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

Diagnosis: Hip Surgery.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is overturned in part. A 1 day inpatient stay was medically necessary. 

This case describes a male patient with a complaint of left hip pain who underwent prior left hip pinning due to a fracture. He developed left hip arthritis and failed to respond to conservative treatment measures. He elected to undergo removal of hardware and total hip replacement surgery. The patient had a successful operation with no documented complications. The patient had an uneventful hospital course and progressed well with physical therapy after the operation. He was deemed stable for discharge to home with home health care. Under review is the inpatient hospital stay.

A 1 day inpatient stay was medically necessary. The patient underwent left hip removal of hardware and total hip arthroplasty. The records document that pain management consultation was necessary for appropriate administration of narcotics. This facilitated the patient's participation in physical therapy and allowed him to ambulate 110 feet and climb 4 steps on day 2. Thus, the inpatient hospital admission is justified based on the provided records and the recommendations of the current, peer-reviewed orthopedic literature.
On day 2, however, the progress notes document that the patient noted good pain control with the current pain mediation regimen. The orthopedic progress note documented that the patient walked 110 steps and climbed 4 stairs. The noted also documented normal vital signs and lab values on this day. Based upon the provided documentation, the patient could have been safely discharged home on this day.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe dementia
Treatment: Consumer direct care 168 hours per week 
The insurer denied the Consumer direct care 168 hours per week.
The denial is overturned. 

The patient is an female with a history of severe dementia. Due to impairments related to this condition, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of 168 hours per week consumer direct care to offer increased activities of daily living (ADL) support.

The proposed treatment of 168 hours per week consumer direct care is deemed medically necessary. 

This is a female with a history of dementia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's provider indicates that due to worsening cognitive decline, decreased functionality and decreased ability to perform ADLs, the currently approved plan of live-in, seven days per week, consumer direct care is insufficient to meet the patient's current needs. Specifically, the provider reports that the patient has demonstrated progressive weight loss and more frequent falls. For these reasons, the proposed treatment 168 hours per week consumer direct care is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Anticipated Admission for Bariatric Surgery
The health plan denied the Anticipated Admission for bariatric surgery.
The health plan's determination is overturned.

The patient is a male suffering from obesity who is status post a laparotomy sleeve. He lost 120 pounds and has hit a plateau in weight loss with a body mass index (BMI) of 39 and co-morbidities, sleep apnea and hypertension. He chose the sleeve as that was what was offered to him and he weighed 390 pounds (superobese). He achieved approximately 60% estimated body weight loss (EBWL) with this operation, however, he still weighs 275 pounds and is looking to be closer to his ideal body weight. Additionally, he still has several co-morbidities related to weight. His upper gastrointestinal (UGI) shows a small hiatal hernia.
At issue is the medical necessity of admission for bariatric surgery.

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

Yes, the proposed procedure is indicated and medically necessary for this patient due to the patient's sleep apnea and hypertension. In addition, he has a new onset hiatal hernia on the UGI- this should be addressed at the next operation.
The patient lost a significant amount of weight from the first operation. It is very common for a plateau to occur after a bariatric procedure, and revision surgery is required in up to 20% of sleeve gastrectomy procedures (SG). As with any disease, obesity may take several therapies to have long term success. A successful operation is usually determined by excess weight lost as well as resolution of co-morbidities. This patient has been able to lose a significant amount of weight but has not been able to achieve resolution of his co-morbidities. Therefore, just like in any other disease, identifying and following up on the next step in treatment is indicated. Typically, surgeons will start with a sleeve as a restrictive operation up front. The plan would be to preserve the anatomy in case further, more invasive interventions, are needed.
A recent consensus review concluded that as a second-stage procedure, biliary pancreatic diversion/ duodenal switch (BPD/DS) is most appropriate after sleeve gastrectomy (SG) for the treatment of super morbid obesity or as a subsequent operation for a reliable patient with insufficient weight loss after SG. 
A second study from 2020 demonstrated that at 1 year, revisional procedures offer further weight loss after a failed primary SG. Bypass-type revisions are preferred over re-sleeve surgery. In the absence of refractory reflux symptoms, duodenal switch-type procedures are safe and most effective options especially in patients with severe obesity before SG.
Finally, a recent meta-analysis found that the BPD/DS has improved weight loss after initial sleeve gastrectomy when the starting body mass index (BMI) is high-- this is the exact description for the patient in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ocular misalignment.
Treatment: Strabismus Repair.

The insurer denied the Strabismus Repair. The health plan's determination is overturned. 

The patient is a female for whom coverage of strabismus repair is the subject of review. According to the provider, this patient requires strabismus surgery to repair a functionally significant ocular misalignment. Among other indications supported in a joint statement by the American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus, the goal of both "Restoration of Binocular Vision" and "Psychosocial Function/Vocational Status" are indications to proceed with reconstruction. Coverage was previously denied as the patient has had this condition since early childhood and not functional impairment was identified. The procedure was considered cosmetic. 

