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

Diagnosis: Lumbar compression fracture 
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is overturned

This case involves a patient with a history of Crohn's disease, chronic obstructive pulmonary disease (COPD), asthma, pericardial effusion, and psoriasis who was seen in the emergency department complaining of severe lower back pain status post fall. The patient underwent computed tomography (CT) scanning of the spine which noted an age-indeterminate superior endplate vertebral body compression fracture deformity at the lumbar (L)1 vertebral body.  Records stated the patient had 6-7 shots of alcohol prior to her fall. She remembered tripping and falling on her hips and described her pain as 10/10 that increased with movement. The patient was subsequently admitted, stayed in the hospital, and underwent vertebral augmentation and cement plasty. The information stated the patient had a history of alcohol abuse, and following surgery, was placed on Clinical Institute Withdrawal Assessment (CIWA) due to a history of alcohol abuse. She was closely monitored throughout her hospitalization until she was safely discharged.  

She received treatment with intravenous fluids and intravenous morphine for pain control. She proceeded with surgery and once all risks were addressed, the patient achieved hemodynamic stability and was cleared for discharge.

The Milliman Care Guidelines (MCG) notes that patients may be supported for inpatient admission when they have a vertebral fracture with evidence of instability or pending instability.  This includes lumbar vertebral fracture with one more the following to include a burst fracture with nerve root or cauda equina involvement. The patient had documented evidence of a burst fracture, and while she did not have nerve root or cauda equina involvement, she did require surgery to prevent either of these conditions from occurring. She was in significant pain and given her history of alcohol abuse, she required close monitoring with pain medications to avoid respiratory distress with the administration of intravenous morphine. Based upon the provided documentation, it was determined that the patient has sustained an injury requiring further treatment that cannot be administered safely and effectively on an observational or outpatient basis. She did require surgery, and it was appropriate given her age and medical history as well as her presenting condition to receive inpatient care.  

Based on the above, the insurer's denial must be overturned. 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 inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic respiratory failure .

Treatment: Partial skilled nursing facility subacute rehabilitation level 1 (continued inpatient admission).

The insurer denied coverage for partial skilled nursing facility subacute rehabilitation level 1 (continued inpatient admission).

The denial is upheld.

 
This is a patient with chronic respiratory failure, atrial fibrillation and anemia. She has a feeding tube, fistula and colostomy bag. Under review is the medical necessity for partial skilled nursing facility (SNF) subacute rehabilitation level 1 (continued inpatient admission).

The patient was initially appropriate for the SNF subacute rehabilitation level 1 care. Her clinical condition and functional deficits were potentially amenable to comprehensive rehabilitation.  She was admitted to the SNF 22 days prior.  According to the physical and occupational therapy initial evaluation notes, she required maximal assistance to full dependence for activities of daily living (ADL), bed mobility and transfer activities. Unfortunately, the treatment notes do not document significant improvement over the subsequent 2-3 weeks of therapy.  According to the most recent physical therapy notes the patient was totally dependent for bed mobility, unable to sit up or transfer. She also continued to require moderate assistance for hygiene/grooming. There were also no specific treatment notes documenting acute medical or complicated nursing issues that required continued stay at the SNF (level 1).   

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 partial skilled nursing facility subacute rehabilitation level 1 (continued inpatient admission) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I occlusion
Treatment: Braces
The insurer denied: Braces
The denial is: Upheld

The patient is a male with a Class I occlusion with a 90% deep overbite and 1 millimeter (mm) overjet. He has maxillary and mandibular crowding. He has treatment planned for orthodontics to correct his malocclusion. The subject under review is the medical necessity for braces, which have been denied by the health plan. 

There is no medical reason to correct the patient's malocclusion with braces. His overbite is deep but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient. While the patient has moderate crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession.

There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.1 This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion.2 If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prostate Cancer
Treatment: Tumor imaging, positron emission tomography (PET) with concurrently acquired (CT) skull base to mid-thigh scan 
The insurer denied: Tumor imaging, positron emission tomography (PET) with concurrently acquired (CT) skull base to mid-thigh scan 
The denial is: Overturned.

The patient is a male with a diagnosis of prostate cancer. Prior therapy includes radical prostatectomy. He has a rising prostate-specific antigen (PSA) and the last PSA was 0.307. Medical necessity for a prostate specific membrane antigen (PSMA) positron emission tomography (PET) computed tomography (CT) scan is under review. The subject under review is the medical necessity for the requested scan.

