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

Cancer - Head/Neck/Throat Cancer

Chemotherapy

The patient is a male who was doing well until he had his first seizure event, consisting of loss of consciousness, tongue biting, and tonic-clonic motor activity. Prior to the seizure, he had been having headaches and loss of memory. He was diagnosed with a large left temporal mass and was eventually seen by a neurosurgeon at Memorial Sloan-Kettering Cancer Center, where he underwent an aggressive debulking resection. The pathology was consistent with a World Health Organization (WHO) grade IV glioblastoma multiforme (GBM), isocitrate dehydrogenase -1 (IDH-1) wild type, O[6]-methylguanine-DNA methyltransferase (MGMT) Promoter unmethylated. After recovering from surgery, he enrolled into the PINS clinical trial (Precision Immunotherapy in the Neoadjuvant Setting), and also had tumor tissue sent for IMPACT molecular phenotyping. For the PINS trial, standard chemo-radiotherapy (chemo-RT; i.e., the Stupp regimen) and adjuvant chemotherapy with Temozolomide (TEM) is delayed as long as the patient is responding to the "up front" immunotherapy treatment. PINS cycle #1, day #1 was started when he received Ipilimumab and Nivolumab. The IMPACT testing revealed amplification of platelet-derived growth factor receptor A (PDGFRA), cyclin-dependent kinase 4 (CDK4), PIK3CA, Kit, and kinase insert domain receptor (KDR); as well as p53 and telomerase reverse transcriptase (TERT) mutations. Based on the results of the IMPACT testing showing PDGFRA amplification, he was also started on Nilotinib (Tasigna) - a PDGFRA inhibitor. 

The health plan denied the Tasigna as not medically necessary. The health plan's determination is upheld. In his case, the patient elected to enroll in the PINS clinical trial, in which standard chemo-RT is postponed while the patient receives neoadjuvant "up front" immunotherapy with Ipilimumab and Nivolumab. It remains unclear why his Neuro-Oncology team decided to add Nilotinib to the clinical trial treatment regimen, since it is a "targeted" molecular drug (i.e., to PDGFRA), and is not a form of immunotherapy. Further, if the addition of Nilotinib was formally allowed as part of the protocol, then it should be paid for by the protocol budget.
Considering the patient was enrolled in the PINS clinical trial of neoadjuvant immunotherapy at the time he was started on Nilotinib, the treatment was not medically necessary at that time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity; Hypertension

Treatment: Positron Tomography

The insurer denied the Positron Tomography.  The denial was upheld.    

This is a female patient with a history of morbid obesity, hypertension, and acid reflux. She presented for a cardiology consult to be evaluated for bariatric surgery. She reported having dyspnea while climbing stairs. She had a body mass index (BMI) of 49.38. An electrocardiogram was performed that revealed sinus rhythm. A positron emission tomography (PET) perfusion stress test was requested.

The use of PET perfusion stress testing is not medically necessary.  Pre-test probability for significant coronary artery disease is low in this young female patient, and the use of any stress testing is inappropriate and not medically necessary.  Despite the patient's morbid obesity, the use of preoperative stress testing is also inappropriate given the patient's pre-test probability of coronary artery disease.  Having morbid obesity frequently leads to dyspnea, and is not an "anginal equivalent."  The use of PET perfusion stress testing is therefore inappropriate and is denied. 

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

The carrier's denial of coverage for the prospective outpatient positron emission tomography of the heart is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Adenoid cystic carcinoma
Treatment: MRI

The 70543 - MRI is medically necessary.


The patient is a male with a history of adenoid cystic carcinoma (a type of salivary gland tumor) of the left submandibular gland s/p (status post) resection and adjuvant radiation therapy.  Annual follow-up imaging was recommended, and MRI of the orbital/face/neck was requested.

Magnetic Resonance Imaging (MRI) is primarily a medical imaging technique most commonly used in radiology to visualize the internal structure and function of the body.  MRI provides much greater contrast between the different soft tissues of the body than computed tomography (CT) or X-rays, making it especially useful in neurological (brain and nerves), musculoskeletal, cardiovascular, and oncological (cancer) imaging.  It is an FDA-approved procedure and it is not subject to IRB (institutional review board) review.

MRI is the standard diagnostic test for patients with suspected brain, spinal cord, peripheral nerve and cranial nerve lesions.  There are abundant clinical data showing that MRI imaging is superior compared to other imaging tests and is the standard of care for the diagnosis of cranial nerve lesions.  

