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

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

The patient is a female with history of recently diagnosed pathological tumor one node one (pT1N1) human papilloma virus (HPV)+ invasive squamous cell carcinoma of her right palatine tonsil status/post (s/p) trans oral robotic surgical resection and right neck dissection to negative margins. There was extra capsular extension seen in the nodal dissection specimen. She has been recommended to proceed with a course of postoperative external beam radiotherapy with curative intent. The subject under review is the medical necessity for proton beam radiation therapy.

The health plan's determination is upheld in whole.

The requested proton beam therapy is not medically necessary for this patient. There is currently insufficient high quality prospective clinical outcomes published in the peer reviewed medical literature to allow definitive conclusions to be made regarding the relative safety/efficacy of proton beam radiotherapy for management of the patient's oropharyngeal cancer, as compared with standard of care photon-based radiotherapy in the form of intensity modulated radiation therapy (IMRT). The American Society for Radiation Oncology (ASTRO) Model Policy for proton radiation does not support its use in the management of resectable head and neck cancer outside the context of a prospective clinical trial. Proton radiotherapy in the patient's setting is the subject of ongoing clinical trials being conducted at various institutions in the radiation oncology community (e.g., National Clinical Trial [NCT] 01893307). There are not any extenuating circumstances present in the member's setting that would necessitate the use of proton beam therapy (e.g., prior receipt of radiation to her head/neck region or presence of a comorbid/genetic condition which increases the risk for normal tissue radiation sensitivity). There are numerous high quality prospective clinical outcomes reported which support the use of IMRT in this setting, and IMRT is utilized throughout the oncology community nationwide as it is associated with a high rate of safety/efficacy. Thus, based on the standard of care, proton beam therapy is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thyroid cancer
Treatment: Brand name Synthroid
The insurer denied brand name Synthroid. 
The health plan's determination is overturned.

The patient is a female with history of hypothyroidism.

The coverage request is for Brand-name Synthroid. Per the office notes, the patient has thyroid cancer and postoperative hypothyroidism and the patient is at intermediate risk of recurrence.

Brand name Synthroid is medically necessary for this patient.

Since the 2001 Food and Drug Administration (FDA) standardization for generic levothyroxine products ("Guidance for Industry Levothyroxine Sodium Products"), all levothyroxine products are now required to be formulated to be released at 100% of the labeled claim. Review of this topic, including trials and expert opinions, generally assess that while there can be small differences in clinical endpoints (eg. effects on thyroid stimulating hormone (TSH)) between brand and generic levothyroxine preparations (mainly stemming from differences in how FDA qualifies bioequivalence and therapeutic equivalence), in most cases different levothyroxine preparations do not significantly affect treatment outcome. However the 2014 ATA (American Thyroid Association) guidelines do note that switching between preparations may lead to disruption of TSH levels and particularly should be avoided if possible in frail patients, those with thyroid cancer, and the pediatric patients.

This patient has been stable on brand name Synthroid and has thyroid cancer with intermediate risk of occurrence which makes it important to maintain stable thyroid levels in the blood. It is clinically appropriate to continue on Brand name Synthroid rather than switch to an alternative plan preferred medication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mycobacterium Avium Infection (MAI)

Treatment: DME (durable medical equipment)- E0483- airway clearance device

The insurer denied coverage for DME- E0483- airway clearance device.

The denial is overturned.

The patient has a history of bronchiectasis, interstitial lung disease (ILD), mycobacterium avium infection (MAI) and obstructive sleep apnea (OSA).  The patient has had recurrent MAI and Pseudomonas in his lungs.  He has chronic productive cough.

The patient's maintenance medications include Albuterol and Ipratropium via Nebs, long-acting beta-agonist (LABA)/inhaled corticosteroid (ICS) Combo, Mucolytics and Hypertonic Saline via Nebs.  The patient had also had the High frequency chest wall oscillation (HFCWO) - Vest for mucociliary clearance.  The patient has been using it for a long time and uses it twice daily (BID) at least.  The patient has benefitted from the use of the vest.

