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

Diagnosis: Numbness and weakness
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
 The denial is upheld

The patient presented with numbness, headache, and weakness. She was afebrile and the vital signs were stable. The neurologist found asymmetric weakness. A head CAT (computed tomography) scan was negative for acute disease. The MRI (magnetic resonance imaging) was also negative for infarct, hemorrhage, or mass. Chronic sinusitis was found. She developed arthralgias and was felt to have rheumatoid arthritis. The neurologist advised that she had sensory phenomena due to CNS (central nervous system) adaptation to peripheral pain. The plan was for an outpatient rheumatology workup. An antibiotic was given for the sinusitis. 

The hospital has referenced MCG (Milliman Care Guidelines) for Neurology GRG:MG-N. Clinical indications for admission include encephalitis, severe CNS infection, severe mental status changes, a severe neuropathy as indicated by cerebral thrombosis or nerve toxin injury, and severe neurologic trauma. The patient did not have these conditions. 

This patient required a workup for the numbness and weakness. However, the neurology consults and scans could have been done with observation status. The sinusitis was amenable to treatment with an oral antibiotic as an outpatient. She did not have an acute neurological event. She did not meet MCG criteria for admission for Neurology. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld. 

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 the inpatient admission services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer.
Treatment: Procedure code- 81519 (Oncotype DX Breast Cancer Assay).

The health plan denied procedure code- 81519 (Oncotype DX Breast Cancer Assay).  The health plan's determination is upheld.

This is a female with a resected, 0.6 centimeter (cm), node negative estrogen receptor/progesterone receptor/human epidermal growth factor 2 (ER+/PR+/HER2), stage IA right breast cancer. The documentation repeatedly states the patient does not wish to receive adjuvant endocrine therapy. The Oncotype DX Assay was obtained "to evaluate the benefit of Tamoxifen and to assess there was any benefit to chemotherapy given her young age." This is under review for medical necessity.

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

The Oncotype DX assay has been validated for predicting the benefit of adding adjuvant chemotherapy to further reduce the risk of recurrent breast cancer. This assay has no role in determining the benefit of adjuvant hormonal therapy. In this scenario, the National Comprehensive Cancer Network (NCCN) recommends consideration of the Oncotype assay "if the patient is a candidate for chemotherapy"; however, there is not documentation of a meaningful conversation regarding the patient's willingness to receive adjuvant chemotherapy, which is a primary determinant of her candidacy for the intervention. If the patient is not open to consideration of chemotherapy, the results of this assay are not of value. This approach is consistent with American Society of Clinical Oncology (ASCO) guideline recommendations. For these reasons, the medical necessity for this service has not been established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/ Injuries - Injury.
Treatment: Inpatient Hospital Stay.

The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female who sustained a severe injury to her left hand while trimming bushes. She sustained a complete amputation of the left ring finger at the level of the distal inter-phalangeal joint and a near amputation of the left middle finger just distal to the proximal inter-phalangeal joint. She was transferred and accepted at the hand service at a hospital. She was admitted to the hospital on after a revision amputation of the ring finger was competed in the emergency department (ED). Observation was recommended for the middle finger laceration repair, and no further surgical intervention was required. The patient was subsequently discharged.
At issue is the medial necessity of the inpatient hospital admission.

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

The requested health service/treatment of an inpatient hospital admission was not medically necessary for this patient. The medical records document that this female patient underwent revision amputation of a left ring finger avulsion/amputation at the distal interphalangeal joint as a result of an accident with a hedge trimmer. This procedure was performed in the ED without complication. This care was consistent with the recommendations of the current, peer-reviewed literature as documented by Yuan and colleagues in the Plastics and Reconstructive Surgery journal in 2015. Their study concluded that "Revision amputation and conservative treatments result in better static two-point discrimination outcomes compared with local flaps. All techniques preserve total active motion, although arc of motion is slightly better with revision amputation. Revision amputation procedures are frequently associated with cold intolerance. Patients report "satisfactory," "good," or "excellent" ratings in appearance and quality of life with all nonreplantation techniques." Observation was recommended for the left long finger laceration injury. No further surgical interventions were required for this patient. Thus, based upon the documentation in the provided medical records, the inpatient hospital admission was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lafora Disease
Treatment: Lumizyme
The insurer denied the Lumizyme.
The determination is upheld.

