicated by the diagnosis of a learning disability, attention deficit hyperactivity disorder (ADHD), behavioral problems, anxiety, and depression for which he has been treated with multiple medicines including Ritalin, Xanax, Strattera, Wellbutrin, and Abilify.

His healthcare provider is requesting a month acute rehabilitation admission for chronic illness inpatient management program to improve his compliance and diabetes control.

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

Yes. Diabetes mellitus is a chronic disease that requires continuous medical care. The management plan for diabetes includes frequent blood glucose testing, carbohydrate counting, regularly administering insulin and keeping record of self-management. Lowering HbA1C(Hemoglobin A1C) to below or around 7% has been shown to reduce complications of diabetes. Therefore, a reasonable HbA1C goal should be < 7%; however, it is usually individualized based on clinical circumstances.
This patient is seeking one-month acute rehabilitation admission for chronic inpatient management program which is similar to a chronic care model. The chronic care model defines collaborative, multidisciplinary teams' approach to provide care for people with chronic conditions such as diabetes to facilitate patient's performance of appropriate self-management and has been shown to be effective.
   
This patient has been diagnosed with type 1 diabetes and his control has been poor due to noncompliance. He is not acting on his blood sugar results and frequently missing his blood coverage, and his control is deteriorating with time.
Although noncompliance is not an absolute indication for acute rehabilitation admission for chronic illness inpatient management program, his clinical course is also complicated by learning disability, ADHD, behavioral problems, anxiety, and depression which may be contributing to noncompliance and he should be given a chance to improve his control and help modify his behavior.
Residential treatment can improve diabetes control with poorly controlled diabetes by providing patient education, improved diabetes management and the psychosocial intervention. Success in such facilities is probably related to the stable environment in addition to medical and mental health supervision. However, it may or may not be sufficient to ensure compliance after discharge from such facility as results are mixed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer-Anal/Rectal Cancer
Treatment: Radiation Therapy- SBRT
The health plan Stereotactic Body Radiation Therapy as not medically necessary. 
The reviewer has upheld in whole the health plan determination.

This is the case of a patient who has a history of rectal cancer. The patient underwent several different treatments. The recent positron emission tomography (PET) scan showed multiple bilateral pulmonary nodules consistent with metastasis with a single site of progression at the left hilum. The patient is being evaluated for Stereotactic Body Radiation Therapy(SBRT). 

The requested health service/treatment of Stereotactic Body Radiation Therapy is not medically necessary for this patient.

This patient has recurrent disease and then metastatic disease for which she was treated with several different modalities. The last PET scan again showed bilateral pulmonary metastasis (full report not available). The progression of disease in left hilum has no note that it is symptomatic. This area was not treated with radiation before. This patient has still widespread metastatic disease.

There is no published data to support SBRT in such clinical scenario.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional-Diabetes. 
Treatment: Pharmacy/Prescription Drugs-Jardiance. 

The health plan denied the request for coverage of Jardiance as not medically necessary. 
The reviewer overturns in whole the medical necessity for the prescription drug Jardiance. 

Jardiance is medically reasonable and necessary for this patient. 

The American Diabetes Association/European Diabetes Association in their 2018 guidelines and American Association of Clinical Endocrinologists in their 2019 guidelines on treatment of type 2 diabetes both endorse metformin as the first line agent, with addition as needed of other agents to achieve glycemic goals (ranging from A1C < 6.5 to < 7% based on individualized targets) including sulfonylureas, dipeptidyl peptidase 4 (DPP4) inhibitors, glucagon-like peptide 1 (GLP1) agonists, insulins, Sodium glucose co-transporter 2 (SGLT2) inhibitors, etc. According to the notes provided for review, the patient is on metformin 1G twice daily, Glimepiride 4 MG, and Trulicity weekly. 