HCFWO devices are standard of care in congestive failure (CF) and have been approved for use in Bronchiectasis and provide improvement in both pulmonary function and quality of life related parameters and should be included among the principal options in chest physiotherapy.

This patient has advance disease and needs the Vest device to improve mucociliary clearance and avoid hospitalizations with Pneumonia.  Powner et al have shown that the HFCWO vest resulted in a significant decrease in hospitalizations and decrease in antibiotic usage in patients with bronchiectasis. 

This patient has been using the HFCWO Vest for many years and should be approved for continued usage of the device.

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 DME - E0483- airway clearance device is reversed. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services (All). 
The insurer denied Radiofrequency ablation (RFA) as experimental/investigational. 
The denial is overturned.

The patient is a female with chronic pain. Documentation noted that the patient had bilateral sacroiliac joint steroid injections with significant pain relief and improved function, but results were not long lasting. Documentation noted that physical therapy did not help, and steroid injections could not be continued at this frequency. Recommendation is for a sacroiliac joint radiofrequency ablation.
At issue is whether the treatment of Radiofrequency ablation (RFA) is likely to be more beneficial than any standard treatment or treatments.

The health plan's determination regarding the proposed health service or treatment is overturned in whole.

The proposed health treatment of Radiofrequency ablation is likely to be more beneficial than any standard treatment or treatments for the insured's disabling condition of chronic pain.

The patient is a female with chronic pain. Documentation noted that she has had good results from bilateral sacroiliac joint steroid injections but, unfortunately, results were not long-lasting. Documentation noted that the patient had tried and failed physical therapy. Given the patient's chronic pain history, it is reasonable and considered the standard of care to proceed with diagnostic sacral nerve blocks and if relief is 80% or greater for both diagnostic blocks to proceed with the radiofrequency ablation.
Therefore, the proposed health treatment of Radiofrequency ablation is likely to be more beneficial than any standard treatment or treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: New onset seizure.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission. 
The denial is upheld. 

This is a male child who presented to the Emergency Department with a past medical history of attention deficit hyperactivity disorder (ADHD) as well as behavioral issues. The documentation indicated the patient's mother stated he started a new medication 4 days prior which he was experiencing side effects from. The documentation indicated she called 911 due to her daughter waking her up indicating the patient was shaking. She reported she went to see him, and his eyes were rolled back, and he seemed to be shaking and kept repeating he was cold. The physical examination revealed the patient was in no distress and was interacting appropriately. He was alert and oriented. The triage vital signs revealed temperature of 97.8 degrees with a heart rate of 109 beats per minute. The documentation indicated laboratory and diagnostic studies were recommended. The electrocardiogram (EKG) revealed a normal study. Laboratory studies revealed no significant findings. The physician indicated the patient should be admitted due to a new onset seizure. The documentation indicated the patient was admitted and underwent magnetic resonance imaging (MRI) of the head. The examination revealed an unremarkable study. It was recommended the patient be placed on a video electroencephalogram (EEG). The documentation indicated medications were also adjusted during the stay. The documentation indicated throughout the stay there was no further significant events. The video EEG did not reveal any abnormalities. The patient was discharged with instructions to follow-up. 

According to the guidelines provided by the InterQual 2019, this acuity of this case is considered to have required observation as the patient who had a seizure that self-resolved without intervention and the patient was at his reported baseline at presentation. Upon arrival the patient was not considered to be in status epilepticus. No events concerning for seizures were noted during the stay. Precautionary testing with MRI and EEG were performed. No other interventions were necessary. The patient did not require an escalated level of care or any interventions.

The current literature indicates a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. However, the submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. The documentation detailed the patient did continue to slowly improve and was discharged. The requested inpatient admission would not be the most appropriate level of care.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines
Treatment Vyepti
The insurer denied Vyepti
The determination is upheld.