The patient was diagnosed with Lafora Disease (LD) due to intractable seizures and regression. Her genetic test at Ambry showed a homozygous pathogenic variant which is consistent with LD. Her healthcare provider wants to treat her off label with Lumizyme which is an enzyme replacement therapy (ERT) used for patients with Pompe Disease (PD). The clinic note states that there's some benefit for LD from Lumizyme because the latter degrades glycogen but there was no reference given that such evidence exists. The patient's health plan denied this request as not medically necessary. At issue is the medical necessity of the Lumizyme.
This treatment would be ineffective for this patient and is not Food and Drug Administration (FDA)-approved for this purpose. There's no evidence that the off-label use of Lumizyme would be have any effect on the patient with LD. Lumizyme degrades glycogen in lysosomes of PD patients in skeletal and cardiac muscle but not in the brain because Lumizyme is a bulky protein molecule that cannot cross the blood-brain barrier. Even if it could, it would not break down glycogen in the Lafora bodies that cause seizures and regression in the brain. The mechanism of glycogen accumulation in the neurons in LD is completely different from glycogen accumulation in skeletal and cardiac muscle in PD. Lysosomal glycogen in PD is in a soluble form which fails to be degraded due to absence of the native acid-maltase enzyme and progressively accumulates in lysosomes resulting in their rupture and cellular toxicity. On the contrary, the glycogen in LD is insoluble because of an impairment in chain-length regulation due to malfunction of laforin as a result of EPM2A (epilepsy, progressive myoclonus type 2A) mutations and accumulation of abnormally branched glycogen molecules or polyglucosans which crystalize and form Lafora bodies. Those mechanisms are very different from each other and it is uncertain how Lumizyme would help this patient from both a mechanistic standpoint and its inability to cross the blood-brain barrier.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's. 
Treatment: Home health care. 

The insurer denied Personal Care Aide Services: 7 Days per Week, 2 x 12 Hour Shifts per Day ("Split Shift"). The health plan's determination is upheld. 

The patient is a female with past medical history of dementia, urinary incontinence, osteoarthritis, osteoporosis, Parkinson's disease, transient ischemic attack (TIA), and orthostatic hypotension who had been assigned PCA (personal care aide) services. 

Personal Care Aide Services: 7 Days per Week, 2 x 12 Hour Shifts per Day ("Split Shift") are not medically necessary for this patient. 

There is no documentation from the patient's family or the patient's medical provider of nighttime assistance needs that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. Specifically, there are no overnight care logs documenting the specific timing and specific tasks that require assistance in the overnight hours. There is no documentation from the patient's medical provider of medical necessity of turning and repositioning every 2 hours. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 7 days/week, 2 x 12 shifts per day (split shift) are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic head and neck pain

Treatment is physical therapy (procedure code 97110)

The insurer denied coverage for physical therapy (procedure code 97110)
 
The denial is upheld

This is a young adult female with complaints of chronic head and neck pain which she relates to a motor vehicle accident. Treatment included physical therapy (PT) and analgesic/muscle relaxant medications. Under review is the medical necessity of (procedure code 97110). 

The limited clinical records submitted for review do not support the medical necessity for physical therapy (PT). According to the (undated) appeal letter from the patient, she participated in PT. However, after several months of intermittent PT sessions there was no reported sustained pain relief. There are no PT notes submitted to document the specific condition being treated, treatment goals or prognosis for recovery.  There are office visit notes from a pain management specialist submitted for review. The clinical notes document her complaint of head/neck pain and the provision of trigger point injections. However, the lack of physical therapy notes and limited documentation of any specific functional deficits in the doctor's treatment notes do not support the medical necessity of the requested PT.  

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

From a physical medicine and rehabilitation/pain management perspective, physical therapy (procedure code 97110) is not medically necessary.  