In this case, the patient is a male with a history of adenoid cystic carcinoma (a type of salivary gland tumor) of the left submandibular gland s/p resection and adjuvant radiation therapy.  Annual follow-up imaging was recommended, and MRI of the orbital/face/neck was requested.  Because adenoid cystic carcinoma has a tendency to invade the cranial nerves and progress towards the base of skull, it would be very difficult to visualize on examination.  

According to NCCN guidelines, post treatment imaging with the pre-treatment baseline imaging of the primary (MRI in this case) is indicated.  In addition, "Routine annual imaging (repeat use of pretreatment imaging modality) may be indicated in areas difficult to visualize on exam."  MRI is the best imaging to assist in early detection of recurrence for head and neck and cranial nerve lesions for this patient and is, therefore, medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Primary central nervous system lymphoma
Issue under review: Elevating leg rests for manual wheelchair

Determination:
The Elevating leg rests for manual wheelchair are medically necessary.

The patient is an adult female.  The patient has a history of primary central nervous system lymphoma diagnosed last year.  She underwent treatment.  A few months ago, she started to have weakness and falls.  She was found to have recurrence of her primary central nervous system lymphoma.

Occupational therapy evaluation noted that the patient required 2 person mod assist for transfers.

A letter of medical necessity noted that the patient needed a wheelchair due to severe limitations in her ambulation.  She could not use a cane or walker.

Examination noted right hemiparesis.  There was bilateral lower limb pitting edema.

A letter of medical necessity noted that the patient needed a wheelchair in the home to accomplish her activities of daily living.  Elevating leg rests were needed to prevent edema.

The patient has recurrent brain neoplastic disease.  Her mobility is severely compromised.  She requires a manual wheelchair for mobility in the home.  She also has lower limb edema bilaterally.  She requires the elevating leg rests to manage this edema.  The available records would indicate that the health plan was not aware of the indication for the elevating leg rests when coverage of these wheelchair parts was originally denied.  The elevating leg rests are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia; HTN; Diabetes
Treatment: Increase in consumer directed Personal Assistance Program (CDPAP) for a total of 168 hours/week (split-shift) 
The insurer denied the Increase in consumer directed Personal Assistance Program (CDPAP) for a total of 168 hours/week (split-shift).
The denial is overturned.

The Increase in CDPAP for a total of 168 hours/week (split-shift) is medically necessary.

The patient is a female who resides at home. She has a medical history including advanced dementia; depression; hypertension; diabetes type II; decubitus ulcer; urinary and fecal incontinence; CVA (cerebrovascular accident) in 2015 with extremity contractures resulting in documented bed bound immobile condition requiring total care. The patient's medical condition was documented and certified.  The patient is currently authorized to receive personal care assistant (PCA) 24/hours per day.  However, the patient's recent deterioration in condition most nights does not allow personal care assistance (PCA) to obtain total of eight hours of sleep with five hours being continuous.  The patient requires every two (Q2) hours turning; recurrent incontinence care; skin care; pain management; and general attendance of medically necessary attendance not predictable or foreseeable.

Based upon the current available medical records and documents supported by the patient's primary care providers, the patient requires 24/7 split shift care in order to maintain living independently in her home.  The patient's recent deterioration in condition most nights does not allow PCA to obtain total of eight hours of sleep with five hours being continuous.  The patient requires Q2 hour turning; recurrent incontinence care; skin care; pain management; and general attendance of medically necessary attendance not predictable or foreseeable. The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, based upon her documented current medical needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite
Issue under review: Braces and monthly visits

Determination:
The denial was upheld.

The patient is a teen-aged male. 

Based upon the photos provided, and the information on the handicapping scale, this patient does not have any medical necessity for orthodontic treatment. Therefore, the braces and monthly visits are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Persistent abdominal pain, nausea, and diarrhea
Treatment:  Computed tomography of abdomen and pelvis 
The insurer denied the CT of abdomen and pelvis.  The denial is upheld.  The performance of a CT scan of the abdomen and pelvis for a patient who had some fecal stasis on plain films and whose provider noted a possible post-infectious colitis or Crohn's disease is not medically necessary at this time. 

The patient is a male.  He underwent a computed tomography (CT) scan of the abdomen and pelvis.  The indication for this procedure was the evaluation of persistent abdominal pain as well as nausea and diarrhea.  The patient also reported a change in bowel habits and gas.  No blood was seen.  A series of plain x-rays was performed which did not reveal an etiology. 