The patient has a history of migraines and was evaluated for headaches, a change in mental status and seizure-like episodes. She underwent evaluation and was diagnosed with non-epileptic seizures. A review of the office notes indicates treatment with Botox, Ajovy and Emgality. She derived some benefit from Botox and from Emgality. She also benefited from Nurtec for acute migraine.
She was using Nurtec and Emgality. She did not like the way she felt after taking Botox. She did not have improvement in her dizziness; the headaches were improved. The medications were continued and she was referred for a cervical spine magnetic resonance imaging (MRI) scan.
She had continued complaints of migraines with dizziness. Her provider was concerned about orthostatic hypotension. Otherwise, it was noted that a change to Vyepti was being considered.
She complained of increasing headaches, and dizziness. She was waiting for a change to Vyepti, the Emgality was helping somewhat.
The patient continued to have severe headaches. The neurological examination remained normal, and she was prescribed sumatriptan. Vyepti had not yet been initiated.
She had complaints of increasing tremors and headaches. Her specific medications on that date were not provided for review. A repeat electroencephalogram (EEG), carotid Doppler, transcranial Doppler, cervical spine magnetic resonance imaging (MRI) scan, 24 hour EEG and magnetic resonance (MR) venography were recommended, the last in particular as she had an elevated D-dimer. MR angiography of the brain revealed patent dural venous sinuses. A brain MRI was interpreted as normal.
A letter of medical necessity indicated that the patient has a history of chronic severe and debilitating migraines with no relief from prior medications and treatments, and she complained of being weak and having difficulty with her balance. Sumatriptan was not effective as Nurtec. Emgality helped but not completely, and then there was no relief with Aimovig. She tried Botox in the past.
She had continued complaints of severe headaches. Her neurological examination remained normal. She was continued on Emgality and Nurtec at that time. At issue is the medical necessity of Vyepti.

The Vyepti is not medically necessary for this patient. She has failed three self injectable CGRP antibodies (Aimovig, Ajovy and Emgality). Vyepti, like Emgality and Ajovy, is a monoclonal antibody that targets the calcitonin gene-related peptide (CGRP) (Aimovig targets the CGRP receptor). If the patient had not responded to two medications in the same class (Emgality and Ajovy), further treatment in that class is not indicated. There is, therefore, no indication for the patient to be treated with Vyepti as it is not expected to be effective and its use is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation.
Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is upheld.

This is a patient with a history of asthma, diabetes mellitus, hypertension, gastroesophageal reflux disease (GERD). The patient has a history of 3 prior intubations and presented to the emergency department (ED) with complaints of shortness of breath (SOB) and wheezing. Vital signs at presentation: Temperature 98.4, Heart Rate 87, Respiratory Rate 18, Blood Pressure 138/70, and oxygen (O2) saturations 99%.  The patient had reportedly taken Prednisone and Doxycycline in the past. The patient was treated with intravenous (IV) Steroids and bronchodilators in ED.  The patient's exam described her to be in no acute distress. Lung exam revealed bilateral (B/L) wheeze. The patient was alert and oriented.  Her white blood cell count (WBC) was 6.8, hemoglobin 12.5, Electrolytes within normal limits (WNL), Lactate was WNL. Chest X-ray revealed (CXR) no acute infiltrate.  The patient was admitted to the hospital with diagnosis of asthma exacerbation secondary to bronchitis.

At the time of admission, she did not exhibit any signs of shortness of breath. The patient was in no acute distress (NAD). O2 saturation (sats) was 99% (percent) on room air. As per history and physical (H&P) the patient was in NAD with non-labored breathing. The patient was speaking in full sentences, was afebrile and hemodynamically (HD) stable with bilateral wheeze heard on exam. The patient was alert and oriented to person, place and time. The neurological exam was non focal.

The patient labs were as noted above. The patient was unable to do peak expiratory flow (PEF) testing due to technique.

The patient was continued on intravenous (IV) steroids, IV antibiotics and Duo Nebs.
The patient was seen by Pulmonary, improved over the next few days and was subsequently discharged home.