Based on the information submitted there is no duration of how long the patient has been on metformin 1g twice daily, a listed alternative medication. Although there is no glucose (fingerstick data) or A1C data available as evidence of glycemic control for this review, the provider states that the patient is stable on Jardiance and that discontinuation of or change would be detrimental to the patient's glycemic control. Therefore, Jardiance is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperkalemia, Hypertension urgency, Shortness of breath

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a female patient with end stage renal disease (ESRD) on dialysis as an outpatient who was admitted for hyperkalemia and hypertension urgency with shortness of breath due to missing outpatient dialysis treatment. The patient was treated with routine hemodialysis and blood pressure medication. The patient's condition responded to daily dialysis. The patient did not have persistent severe hyperkalemia, signs of severe volume overload or hypoxia, nor documentation of severe uremia such as encephalopathy or uremic bleeding. The patient had established dialysis access and did not require emergent vascular intervention. Based on the review of the medical record and literature, this patient's condition could have been treated safely under lower level of care.

As per review of the medical record and literature, the inpatient admission is not considered medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo
Treatment: Consumer directed personal assistance services (CDPAS)

The insurer denied coverage for consumer directed personal assistance services (CDPAS).  The denial is upheld. 

This is a female patient with a past medical history of diabetes mellitus, dizziness, acute non-intractable headaches, seizure-like activity, and facial droop. The Uniform Assessment form noted the patient needed someone to help her wash a little. She needed somebody to help her around the house. The patient was able to complete all activities of daily living independently when she was not dizzy. Her significant other voluntarily helped with all tasks including transportation, housekeeping, meal preparation, laundry, and grocery shopping as needed. She was hoping to make her significant other her formal aide. She had the voluntary assistance of a friend who provided help with household tasks and childcare. She ambulated independently. Her durable medical equipment included a glucometer and blood pressure machine from complications related to her last pregnancy. She was utilizing oral medications. She requested consumer directed personal assistant services (CDPAS).
A letter indicated the patient had vertigo, falls, and staring episodes. She was undergoing a work-up for constellation of symptoms that cause neurologic event functional problems; she was slowly deteriorating in function. She was stable. The current treatment plan included medication management, magnetic resonance imaging (MRI) evaluation, and a referral to Neurology. The patient had difficulty standing, walking, climbing, cooking, bathing, and dressing. The patient relied on her family to assist her because of frequent falls.

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

The requested consumer directed personal assistance services (CDPAS) is not considered medically necessary for this patient. The medical necessity for a personal assistant was not established with the presented documentation. 

Based on the above, the medical necessity for the requested consumer directed personal assistance services (CDPAS) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atrial Fibrillation With Rapid Ventricular Response.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a female.  She has a past medical history significant for atrial fibrillation, status post prior cardioversion several years prior, and again earlier this year.  She presented to the hospital for a complaint of dizziness with episodes of bradycardia and tachycardia.  The patient had dizziness associated with bradycardia and dyspnea associated with tachycardia. 

The patient was seen in consultation by cardiology.  Her heart rate was reported in 48 to 107 range.  The patient was started on anticoagulation.  She previously did not tolerate AV (atrioventricular) blocking agents due to episodes of bradycardia.  ECG (electrocardiogram) revealed atrial fibrillation.  Blood pressure was stable.  Troponin was negative. 

The patient underwent TEE (transesophageal echocardiogram)/cardioversion with restoration of normal sinus rhythm and was scheduled for outpatient ablation.

No, the inpatient admission was not medically necessary.

The patient with known history of atrial fibrillation, presented with a recurrent episode of atrial fibrillation.  The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative.  There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability.  The patient was started on oral anticoagulation and underwent cardioversion with a plan for outpatient follow-up for ablation.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission.  The care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bradycardia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history of opioid dependence. He presented for detox from heroin and Xanax. His last used was in the morning.  He was transferred to the ED (emergency department) from detox after a finding of bradycardia. He complained of mild body ache.  