There was no notation of fecal occult blood testing or an ultrasound.  A colonoscopy was not performed.  A CT scan for chronic intermittent, crampy, abdominal pain with diarrhea and loose stools and gas is not one of the initial steps after a plain x-ray.

McQuaid notes the utility of stool testing and an ultrasound in the evaluation of vague abdominal pain.  Smith also notes these tests as options prior to a CT scan.

Mendelson forcefully notes as follows:  "Diagnostic imaging is often not indicated in chronic abdominal pain.  In particular, undifferentiated abdominal pain is rarely an indication for a CT scan."
Appeal type: Medical necessity
Decision: Upheld

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

The Inpatient admission was not medically necessary.

The patient is a male.  He has a past medical history significant for BPH (benign prostatic hyperplasia).  He presented to the ER for complaints of palpitations associated with chest pain and diaphoresis. 

The patient was found to be in atrial fibrillation with rapid ventricular rate.  He spontaneously converted to normal sinus rate.  His troponins were normal.  The patient was started on metoprolol and was admitted to telemetry for monitoring.  His prior cardiac work-up included an echocardiogram, which revealed reduced LV (left ventricle) function.  During this admission, the patient remained in sinus rhythm after conversion in ER.  Repeat troponin was negative, as well.  2D echo was obtained, revealing EF (ejection fraction) of 55-60%.  No inpatient ischemic work-up was performed or planned during this admission.  TSH (thyroid stimulating hormone) was within normal limits.  The patient was started on anticoagulation with Eliquis and PRN (as needed) Metoprolol, and was discharged home with a plan for outpatient follow-up.

The patient presented for evaluation of palpitations and chest pain.  He was found to have atrial fibrillation and spontaneously converted to normal rhythm.  The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative.  No inpatient stress test or catheterization was planned.  There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), recurrent arrhythmia or hemodynamic instability.  Echocardiogram revealed preserved EF.  Patient was anticoagulated with Eliquis.  The clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient Admission

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

This is a male patient with a history of diabetes mellitus, high cholesterol and hypertension, smoking cigarettes and daily alcohol use. He presented to the Emergency Department (ED) with complaints of chest pain, severe back pain, with an episode of passing out. He rated the pain 10/10 in severity. An electrocardiogram (EKG) was performed that showed normal sinus rhythm. A chest x-ray was done that showed no evidence of disease. A computed tomography (CT) of the head was done that was negative for an acute pathology. A CT of the chest was performed with negative results. Radiograph of the lumbar spine was done that showed grade one anterolisthesis of L4 on L5 with spondylosis with degenerative disease of L4-5 and L5-S1. The patient was monitored on telemetry. An echocardiogram was done that showed left ventricular hypertrophy (LVH) with normal systolic function and ejection fraction of 68%. It was suggested that the patient's syncopal episode was secondary to drug intoxication; cocaine and heroin. The patient was medically stable and discharged. 

Syncope may be classified as reflex, orthostatic, hypotensive, and cardiac. The commonest cause, irrespective of age, sex, or comorbidity, is vasovagal. (1)  Orthostatic integrity is largely maintained by the interaction between the skeletal muscle pump, neurovascular compensation, neurohumoral effects, and cerebral blood flow regulation. Subclinical levels of inadequate blood pressure regulation in response to orthostasis have been linked to increased depression and anxiety. (2) A widely accepted guide to the treatment of syncope was published in 2009 as a State-of-the-Art paper (3) In general, hospital admission is prudent if the suspected underlying problem is associated with high risk of early mortality or injury, the proposed treatment requires in-hospital care, or the affected individual is unable to care for himself or herself. Specific findings supporting in-hospital evaluation include:  Symptoms suggesting acute MI, aortic dissection, CHF or pulmonary embolism. In addition, if there is suspicion of other cardiac conditions such as significant AS or hypertrophic cardiomyopathy (HCM). Also included is syncope during exercise or syncope causing a motor vehicle accident or severe injury, family history of premature sudden death or ECG abnormalities such as pre-excitation, high grade atrio-ventricular (AV) block or evidence of a channelopathy i.e. long QT, Brugada syndrome. It is clear that none of these conditions were present in this patient. The low risk group is the largest subgroup of syncope patients and includes mostly vasovagal and orthostatic faints. This type of syncope is relatively benign, in terms of mortality, and most can be discharged (4)

Based on the above, the medical necessity for inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Shortness of breath, tachypnea, elevated blood pressure
Treatment:  Inpatient admission
The insurer denied the inpatient admission.  The denial is overturned in part.

