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

Diagnosis: Displaced bicondylar fracture left tibia plateau
Treatment: Continued skilled nursing facility admission 
The Continued skilled nursing facility admission was not medically necessary.

The patient is a female with history of fall and sustaining displaced bicondylar fracture Left Tibia plateau. She was admitted to SNF (skilled nursing facility). She has significant past medical history of Fibromyalgia, hypertension, morbid obesity, etc.

Prior to admission, the patient was independent using cane living with spouse and children in a two-story house with multi steps to enter house.

The patient was admitted to SNF.  As of the dates of service under review, she is non-weight-bearing left lower extremity and non-ambulatory, dependent on bathing, functional transfers, toilet transfer, sit-to-stand with inability to stand, requires maximum assistance for toileting, lower body dressing, requires supervision for grooming, upper body dressing, independent for feeding, etc without showing tangible improvement.

There is no documented evidence of any tangible progress in SNF. The patient was admitted to SNF. As of the dates of service under review, she was non-weight-bearing left lower extremity and non-ambulatory, dependent on bathing, functional transfers, toilet transfer, sit-to-stand with inability to stand, requires maximum assistance for toileting, lower body dressing, requires supervision for grooming, upper body dressing, independent for feeding, etc.

As stated above, the proposed stay in SNF is not medically necessary. Withholding the continued stay in SNF, in whole or in part, is not reasonably expected to affect the patient's health adversely. An alternative custodial care may be more suitable for the current circumstance of the patient due to lack of tangible progress in SNF rehabilitation.
Appeal type: Medical necessity
Decision: Overturned

Digestive System/Gastrointestinal
Inpatient Hospital

This is a patient with a past medical history of hyperlipidemia and recent diagnosis of common bile duct stones on magnetic resonance cholangiopancreatography (MRCP) who presented for an elective endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy and biliary/pancreatic duct stent placement. Post-procedure, she was noted to have significant right upper quadrant pain refractory to a dose of fentanyl with the decision made to bring her into the hospital.
Otherwise, post-procedure, she was noted to be afebrile with a blood pressure of 108/59, heart rate 81, respiratory rate of 20, and oxygen saturation of 98% on room air. Lab results showed white blood cell count (WBC) 9.3, hemoglobin (HGB) 12.5, platelets 224, basic metabolic panel within normal limits, aspartate aminotransferase (AST) 104, alkaline phosphatase (Alk Phos) 65, total bilirubin (T. Bili) 0.4 and lipase 359. There was concern was for pain with possible post-ERCP pancreatitis with plans for morphine, oxycodone and Tylenol as needed (PRN) for pain control in addition to intravenous (IV) fluids and nothing by mouth (NPO) status, with plans to discharge in the morning if her pain was controlled.
The patient was hemodynamically stable without a fever, hypotension, tachycardia, tachypnea, or hypoxia. She continued to have abdominal pain and nausea. Her lipase was noted to increase to 493 with a repeat complete blood count (CBC) and comprehensive metabolic panel (CMP) unremarkable. The plan was to continue aggressive intravenous (IV) fluids at 200-250 cubic centimeters (cc) per hour, to keep the patient NPO given the ongoing pain, and consider starting clears.
The health plan's determination is overturned.
This patient presented for an elective ERCP with biliary sphincterotomy and biliary/pancreatic duct stent placement and subsequently developed significant pancreatitis with severe abdominal pain and lipase that climbed to 493 (greater than eight times [>8x] the upper limit of normal listed as 60 for this lab). She required NPO status even on day 2, aggressive IV fluids at 200-250 cc per hour and pain control with IV opiates. Ultimately, she could not be discharged until she was noted to be symptomatically improving and able to tolerate oral intake. Inpatient care was medically necessary for this patient with pancreatitis manifesting with severe abdominal pain, lipase that peaked at 8x the normal upper limit, requiring aggressive IV fluids, symptom control and NPO.
The Milliman Care Guidelines note that inpatient care is medically necessary if a patient has epigastric or left upper quadrant pain in addition to a serum lipase greater than 3 times the upper limit of normal. This patient with abdominal pain and lipase that reached 8x the upper limit of normal clearly met medical necessity for requiring inpatient admission based on these criteria as well.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza

Treatment: Inpatient hospital admission

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

This patient is a female who presented to the Emergency Department (ED) with complaints of shortness of breath (SOB), cough, rib pain, fever, and some abdominal pain of two days duration.  The patient has past medical history of asthma, hypertension (HTN), breast cancer status post mastectomy. The patient complained of fever to 101.5 at home. Vital signs at presentation were temperature (T) 37.5, heart rate (HR) 76, blood pressure (BP) 179/79 mm Hg respiratory rate (RR) 20 and oxygen (O2) saturations 96 %.  Physical exam revealed coarse breath sounds. White blood cell (WBC) count was 4.6K.  Electrolytes were within normal limits.  Lipase was 57, Troponin <0.03 and RVP was positive for Influenza A. Chest x-ray was within normal limits.  CT Chest was consistent with bronchitis/bronchiolitis. The patient was admitted and treated with nebulized bronchodilators, 1 dose of Prednisone and Tamiflu. The patient also received Toradol and Cyclopbenzaprine in the ED X 1.