The health plan's determination is overturned.

The requested imaging is medically necessary. Based on the available documentation, the patient has recurrent prostate cancer after radical prostatectomy. It is highly unlikely that a bone scan will reveal source of recurrence with such a low PSA. Performing a PSMA PET/CT scan is considered a clinically appropriate and generally excepted standard for management of this patient's medical condition. Hence it would be considered medically necessary.

National Comprehensive Cancer Network (NCCN) Guideline on Prostate Cancer, 2023 states "For symptomatic patients and/or those with a life expectancy of greater than 5 years, bone and soft tissue imaging is appropriate for patients with unfavorable intermediate-risk, high-risk, and very-high-risk prostate cancer. Bone imaging can be achieved by conventional technetium-99m-methylene diphosphonate (MDP) bone scan. Soft tissue imaging of pelvis, abdomen, and chest can include chest CT and abdominal/pelvic CT or abdominal/pelvic magnetic resonance imaging (MRI). Alternatively, Gallium (Ga)-68 PSMA-11 or F-18 Pylarify (PyL) PSMA PET/CT or PET/MRI can be considered for bone and soft tissue (full body) imaging. Because of the increased sensitivity and specificity of PSMA-PET tracers for detecting micrometastatic disease compared to conventional imaging (CT, MRI) at both initial staging and biochemical recurrence, the Panel does not feel that conventional imaging is a necessary prerequisite to PSMA-PET and that PSMA-PET/CT or PSMA-PET/MRI can serve as an equally effective, if not more effective front- line imaging tool for these patients."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal Bleeding/Bleeding of Intestines
Treatment: Full Hospital Admission
The health plan denied the requested full hospital admission as not medically necessary. The health plan's determination is upheld.

The patient is a male with a medical history of diabetes mellitus, hypertension, hyperlipidemia, vertigo, psoriasis, Helicobacter pylori infection, and a bleeding gastric ulcer. He presented to the emergency department with melena and weakness. He went to move his car and returned diaphoretic, pale, with near-syncope and a low blood pressure of 81/57 millimeters of mercury (mmHg). Labs showed an unremarkable complete blood count, an unremarkable basic metabolic panel, and an elevated aspartate aminotransferase of 50. He was treated with intravenous fluids and Pantoprazole. A nasogastric tube was placed. He was made nothing by mouth (NPO). Labs showed a low hemoglobin of 10.4, a hematocrit of 32.2, and an unremarkable basic metabolic panel. A gastroenterology consultation noted melena, and recommended nothing by mouth (NPO), intravenous Pantoprazole 40 milligrams twice daily, serial complete blood counts with transfusion as needed, and an esophagogastroduodenoscopy that day. The esophagogastroduodenoscopy showed a normal esophagus, erythematous mucosa in the gastric body likely secondary to nasogastric tube trauma, two non-bleeding prepyloric ulcers (5 millimeters and 10 millimeters), and a normal duodenum; the recommendation was to resume a diet, Pantoprazole 40 milligrams twice daily, and treat Helicobacter pylori if positive. Later, labs showed a low hemoglobin of 10.0, a hematocrit of 31.1, and an unremarkable basic metabolic panel. He was discharged on Pantoprazole, with a plan for primary care and gastroenterology follow-up.

At issue is the medical necessity for the inpatient level of care. The health plan's determination of medical necessity is upheld, in whole. The inpatient level of care is not supported as medically necessary.

In this case, the patient presented with melena and symptomatic anemia (including near-syncope), and his hemoglobin declined with intravenous fluid administration after presentation. The patient had close monitoring, which was warranted, as bleeding can be severe and sudden in onset. [1-5] He appropriately had an esophagogastroduodenoscopy to evaluate for sources of gastrointestinal bleeding, but no active bleeding was found, and there were no high-risk stigmata; the gastric ulcers found were small. [1-5] His symptoms improved, and he was appropriately discharged on proton pump inhibitor therapy. All of the measures that were undertaken, including monitoring, labs, gastroenterology consultation, proton pump inhibitor therapy, and an esophagogastroduodenoscopy, could have been performed without the inpatient level of care, at a lower level of care. [2-5] The Milliman Care Guidelines for "Gastrointestinal Bleeding, Upper" do not support the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.
 