The patient's VS (vital signs) were as follows: Temperature 97.6, heart rate 49, Respiration rate 17, blood pressure 100/64, oxygen saturation 98% on RA (room air).  His COWS (clinical opiate withdrawal scale) score was 4. His exam was unremarkable. His EKG (electrocardiogram) revealed sinus bradycardia at 40 bpm (beats per minute). His CXR (chest x-ray) revealed NAD (no active disease. He patient's labs were as follows: WBC (white blood count) 8.4, H/H (hemoglobin hematocrit) 12.8/37.9, Plt (platelets) 219, Na (sodium) 142, K (potassium) 3.9, BUN/Cr (blood urea nitrogen/creatinine) 11.6/.76,  Mg (magnesium) 2, Phos (phosphorus) 2.5.  His urine toxicology was positive for opiates, methadone, benzodiazepines, and cannabinoids.  

The patient was admitted with asymptomatic bradycardia.  Plan of care included cardiac monitoring.  Methadone and Ativan were provided prn (as needed) for withdrawal symptoms.  

The following day the patient's vital signs were stable. His HR (heart rate) was 50. His COWS (clinical opiate withdrawal scale) score was 8-9. Cardiac monitoring was continued, and methadone was started.  

The next day, the patient's vital signs were stable. His HR (heart rate) was 58. His COWS (clinical opiate withdrawal scale) score was 6-7. He complained of nausea, anxiety, body ache and sweating. Current management was continued.  

Admission day 4, the patient's vital signs were stable. His HR (heart rate) was 50. His COWS (clinical opiate withdrawal scale) was 3-4. He was downgraded to floor.  

The patient was cleared for discharge.

No, the Inpatient admission was not medically necessary.

This patient was admitted for opiate withdrawal.  The patient was hemodynamically stable with asymptomatic bradycardia.  He did not have arrhythmia.  He had normal oxygenation.  He did not have nausea, vomiting, tremor or perspiration.  There were no physical signs of withdrawal.  Labs were unremarkable.  He did not have electrolyte abnormalities or dehydration.  The patient was admitted with plan for monitoring and COWS (clinical opiate withdrawal scale) protocol.  He is noted to have mild withdrawal symptoms admission day 2 and was started on methadone.  Heart rate remained stable with no intervention needed.  The patient was clinically stable and did not have findings of severe withdrawal.  He did not have symptoms that required an acute inpatient level of care.  He had not failed management in a lesser level of care.  The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cognitive impairment.
Treatment:  Consumer Self-Directed Personal Assistance Services (CDPAS) - 24 hours a day (split shift), 7 days a week.

The insurer denied the Consumer Self-Directed Personal Assistance Services (CDPAS) - 24 hours a day (split shift), 7 days a week.  The denial is overturned. 

The patient is a male with a history of stroke with residual left sided weakness.  Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). 

The proposed treatment of 24 hours a day (split shift), 7 days a week Consumer Self-Directed Personal Assistance Services  is deemed medically necessary. 

This is a male with a history of stroke with residual left sided weakness.  Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs).  Recent documentation of the patient's functionality and ability to perform activities of daily living (ADLs) was received in correspondence from the patient's medical provider.  This correspondence reports that due to the patient's cerebral vascular accident (CVA) with left sided weakness, the patient is chronically bed bound and requires a Hoyer lift for transfers.  He is incontinent of bowel and bladder and has a percutaneous endoscopic gastrotomy (PEG) tube with 16 hour feeding schedule.  For these reasons, the currently approved plan of 84 hours per week Personal Assistance Services is insufficient to meet the patient's current needs.  For these reasons, the proposed treatment of 24 hours a day (split shift), 7 days a week Consumer Self-Directed Personal Assistance Services is deemed medically necessary.

Appeal review requested for potential approval of 24 hours a day (split shift), 7 days a week Consumer Self-Directed Personal Assistance Services to offer increased activities of daily living (ADLs) support.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She presented with the complaint of knee pain.  In the emergency ward she had an episode of loss of consciousness. She reportedly had a similar event prior to this presentation.  