The Outpatient Procedure: Strabismus Repair is medically necessary for this patient.
It has been estimated that up to 4% of the adult population has strabismus, and strabismus surgery is commonly performed on adult patients. Childhood strabismus may persist into or recur in adult life. Adults may also develop new-onset strabismus as a result of such varied conditions as microvascular cranial neuropathies, trauma, thyroid-related ophthalmopathy, cerebrovascular disease, or as a consequence of previous ocular or orbital surgery.
In this case, strabismus surgery is proposed to restore alignment in an adult patient with a huge alternating exotropia which has been present since childhood and was reportedly never addressed. According to the Joint Statement of the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology, adult strabismus surgery seeks to restore/reconstruct normal ocular alignment. Indications for surgical intervention in adult strabismus include diplopia, visual confusion, restoration of binocular vision, intolerance of prism glasses or patch, restoration of visual field, elimination or improvement of abnormal head posture, or psychosocial function/vocational status. Therefore, medical necessity for strabismus surgery is established per standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, hypertension, end
stage renal disease
Treatment: Increase in personal care worker service to 7 days per week 10 hours per day
The insurer denied the Increase in personal care worker service to 7 days per week 10 hours per day. 
The denial is overturned. 

The patient is a female with a history of congestive heart failure, cardiac arrhythmia, hypertension and end stage renal disease. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 70 hours per week personal assistance services to offer increased activities of daily living support.

Yes, the proposed treatment of 70 hours per week personal assistance services is deemed medically necessary. 

This is a female with a history of congestive heart failure, cardiac arrhythmia, hypertension and end stage renal disease. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation received from the patient's provider indicates that due to worsening functional decline, frequent bouts of hypotension, gait ataxia and high fall risk; the patient requires more assistance that what is offered but the currently approved plan of 35 hours per week personal assistance services. For these reasons, the proposed treatment of 70 hours per week personal assistance services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Braces
The insurer denied the braces.
The denial is overturned. 

The patient is a female. The request is for orthodontic benefits.

Yes, the Dental Services (braces) are medically necessary.  The patient has a crossbite of an anterior tooth (#11) with loss of gingival attachment. This is an automatic qualifier according to the handicapping index scale. The requested services are medically necessary in order to treat this.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal, Vomiting

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient who was hospitalized for abdominal pain and vomiting. She was afebrile and her vital signs were stable. There was no abdominal rebound or guarding. In the Emergency Room (ER), she was treated with intravenous hydration, Zofran, and Famotidine. It was felt that the vomiting was due to cannabinoid use. She was also treated for a pelvic infection with metronidazole. Her renal function was normal. She responded to treatment and was able to tolerate oral feedings.

Clinical indications for admission for Pediatric Vomiting (P-371) include gastrointestinal obstruction, a significant metabolic derangement, hemodynamic instability, severe vomiting, severe pain, acute renal failure, and inability to maintain oral hydration after receiving observation care. The patient did not have these conditions.

This patient had vomiting that was likely related cannabinoid use. She required intravenous hydration and antiemetics. This treatment could have been given with observation status. She responded to the treatment and was then able to tolerate a diet.  She did not meet Milliman Care Guidelines (MCG) criteria for admission for vomiting.  The healthcare plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

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

Diagnosis: Left hip arthritis. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is overturned. 

This is a female patient with a medical history of osteoarthritis, lumbar radiculopathy, and lumbar stenosis with multiple back surgeries with instrumentation who presented for a scheduled hip surgery. Per the operative report, the patient underwent a left total hip replacement with the pre-operative diagnosis of left hip arthritis; post-operative diagnosis same for the indication of pain/arthritis. The patient tolerated the procedure well without complications and was taken to recovery in stable condition. 

The patient was admitted to a regular unit post-operatively. She was pain controlled with intravenous (IV) and oral pain medication. The post-operative course was complicated by hemoglobin-9.3, hematocrit-26.5 and systolic blood pressure in the 70s on day 2 of admission. Physical therapy (PT) and weight bearing as tolerated was limited by complaint of dizziness and hypotension which was resolved with 1 unit packed red blood cells and IV fluids. She ambulated 25 feet x 2 with PT on day 3 of admission and 100 feet and negotiated stairs on day 4 of admission. The patient was also noted with contact dermatitis rash from foam tape dressing and was treated with Benadryl and Kenalog cream. The patient was medically cleared for discharge home on day 4 of admission with home care services arranged and instructions to follow up with Orthopedics and Dermatology. 

The patient's medical record demonstrated a complicated post-surgical course. The patient was found to have a blood pressure of 74/50 on the day after surgery. Hematocrit was below normal. She was unable to stand or complete PT secondary to dizziness. She required additional treatment of a transfusion. She required fluid bolus. These services are at a high level and cannot be provided as outpatient. She was at risk for additional problems. Monitoring of hematocrit after the transfusion would be required. Ongoing assessment of vital signs would be necessary. 

The patient also developed an extensive rash and a Dermatology consult was required. These events substantiated necessity of admission and services provided. The inpatient hospital admission is considered medically necessary for this patient. 

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

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

Diagnosis: Hypothyroidism, hypertension, GERD, Coronary Artery Disease and Depression. 
Treatment: Increase Consumer Directed Personal Assistant Program (CDPAP) Services From 36 Hours Per Week To 63 Hours Per Week. 