This patient did not need acute inpatient hospitalization. She was afebrile and HD stable. She was in NAD, able to speak in full sentences and not hypoxic with O2 sats 99 to 100 % on room air. WBC was normal. Electrolytes WNL. Influenza was negative. No pneumonia or pneumothorax or pleural effusion on CXR. She was able to tolerate oral intake (PO) and was ambulatory.

This patient could have been placed in Observation status (which could last for up to 48 hours) while diagnostic testing and treatment were being carried out. The patient remained stable after admission. She was stable to be discharged home on oral Steroids, and bronchodilators and oral antibiotics, if clinically indicated, with further follow up in the outpatient setting.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Withdrawal, sweating, joint aches.
Treatment: Inpatient admission.

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

The patient is a male (at the time of admission to the hospital) with a past medical history significant for hypertension (HTN), type II diabetes mellitus, hepatitis C, polysubstance abuse, and chronic heroin and cocaine abuse.  He presented for detox. 

The patient had mild withdrawal symptoms, including mild sweating, difficulty sitting still, joint aches, nasal stuffiness, stomach cramps and irritability. There was no documented syncope or palpitations. The patient was hemodynamically stable. Electrocardiogram (ECG) revealed normal sinus rhythm, with prolonged QT (QT interval) of 512 milliseconds (ms). Due to asymptomatic QTc (corrected QT interval) prolongation, the patient was admitted to telemetry for monitoring. There was no evidence of arrhythmia. The patient signed out against medical advice (AMA).

No, the proposed inpatient admission was not medically necessary.

The patient presented for detox due to heroin and cocaine abuse. The patient was found to have asymptomatic QTc prolongation. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. The patient had mild withdrawal symptoms. 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: Erythema.
Treatment: Hospital Admission.

The insurer denied coverage for hospital admission.  The denial is upheld.

The patient is a female with a benign past medical history. She presented to the emergency department with complaints of right thigh erythema and swelling following an insect bite.  Vitals on presentation included: Temperature 37.2 Celsius, Blood Pressure 118/73, Pulse 101, Respiratory Rate 16, oxygen (O2) saturation 100 percent (%) on room air. Laboratory values were notable for the following: white blood count (WBC) 9.0, hemoglobin (Hgb) 12.8, hematocrit (Hct) 38.7, creatinine-0.82, c-reactive protein (CRP) 42.8. 

The patient was admitted for cellulitis of the right thigh following an insect bite. She was started empirically on antibiotics (clindamycin). The patient also received as needed Tylenol and Motrin. She had an episode of chest discomfort, with negative electrocardiogram (EKG) results, believed to be secondary to anxiety. The patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue oral antibiotics (clindamycin) as an outpatient.

According to documentation, the patient was admitted with a possible lower extremity cellulitis following an insect bite. Otherwise, she was afebrile, hemodynamically stable with unremarkable laboratory results. There was no evidence of a disseminated infection, patient was able to tolerate oral intake, and no surgical intervention was required. Based on these findings, the patient did not meet criteria for acute care hospitalization. 

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

The insurer's denial of coverage for the hospital admission is upheld.  Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowding; Overjet.
Treatment: D8080 Braces, Pre-service.

The insurer denied the D8080 Braces, Pre-service.  The denial is overturned.

The patient is a male. The request is for orthodontic treatment (Braces).  The orthodontic records included x-rays/photos.

The patient presents with crowding in Maxilla and Mandible, overjet, and open bite on right premolar area. The patient has been in speech therapy to correct lisp caused by the mal-alignment of the teeth.

Yes, the Braces are medically necessary.

The mal-alignment of the Patient's teeth are severe enough to affect the ability to chew effectively. It also affects the patient's ability to enunciate certain letters necessary for proper speech.

This patient has been taking speech therapy to try to reposition the tongue to form the proper sounds. However, this is severely challenged by the open bite in the right premolar area, as evident in the photos.

Given the severity of the mal-alignment, if no treatment is provided, the chances for long-term consequences, as they relate to the patient's speech and other dental problems, to develop is very high.