The patient symptoms improved with the above treatment.  The patient remained afebrile and hemodynamically stable overnight.  The patient's rib pain had improved.  The patient was in no acute distress.  T 36.8 C, HR 104, BP 160/83 mm Hg, RR 10 and oxygen saturations were 98%.  Electrolytes were within normal limits. It appears that this patient had Influenza.  She did not need acute inpatient hospitalization.  She could have been placed in Observation status while diagnostic testing and treatment were initiated.  The patient was afebrile and hemodynamically stable.  She was tolerating oral intake.  The patient remained stable after admission and responded to the treatment initiated. This patient was stable for discharge on oral medications after a period in observation with close follow-up in an outpatient setting.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Hypoxic-ischemic encephalopathy 
Treatment: Inpatient rehabilitation
The Acute inpatient rehabilitation admission is not medically necessary.

This is a case of a female child with history of hypoxic-ischemic encephalopathy secondary to placental abruption. Her child birth history was remarkable for evidence for cardiopulmonary resuscitation at birth, low Apgar scores 0/2/2/2/4, prolonged stay at NICU (neonatal intensive care unit) with ventilatory support, feeding difficulties with placement of gastrostomy tube, hypothalamic dysfunction with temperature instability, evidence of spasticity, seizure activity with evidence of diffuse slowing at the video EEG.   Initial care has been provided at the tertiary care Children's Hospital. 

The patient was referred to pediatric rehabilitation facilities for acute inpatient rehabilitation. Initial request for acute inpatient rehabilitation has been denied following medical review and Health plan guidelines (MCG guideline called Inpatient Rehabilitation Facility (Acute Rehabilitation): Neurologic (ORG: I-7005) (RFC)).

Based on the review of medical records, the patient exhibits low functional abilities and will not be able to tolerate and participate in intensive acute inpatient rehabilitation. The patient will continue to require medical supervision and skilled therapy and nursing interventions in order to achieve long term goals.

From a pediatric rehabilitation point of view, continued rehabilitative interventions in order to achieve long term goals would be indicated for a patient such as this. However, this patient cannot participate in acute inpatient rehabilitation interventions due to significant degree of developmental delays and functional deficits secondary to severe hypoxic-ischemic encephalopathy.

Therefore, given that the patient cannot participate in the acute inpatient rehabilitation interventions, the Acute inpatient rehabilitation admission is not medically necessary.

Based on the review of medical records, the patient exhibits low functional abilities and will not
be able to tolerate and participate in intensive acute inpatient rehabilitation. The patient will
continue to require medical supervision and skilled therapy and nursing interventions in order to
achieve long term goals.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Pain injections
The insurer denied the pain injections. 
The denial is overturned. 

The patient is a gentleman with moderate to severe spinal stenosis and neurogenic claudication.  The patient has failed conservative treatment.  He previously had an epidural steroid injection with greater than 90% relief.  The pain has started to return.  It has been over two months since his last injection.

Yes. the 64483 x 2 - Pain injections are medically necessary.

The patient is a gentleman with severe spinal stenosis in neurogenic claudication. The patient has done physical therapy, has tried various medications including NSAIDs (nonsteroidal antiinflammatory drugs) and gabapentin. The patient had an epidural steroid injection with greater than 90% relief. The pain relief was short-lived and has returned. Epidural steroid injection was requested at bilateral L5 (fifth lumbar spine vertebra)-S1 (first sacral vertebra). The patient has failed conservative treatment. He is trying to avoid surgery if at all possible. The patient has moderate to severe stenosis, which is consistent with his symptoms. An epidural steroid injection, given the fact that he had over 90% relief with the initial injection, is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines
Treatment: Formulary exception for Emgality 120 mg/ml pwn.
The insurer denied the Formulary exception for Emgality 120 mg/ml pwn.
The denial is upheld. 

The patient is a female with migraine headache disorder.  She has tried and failed topiramate, atenolol, gabapentin, pregabalin, escitalopram, and Aimovig for migraine prevention. Her provider is requesting Emgality for migraine prevention.