Based on the above, the insurer's denial is 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 physical therapy (procedure code 97110) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plantar fasciitis

Treatment is durable medical equipment, custom shoe inserts (L3000 x 2)

The insurer denied coverage for durable medical equipment, custom shoe inserts (L3000 x 2)
 
The denial is overturned

This is a child diagnosed with Plantar fasciitis who is being recommended for durable medical equipment in the form of custom shoe inserts (L3000 x 2). The patient was seen regarding bilateral heel pain and intoe gait. He previously tried stretching, NSAIDs (non-steroidal anti-inflammatory drugs), and over-the-counter arch supports. Physical exam findings noted bilateral ankle dorsiflexion of 7 degrees associated with pain. He had plantarflexion measuring 35 degrees with bilateral intoe gait, bilateral flattening of the arch, and calcaneal eversion. He endorsed bilateral heel pain on palpation to the plantar fascia with findings of thickening of the plantar fascia. The physician recommended custom shoe inserts.  

The patient received a notice of adverse determination which stated that the patient did not meet criteria for custom shoe inserts as he must have symptoms for more than 3 months and tried and failed other modalities of care. An appeal was submitted stating that the patient had been in pain for 3 months, tried other conservative measures, and has a covered diagnosis of plantar fasciitis.  According to the guidelines, the patient is eligible for coverage of custom orthotics. This review pertains to the denial of coverage for the durable medical equipment, custom shoe inserts (L3000 x2). 

Current medical literature notes that Plantar fasciitis is one of the most common types of foot injuries. Literature notes that there are various conservative measures that can be utilized to treat this condition. The physician was recommending custom orthotics given that the patient had tried over-the-counter arch supports. In taking the patient's age into consideration, custom orthotics would be appropriate as a means of treating his condition.  

The recommendation for the durable medical equipment is supported. The request for durable medical equipment, custom shoe inserts (L3000 x 2) is medically necessary.  

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 the durable medical equipment, custom shoe inserts (L3000 x 2) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma/Injuries - Fractures.
Treatment: Inpatient Hospital Services.
The insurer denied Inpatient Hospital Services.
The denial is overturned. 

This is the case of a female with a history of cerebrovascular accident (CVA), Bell's Palsy, morbid obesity, and mitral valve prolapse (on acetylsalicylic acid (ASA) and Plavix). She presented to the emergency room as a trauma after she was a pedestrian struck in a motor vehicle collision (MVC). She complained of left arm pain. There was no loss of consciousness (LOC). She was found to have a possible avulsion fracture at the left lateral condyle and left superior/inferior pubic rami fractures with associated hematoma. She had a non-displaced left iliac bone fracture. She was evaluated by the trauma service, as well as orthopedic surgery. Nonoperative intervention for all of the fractures was recommended. The patient was transferred to a step down after hypotension and a hemoglobin (hgb) drop. The hypotension was to the 70's and 80's systolic. Ultimately the patient's hemoglobin dropped from 12.5 to 7.5 and she received 2 units of Packed red blood cells (PRBCs). Repeat computed tomography angiography (CTA) showed no evidence of an ongoing bleed. The patient was discharged to a subacute rehab.
At issue is the medical necessity of Inpatient Hospital Services.

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

Yes, the requested health service/treatment of Inpatient Hospital Services was medically necessary for this patient.
This is an elderly female on ASA and Plavix who was struck by a car while a pedestrian. This is a patient with pelvic fractures and hematomas with a 5-point hemoglobin drop and hypotension, mandating a blood transfusion of 2 units of blood. The patient's issues did not fully resolve until around 5 days into the injury. The patient required an arterial line and the skilled staff and frequent interventions of a Step-Down unit for blood pressure monitoring. This could not be accomplished safely in a lower level of care, as clearly the intensity of monitoring and interventions requires an acute setting.
Therefore, the requested health service/treatment of Inpatient Hospital Services was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior mediastinal mass
Treatment: Positron Emission Tomography-Computed Tomography (PET-CT)
The insurer denied Positron Emission Tomography-Computed Tomography (PET-CT). The health plan's determination is upheld. 

The patient is a male with a 12 x 7.5 x 9.9 centimeter (cm) anterior mediastinal mass. There was a history of smoking. A Positron Emission Tomography-Computed Tomography (PET-CT) is under review. 

Positron Emission Tomography-Computed Tomography (PET-CT) is not medically necessary for this patient.