The patient was treated with Keppra and admitted to the acute inpatient service. She was evaluated by neurology. Anticonvulsants were discontinued, and she was discharged home.  

The patient's neuroimaging and EEG (electroencephalogram) were negative. 

No, the Inpatient admission was not medically necessary.

The patient was admitted after a single episode of loss of consciousness. She returned to her baseline mental status, had no focal neurological deficits on examination, and diagnostic studies were negative. She did not have any recurrent events. The diagnostic studies, neurological consultation, treatment and monitoring could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Postoperative pain. 
Treatment: Nucynta 50 mg. 

The insurer denied Nucynta 50 mg. 
The determination is upheld. 

The patient was diagnosed with postoperative pain and the patient's provider prescribed Nucynta 50 milligrams (mg) for the treatment of postoperative pain. This was denied by the health plan noting that the plan only covers this drug when one of the following conditions is met: there are no preferred formulary alternatives for the condition; the patient needs a form of the drug that is not on the formulary; the patient has a clinical condition for which there is no formulary alternative; the patient tried the required number of preferred formulary alternatives (tramadol, hydromorphone, methadone, hydrocodone/acetaminophen) on the formulary first and these drugs did not work or the patient cannot take them. The doctor must provide documentation that the patient meets one of these conditions and these criteria were not met. 

There is a handwritten appeal from the provider's office stating that the patient has tried tramadol, hydromorphone, and methadone in the past and it does not help. She has used Nucynta with success. 

There is a progress note indicating the patient seen for follow-up visit for the right knee reporting pain is rated at 7/10 localized over the right knee at rest and becomes up to 10/10 with physical activity. The patient reported Percocet makes her feel itchy and requested to use Nucynta postoperative for pain management as she reports that this has helped her in the past. Current medications included Ambien, cyclobenzaprine, Flexeril, fluticasone nasal spray, Lipitor, Maxalt, probiotic formulae, valacyclovir, Valtrex, vitamin D3, Xanax, and Zoloft. An allergy was listed as Percocet. The plan was to proceed with right knee surgery and it was noted the patient would be given Nucynta for postoperative pain, again stating that this has helped in the past. 
At issue is the medical necessity of Nucynta. 
Question(s): Did the health plan, in its determination of medical necessity, act reasonably, with sound medical judgment and in the best interest of the patient? 
The requested health service/treatment of Nucynta 50MG OR TABS is not medically necessary for this patient. The treating provider states that the patient has tried tramadol, hydromorphone, and methadone in the past and it does not help, and to reference the progress note. However, the  progress note does not mention those medications having previously been tried or failed and only notes the patient to have previously tried Percocet that makes her feel itchy. There were no actual progress notes/medical records provided showing that the patient has ever tried and failed tramadol, hydromorphone, or methadone. Therefore, the requested Nucynta 50 mg is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Radiation Therapy. 
The insurer denied: Proton Beam Radiation Treatment. 
The denial is upheld in whole.

This patient is a female with a stage IIB Hodgkin Lymphoma post chemotherapy with metabolic complete response on positron emission tomography (PET) scan. Radiation therapy is recommended as consolidation for 20 treatments and proton beam approach is requested.
The subject under review is the medical necessity for the requested therapy.

The health plan's determination is upheld in whole.

The requested health service/treatment of proton beam radiation therapy is not considered medically necessary for this patient. The requested proton beam radiation therapy is not considered the standard option of radiation therapy in Hodgkin lymphoma post chemotherapy. There are minimal reports of using proton beam radiation therapy for patients in this clinical situation. The benefits are not established when comparing to conventional photon radiation therapy. The doses needed for this patient's clinical situation are low, and there is no proven benefit to the use of proton beam radiation therapy. The few studies that are reported are small numbers of patients and recommend randomized trials to determine the efficacy and safety of proton radiation for this clinical scenario.