No, the health plan should not cover the Formulary exception for Emgality.

The patient has a contraindication to divalproex sodium (female childbearing age) and propranolol due to asthma diagnosis. However there is no documented reason provided as to why the patient cannot be treated with preferred oral medications such as amitriptyline or venlafaxine.  There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Emgality relative to the preferred oral agents.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. 
The insurer denied surgical procedure on esophagus. 
The denial is upheld.

This male patient has chronic gastroesophageal reflux disease (GERD) which has worsened following a peroral endoscopic myotomy (POEM) procedure done to treat achalasia Type 2. He has tried multiple proton-pump inhibitors (PPIs) without relief of his symptoms. He had an esophageal pH study that demonstrates significant reflux. The attending provider would like to do a transoral incisionless fundoplication (TIF) procedure to treat this patient's GERD. The subject under review is whether the procedure would be more beneficial than any standard treatment for the patient's condition.

The health plan's determination is upheld.

the proposed health service or treatment surgical procedure on esophagus is not more likely to be more beneficial than any standard treatment or treatments for the patient's condition. There are two endoscopic interventions for GERD that are currently available in the United States they are the Stretta procedure, and transoral incisionless fundoplication (TIF). In studies evaluating these endoscopic interventions, patients with significant structural Esophagogastric junction disruption (e.g., hiatus hernia larger than 2 centimeter [cm]), significant esophagitis (Los Angeles Classification of GERD grade C or D), and GERD complications (Barrett's esophagus [BE], peptic stricture) were excluded. In a multicenter study that compared TIF to a sham procedure and PPI therapy, esophageal pH decreased, and regurgitation was better resolved 6 months after TIF, although TIF did not reduce GERD symptom scores.
A randomized controlled trial of transoral incisionless fundoplication vs. proton pump inhibitors for treatment of gastroesophageal reflux disease by Witteman and colleagues showed that although TIF resulted in an improved GERD-related quality of life and produced a short-term improvement of the antireflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved. Similarly, in a systematic review and network meta-analysis of trials of patients with GERD, Richter and colleagues found laparoscopic Nissen fundoplication (LNF) to have the greatest ability to improve physiologic parameters of GERD, including increased lower esophageal sphincter LES pressure and percent time at pH less than (<) 4. Although transoral incisionless fundoplication (TIF) produced the largest increase in health-related quality of life, this could be due to the shorter follow-up time of patients treated with TIF vs LNF or PPIs. TIF is a minimally invasive endoscopic procedure, yet based on evaluation of benefits vs risks, the authors do not recommend it as a long-term alternative to PPI or LNF for treatment of GERD.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. 
The insurer denied surgical procedure on esophagus. 
The denial is upheld.

The patient is a male under evaluation and management for esophageal reflux disease. The patient initially was treated with the peroral endoscopic myotomy (POEM) procedure for achalasia Type 2. This often leaves patients with severe esophageal reflux due to disruption of the lower esophageal sphincter. The patient has chronic heartburn and regurgitation despite treatment with proton pump inhibitor (PPI) therapy. It affects his sleep and quality of life. A Bravo pH study confirmed significant supine and upright acid reflux. The patient's provider has recommended the transoral incisionless fundoplication with EsophyX procedure.
The subject under review is whether the requested procedure is likely to be more beneficial than any standard treatment for this patient's condition.

The proposed transoral incisionless fundoplication with EsophyX procedure is not likely to be more beneficial than the standard treatment for the patient's condition.
This is a very unique case of severe reflux disease. This occurred as a well-recognized complication of the POEM procedure.[1] Because the POEM procedure is not combined with a fundoplication as is performed with a standard Heller myotomy, the patient is left with no reflux barrier. In addition, due to poor motility from achalasia, any acid which reflux tends to empty poorly from the esophagus. Most patients, fortunately, can be managed with aggressive, lifelong anti-secretory therapy. This patient is not responding, even to Dexilant at a daily dose of 60 milligrams (mg). This patient needs the construction of a reflux barrier. The transoral incisionless fundoplication (TIF) procedure attempt to do this endoscopically using a device which plicates the rotated proximal stomach in an effort to create a fundoplication. There are two problems with this procedure in this specific case. First, it has very rarely been applied in this specific scenario and therefore the benefit and side effects are not well-known. Secondly, and more relevant, the durability is unknown. Even with the newer device only five year data is becoming available from non-randomized registry trials. [2] It is extremely likely that further procedures will be needed down the road. The standard of care would be a "loose wrap" (partial fundoplication). Loose to prevent dysphagia and gas/bloat, but tight enough to improve reflux. It is a durable procedure however even data beyond 10 years is not well-studied for a fundoplication however its predicted long-term success rate is much higher. [3] The proposed transoral incisionless fundoplication with EsophyX procedure is not likely to be more beneficial than the standard treatment for the patient's disabling condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Mektovi. 
The denial is overturned.