PET-CT scanning for the evaluation of mediastinal masses may provide information regarding the etiology. It may help differentiate between malignant and benign lesions. However, the mainstay for establishing a diagnosis is essentially a biopsy. This type of scanning may be complementary to evaluate the lesion metabolic activity and if a biopsy is indeterminate. However, in the setting of this case, it has not been definitively established as standard of care towards improved diagnosis or mediastinal mass outcomes compared to more conventional imaging such as a computed tomography (CT) scan, as well as a biopsy. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Atherosclerotic Coronary Artery Disease.
Treatment:  Praluent (alirocumab).
The insurer denied coverage for Praluent (alirocumab). The denial is overturned.

The patient is a male with a history of ischemic heart disease, hypercholesterolemia, remote coronary artery bypass graft surgery and more recent inferior ST (interval on EKG [electrocardiogram] segment) elevation myocardial infarction that required primary intervention. The patient's health care provider clearly states that the patient was treated with maximum dose atorvastatin and Zetia therapy with failure of LDL (low-density lipoprotein) cholesterol to reach guideline directed goals.  She is now prescribing Praluent.  Serum LDL remains above 100mg/dl despite maximal statin and Zetia therapy.  

The patient is on maximal statin therapy, as well as ezetimibe.  The health care provider noted that the patient has failed to achieve an LDL level of <70mg/dl (milligrams per deciliter) even prior to his recent myocardial infarction. Thus, the formulary drug is insufficient for treatment.  This patient suffers from atherosclerotic coronary artery disease (ASCVD).  He is on high intensity statin treatment (atorvastatin 80mg (milligrams) daily) with an LDL cholesterol 105 mg/dl. Addition of a non-statin agent such alirocumab (Praluent) in this setting has been associated with significant event rate reduction regardless of serum LDL level (Reference 1, 2). Current American Heart Association and American College of Cardiology guidelines recommend addition of PCSK-9 (proprotein convertase subtilisin/kexin type 9) inhibitor therapy to maximally tolerated statin therapy in patients at high risk for future ASCVD events including those with multivessel disease and diabetes (Reference 1,2).  According to the European Society of Cardiology guidelines this patient with documented ASCVD and DM (diabetes mellitus) is considered to have "very high risk" of cardiovascular event (Reference 3). Such patients are given a class I indication for treatment with non-statin therapy such as alirocumab when LDL-C (low-density lipoprotein - cholesterol) levels are greater than 55mg/dl (Reference 3). In conclusion, the proposed treatment is medically necessary and is more effective than the formulary medication, as the patient has a contraindication to ezetimibe.

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 the Praluent (alirocumab) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia 
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is overturned

The patient needed high flow nasal cannula at 20 LPM (Liter per minute) and had complaints of tachypnea. There was also some respiratory distress. The chest X-ray showed bilateral infiltrates and ventilation was compromised. Also, there was fever of 103.5 degrees Fahrenheit. Once a patient is on high flow nasal cannula (HFNC), respiratory failure is an impending risk and needs to be monitored in intensive care unit (ICU). The patient is also at risk for sepsis and systemic inflammatory response syndrome (SIRS). The patient is at risk for hypoxia/ hemodynamic instability and associated morbidity. 

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

The medical necessity for the inpatient hospital admission services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute kidney injury and acute chronic renal failure
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is an adult male with history of diverticulitis, medical renal disease and anemia. He came to the emergency department with a complaint of hematuria/ dysuria since day before when patient had a cystoscopy. Computed tomography scan showed small focus of hemorrhage within bladder. Patient admitted for further evaluation.  Foley catheter placed in emergency room. The patient improved, Foley catheter removed, patient able to void and was discharged home. The insurer has denied coverage for the inpatient admission.  They stated the patient could have been placed in observation under monitoring. The inpatient admission was denied due to lack of medical necessity.

According to Milliman Care Guidelines (MCG) (25th Edition): Urologic disease (GRG) - patient fails to meet admission guidelines for inpatient care under 2 subsections: "Gross hematuria" - no clot retention, renal obstruction, severe anemia "Acute urinary retention" - no acute kidney disease (AKI) with 2-fold rise in serum creatinine from baseline. Patient with acute or chronic kidney disease

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 inpatient admission services is not substantiated.