The patient is a homeless female with diabetes, hypertension, advanced kidney disease.  She presented to the hospital with shortness of breath, tachypnea and elevated blood pressure (BP). 

The patient was treated with intravenous diuretics and antibiotics.  She was evaluated by the nephrology team for advanced renal dysfunction and volume overload.  With advanced renal dysfunction and volume overload, plan was in place for initiation of hemodialysis.  The patient had a tunneled hemodialysis catheter placed and was initiated with dialysis treatment #1 and treatment #2.  The patient was discharged with a dialysis facility in place. 

During the end dates of service the patient was on maintenance hemodialysis M/W/F, Venofer and erythropoietin stimulating agent for anemia with optimization of oral antihypertensives for BP controlled and planned for fistula placement.

The Inpatient admission was medically necessary, in part.

Based on the available data, in the beginning, the patient did have uremic symptoms that were severe or persisted despite observation care treatment, significant respiratory findings that were severe or persistent, hypertension requiring inpatient care, as well as urgent treatment of renal failure (e.g., dialysis) necessary on inpatient basis, including placement of tunneled dialysis catheter and initiation of dialysis.  The patient required a permanent access and establishing ESRD (end stage renal disease) status prior to being clinically stable for discharge. 

However, for the end dates of service, continued inpatient admission was not medically necessary, as there were no cardiac arrhythmias of immediate concern, recurrent seizures, encephalopathy, impaired hemostasis, severe infection, unexplained syncope, hemodynamic instability, uremic symptoms that are severe or persist, significant metabolic or electrolyte abnormalities, hypertension requiring inpatient care, urgent treatment of renal failure (e.g., dialysis) necessary on inpatient basis. 

For the beginning dates of service, the patient required inpatient care to establish ESRD and initiate dialysis for volume and advanced kidney disease.  For the end dates of service, maintenance of hemodialysis, fistula planning and optimization of oral anti-hypertensive therapy did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female with uncontrolled insulin-dependent diabetes. She presented to the emergency department with hyperglycemia, mild epigastric abdominal pain, and thirst. 

The patient was noted to look well-appearing and to be oriented. Her glucose was 654 mg/dL, CO2 (carbon dioxide) 25, BP (blood pressure) 143/66 with heart rate 102. Her chest x-ray showed left basilar focal atelectasis. She was given intravenous insulin and then juice and dextrose for glucose of 75 mg/dL. She was evaluated by endocrinology. She received IV Zofran, Pepcid, and fluids. She left against medical advice. 

This patient presented with hyperglycemia and dehydration. The documentation does not support that she was hemodynamically unstable. She had mild tachycardia that resolved with intravenous fluids. She did not have acidosis to support a diagnosis of diabetic ketoacidosis. She did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar syndrome. She had mild epigastric pain without any evidence of an acute abdominal process. She had hyperglycemia that quickly responded to insulin therapy. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Eczema
Issue under review: Dupixent

Determination:
The Dupixent is medically necessary.

The patient is a female child with a history of severe eczema, asthma, and food allergies (peanut).  The request is for approval for Dupixent.

The progress notes clearly support that Dupixent is medically necessary for this patient.  The patient suffers from severe eczema (since childhood with 90% body surface involvement including hand, feet, scalp, neck, face and groin).  The patient has been adherent with conservative treatments and has inadequate response to a topical corticosteroids (group 2 or higher) - Triamcinolone and tacrolimus, and Eucrisa in the past six months.  The patient has tried and failed phototherapy due to unwarranted risk for malignancy as well as to systemic immunosuppressants such as oral steroids.  

The patient has no other alternative therapy to try. Dupixent is the only viable option and has demonstrated clinical efficacy with a sample given at the physician's office.  Therefore, in light of the severity of the disease, the lack of other alternative options as well as the demonstrated success, Dupixent is medically necessary, in this reviewer's medical opinion.

The health plan denied coverage of treatment with Dupixent due to the patient not being at least 12 years of age. However, as stated above, the patient demonstrated efficacy with a sample, and there are no other options for the patient. Therefore, it is this reviewer's opinion that the Dupixent is medically necessary in this patient's clinical scenario, despite their age.