Asked to review the case of a patient that presented to the hospital complaining of chest pain radiating to his left arm and jaw for a four-day period.  Relevant past medical history included ischemic heart disease, previous unsuccessful coronary artery bypass grafting (CABG), hypertension and diabetes mellitus. On arrival to the hospital vital signs were stable and no abnormal findings were noted on physical examination. A 12-lead electrocardiogram (ECG) revealed sinus rhythm with right bundle branch block without ischemic ST (an interval on a ECG) or T wave (an interval on a ECG) abnormalities. Serum troponin levels were not elevated (< (less than) 0.01). The patient underwent cardiac catheterization that revealed diffuse disease of the left anterior descending (LAD) artery with a mid-vessel total occlusion, diffuse disease of the left circumflex artery (LCA) and moderate proximal and distal disease of the right coronary artery (RCA) with collaterals to the distal LAD. He was treated with anti-anginal therapy and released.

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with chest pain and dyspnea. His pretest probability of coronary artery disease was high. Utilizing the HEART score (History, Electrocardiogram [ECG], Age, Risk factors, and Troponin), he was considered high risk. Risk assessment of patients presenting with chest pain and no significant ST changes on an ECG was reviewed by Hedayati et al. Using the HEART score risk stratification schema, this patient would have a high risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge.  In conclusion, admission to the hospital to treat an acute cardiac event was medically necessary. In conclusion, given the patient's presentation with crescendo symptoms of chest pain and multiple cardiac risk factors inpatient hospital admission was medically necessary.

Based on the above, the insurer's denial must be overturned. 

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease (with fistula)
Treatment: Remicade 10 mg/ kg (milligrams per kilogram) every 6 weeks
The insurer denied Remicade 10 mg/ kg every 6 weeks.
The denial is overturned.

The patient is an adult female with fistulizing Crohn's disease. She has failed Asacol, steroids and Humira. Six years ago, she was started on Remicade 5 mg/kg (milligrams per kilogram) every 8 weeks. She initially did well, but then developed increased symptoms and ongoing active fistulas. Remicade was increased to 10 mg/kg every 6 weeks 4 years ago with good results, and with therapeutic serum Remicade levels. The patient's provider is requesting to continue Remicade 10 mg/kg every 6 weeks.

The requested Remicade 10mg/kg every 6 weeks is medically necessary.

Medical literature supports dose intensification of biologics in patients with Crohn's disease (CD) who fail treatment with FDA (United States Food and Drug Administration)-approved dosing. Over 25% (percent) of patients with CD treated with biologics require dose intensification. Remicade has been found to be safe and effective at doses as high as 20 mg/kg every 4 weeks. Therefore, as this patient lost response to Remicade 5 mg/kg every 8 weeks and is doing well on 10 mg/kg every 6 weeks, the requested dose and frequency is supported by current peer-reviewed medical literature, clinical practice guidelines, and is standard of care and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Central nervous system
Home health care

Diagnosis: cerebral vascular accident
treatment: home health care
The insurer denied Personal Care Aide: 7 Days x 12 Hours x 2 Shifts. The health plan's determination is upheld. 

The patient is a female with past medical history of multiple cerebrovascular accidents (CVA's) with right-sided hemiparesis and dysarthria, hypertension, diabetes mellitus type 2, status post resection of right temporal meningioma, depression, osteoarthritis, history of colon cancer, bladder incontinence, and bowel incontinence who had been assigned PCA (personal care aide) services. 

Personal Care Aide: 7 Days x 12 Hours x 2 Shifts are not medically necessary for this patient.
The request for PCA services of 7 days x 12 hours x 2 shifts is not medically necessary as there is no documentation of the specific overnight care needs the patient would have that would not allow a PCA 5 hours of uninterrupted sleep. There were no overnight care logs provided documenting the specific overnight care needs. There was no documentation that the patient's apartment/home would not be able to accommodate sleeping quarters for a PCA. In addition, there was no documentation of medical necessity of turning and repositioning every 2 hours or frequent assistance care needs in the overnight 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 x 12 Hours x 2 Shifts are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Verzenio
The insurer denied: Verzenio
The denial is upheld.