The patient is a male with a history of diffuse hypothalamic / optic pathway glioma. He initially presented with right-sided nystagmus and brain magnetic resonance imaging (MRI) showed a large mass involving the optic chasm, optic tract, and hypothalamus. He was treated with several different medical regimens but did not have a significant response. He was enrolled in a clinical trial with binimetinib (Mektovi) with an excellent response and tumor shrinkage. Three months after completing this treatment, he has had further progression of his tumor. He is not a candidate for surgical resection. The provider is now recommending that the patient be again allowed to receive treatment of his suspected BRAF-mutated glioma with binimetinib. The medical necessity for the use of binimetinib is under review.

The health plan's determination is overturned in whole.

The treatment with Mektovi is medically necessary for this patient. It appears that this request was previously denied simply because there is no specific documentation that the patient's tumor has been biopsied and analyzed for BRAF mutation. Per the National Cancer Institute (NCI), BRAF mutations drive a significant portion of low-grade gliomas where early reports show substantial activity of BRAF inhibitors against these BRAF V600E mutated tumors. They are given in combination with MEK inhibitors as the combination is more effective than either BRAF inhibitors or MEK inhibitors as single agents. The NCI states that the standard treatments for recurrent low-grade gliomas such as this patient's optic / hypothalamic glioma may include surgery, chemotherapy and/or targeted therapy with or without chemotherapy. This patient has already tried and failed the use of vinblastine, carboplatin, and vincristine. The NCI notes that the identification of BRAF mutations driving a significant portion of these tumors has provided a new potential treatment target. These types of medications have resulted in a 41% overall response rate to include some complete responses in children with tumors expressing the BRAF mutation such as the one that this patient has. Truong et al. has also showed the benefits of targeted therapy in pediatric gliomas, to include the use of Mektovi, and Miller et al. showed a volumetric response using this therapy.
This patient has limited treatment options for a life-threatening disease. He has tried and failed all other more "standard" treatment options, and the use of Mektovi is supported by his tumor tissue and the current standards of care in the field. It is also known to be effective for this specific patient based on the results of previous therapy.
Based on the clinical information provided for review, and the current peer-reviewed literature/standards of care, the use of Mektovi is medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriatic Arthritis. 
Treatment: Taltz. 

The insurer denied the Taltz. 

The determination is upheld. 

The patient has a history of psoriatic arthritis and uveitis. Taltz is being denied by the health plan. The reason cited is she has not tried and failed Cosentyx, the preferred alternative drug. Prior treatment included Otezla and Enbrel. At issue is the medical necessity of Taltz. 

The requested health service/treatment of Taltz is not medically necessary for this patient. There is no medical reason that the patient cannot try the formulary alternative, Cosentyx. She does not have a contraindication to Cosentyx and it is equivalent as far as efficacy, mechanism of action and side effects to Taltz. The preferred drug on the formulary is Cosentyx, another interleukin (IL) -17 antagonist that is very similar to Taltz.
In an article published in the New England Journal of Medicine, it was found that 'secukinumab was more effective than placebo in patients with psoriatic arthritis, which validates interleukin-17A as a therapeutic target'. Cosentyx (secukinumab) is the formulary drug. There is no data showing that Taltz is superior to Cosentyx for the treatment of psoriatic arthritis (PsA) and uveitis. There is no medical reason or contraindication to why the patient cannot try Cosentyx instead of Taltz.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient has multiple risk factors and coronary artery disease and recently underwent percutaneous coronary intervention (PCI) of the left anterior descending (LAD). He was also noted to have a chronic total occlusion (CTO) of the right coronary artery (RCA), and he presented electively for PCI of the RCA CTO. Bilateral femoral access was used for the procedure. The procedure was successful and without apparent complication. He was admitted overnight and discharged the following day without significant event.
At issue is the medical necessity of the inpatient medical stay.

An inpatient medical stay is not medically necessary for this patient.

The patient underwent PCI of the RCA CTO. This was an elective procedure that, although complex, was performed successfully and without complication. The care of this patient was most appropriate at a lower level of care. There were no clinical, procedural, electrocardiographic, hemodynamic, laboratory or post procedural issues that warranted an inpatient higher level of service. 

Therefore, an inpatient admission was not medically necessary.