The insurer denied the Increase Consumer Directed Personal Assistant Program (CDPAP) Services From 36 Hours Per Week To 63 Hours Per Week. 
The denial is upheld. 

The patient is a female with a history of hypothyroidism, hypertension, GERD (gastroesophageal reflux disease), coronary artery disease and depression. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review requested for potential approval of 63 hours per week Personal Assistance Services to offer increased ADL (activities of daily living) support.

No, the Increase of CDPAP (Consumer Directed Personal Assistant Program) services from 35 hours per week to 63 hours per week is not deemed medically necessary. 

This is a female with a history of hypothyroidism, hypertension, GERD (gastroesophageal reflux disease), Coronary Artery Disease and Depression. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). The appeal statement reports that this patient has been demonstrating unintentional weight loss due to poor oral intake and requires extensive assistance for feeding. However, an in-home assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and revealed that the currently approved plan of 35 hours per week Personal Assistance Services is sufficient to meet the patient's current needs. There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment 63 hours per week Personal Assistance Services is not deemed medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Meds. 

The insurer denied: Taltz. The denial is upheld in whole.

The patient is a female with moderate to severe psoriasis (30% body surface area involvement while on Humira) of the arms, legs, and trunk. The patient tried and failed topical halobetasol. Enbrel was previously used but was discontinued due to pregnancy. The patient is currently on Humira but will be stopped if Taltz is approved for coverage.

The health plan's determination is upheld in whole.

The non-formulary drug (Taltz) would not be more effective than the formulary drugs. The patient has no documented treatment failure with, or true medical contraindication to, the formulary drugs including Cosentyx, Cimzia, Skyrizi, Stelara, or Tremfya.
Modern dermatology literature [1-4] supports use of the formulary medications as similarly efficacious to the requested Taltz, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized beyond Tumor Necrosis Factor inhibitors and recommend use of these preferred agents as appropriate for this patient's clinical scenario. These agents are all of similar efficacy to the requested Taltz. Therefore, as per current medical standards of care, Taltz is not going to be more effective than the formulary drugs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crohn's Disease.
Treatment:  Remicade.

The insurer denied Remicade.  The health plan's determination is overturned. 

The patient is a male with severe stricturing upper gastrointestinal and ileocolonic Crohn's disease.  He started Remicade.  Testing showed Remicade level of 3.5 ug/mL (microgram per milliliter) with no anti-Remicade antibodies.  A Colonoscopy showed active disease, with ileitis, ileocecal valve inflammation, and possible intussusception of the sigmoid colon.  The request is for continuation of Remicade 475 mg (milligrams) intravenous every 8 weeks for the treatment of Crohn's disease.

The Infliximab (Remicade) is medically necessary for this patient.

At issue in this case is a change from Remicade to a biosimilar, while Crohn's disease is not controlled.  The plan's preferred drugs Inflectra, Renflexis, and Avsola are Food and Drug Administration (FDA) -approved for the treatment of Crohn's disease.  Support for the safety and efficacy of biosimilar medications in inflammatory bowel disease is provided by studies, which either extrapolated safety and efficacy from patients with other diseases (such as rheumatoid arthritis), or from studies in patients, who had controlled inflammatory bowel disease; and many of these trials are underpowered to assess for noninferiority in inflammatory bowel disease patients.

Additionally, multiple studies have shown that patients, who are continued Remicade, had a lower risk of disease worsening or treatment discontinuation, including a fivefold hazard of discontinuing treatment at 12 months, but these did not reach statistical significance.  Assumptions about switching patients from Remicade to a biosimilar should be made with caution, as lack of Crohn's disease control can result in significant adverse events such as worsening flare, fistula, stricture, need for surgery, and need for hospitalization.  Although there is support for switching Remicade to a biosimilar in patients with controlled Crohn's disease (or initiation of therapy with biosimilars rather than Remicade), there is a lack of high-quality data or large studies to support the safety of a switch from Remicade to a biosimilar in uncontrolled Crohn's disease, as in this case.  For these reasons, Remicade is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer
Treatment: Proton Beam Radiation Therapy 

The insurer denied Proton Beam Radiation Therapy. The health plan's determination is upheld. 

This is the case of a patient who was treated with proton therapy. He presented with rising prostate-specific antigen (PSA) and was found with left (L) inferior pubic ramus metastasis. He was previously treated with SBRT (Stereotactic body radiation therapy). He was again treated to the same area with Proton beam therapy. This is the subject of review.

The Proton Beam Radiation Therapy is not medically necessary for this patient. Medically necessary treatment is defined as those treatments which are in accordance with generally accepted standards of medical practice in the United States. The generally accepted standards of medical practice in the United States for this patient's clinical scenario is intensity modulated radiation therapy (IMRT) or SBRT. This patient was previously treated with SBRT and was asymptomatic at the time of Proton treatment.
The National Comprehensive Cancer Network (NCCN) guidelines do not recommend proton beam therapy for palliative treatment of metastatic prostate cancer. There is no published data of Proton beam therapy for metastatic prostate cancer on PubMed.