The patient is an adult female with metastatic, estrogen receptor positive (ER+), human epidermal growth factor receptor two positive (HER2+) breast cancer. The attending physician (AP) has requested the use of Verzenio.

The proposed treatment is not medically necessary.

The drug Verzenio is not currently approved or supported by the literature to treat human epidermal growth factor receptor two positive (HER2+) breast cancer. While some small phase II trials have been conducted in estrogen receptor positive (ER+), human epidermal growth factor receptor two positive (HER2+) disease, the National Comprehensive Cancer Network (NCCN) only supports the use of Verzenio to treat estrogen receptor positive (ER+), human epidermal growth factor receptor two negative (HER2-) disease, as per the Food and Drug Administration (FDA) labeling. The National Comprehensive Cancer Network (NCCN) does address treatment of estrogen receptor positive (ER+), human epidermal growth factor receptor  two negative (HER2-) breast cancer and does not recognize the use of Verzenio with aromatase inhibitor (AI) therapy and Herceptin in this setting.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Breast Cancer
Treatment: Radiation Therapy for Breast Cancer - Initial Phase: 28 fractions Intensity Modulated Radiation Therapy (IMRT); Boost Phase: 8 Fractions Intensity Modulated Radiation Therapy (IMRT)
The insurer denied: Radiation Therapy for Breast Cancer - Initial 
Phase: 28 fractions Intensity Modulated Radiation Therapy (IMRT); Boost Phase: 8 Fractions Intensity Modulated Radiation Therapy (IMRT)
The denial is partially overturned

The patient is an adult female with a diagnosis of stage cT2N1M0 right breast cancer status post neoadjuvant chemotherapy and right mastectomy. Adjuvant radiation therapy was recommended, and intensity modulated radiation therapy (IMRT) was requested for both the initial chest wall radiation phase as well as the scar boost phase.

The requested intensity modulated radiation therapy (IMRT) for the initial phase is medically necessary. However, intensity modulated radiation therapy for the boost phase is not considered medically necessary.

Intensity modulated radiation therapy for the initial treatment phase would be a superior technique compared to conventional conformal radiation therapy in reducing dose to the normal 
tissues such as the skin, heart and the lung. This patient had a mastectomy done and the treatment fields are very extensive, including axillary, supraclavicular and internal mammary nodal chains, and care must be taken to minimize radiation exposure to the heart, lung and opposite breast using intensity modulated radiation therapy. In a 2007 Model Policy for intensity modulated radiation therapy, the American Society for Therapeutic Radiation and Oncology (ASTRO) considers intensity modulated radiation therapy a treatment option for "Selected cases of breast cancer with close proximity to critical structures". While intensity modulated radiation therapy is not a recommended treatment for all breast patients, for this patient, it is a medically necessary treatment and should be implemented in order to reduce the risk of treatment related toxicity.
In regard to the boost phase of radiation, the target is the mastectomy scar. The standard of care of a scar boost is with electrons. In fact, intensity modulated radiation therapy may result in more dose exposure to the lung compared to electrons. The requested intensity modulated radiation therapy for the scar boost (eight fractions), therefore, is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis.
Treatment: Dupixent (dupilumab).

The insurer denied coverage for Dupixent (dupilumab).  The denial is overturned.

This patient is a young adult with a diagnosis of atopic dermatitis. The patient has failed topical therapy, and the health plan has denied light therapy. The patient has moderate disease with a documented Immunoglobulin A (IgA) of 3.0. The requested medication is Dupixent.

The patient has moderate atopic dermatitis that involves a larger surface area. The patient requires systemic therapy given the extent of involvement, and the use of Dupixent would appear to be reasonable given that it is Food and Drug Administration (FDA) approved for the treatment of atopic dermatitis.

The request for Dupixent is supported by the medical literature and specialty society guidelines.  Dupixent is the first systemic therapy approved by the FDA for the management of atopic dermatitis (AD).  In early 2017, the FDA approved Dupixent for adults with moderate-to-severe AD, who are inadequately controlled with topical treatments. According to consensus guidelines "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe AD .... Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment ... with moderate-to-severe AD who are uncontrolled with topical therapies".  As such, the decision is overturned and Dupixent is approved at the medical discretion of the physician based on the standard of care and the provided medical documentation.

Based on the above, the insurer's denial must be overturned. 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 Dupixent (dupilumab) services is substantiated.