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

Diagnosis: Adenocarcinoma of the prostate.

Treatment: Positron Emission Tomography and Computed Tomography (PET CT) Imaging.

The insurer denied coverage for Positron Emission Tomography and Computed Tomography (PET CT) Imaging.

The denial is upheld. 

This is a male patient with high-risk prostate cancer.  The patient was noted to have clinical adenocarcinoma of the prostate with a Gleason score of 4+5 = 9 and a prostate-specific antigen (PSA) of 7.6.  The patient underwent a computed tomography (CT) scan revealing multiple retroperitoneal lymph nodes in the left peri-aortic chain as well as a questionable 5 millimeter (mm) sclerotic lesion which had uptake on the bones and in the left acetabulum.  The provider requested a positron emission tomography (PET) scan to understand these extrapelvic sites.

Based on the review of the medical record and literature, the Positron Emission Tomography and Computed Tomography (PET CT) Imaging is not considered medically necessary for this patient.

The medical provider is requesting fluciclovine positron emission tomography (PET) scan, which is Food and Drug Administration (FDA)-approved for detecting prostate cancer disease after prostate-specific antigen (PSA) recurrence after definitive treatment with surgery or radiation.  While it seems rational that the fluciclovine PET scan would be clinically useful in this scenario, to see if there is uptake in the enlarged para-aortic lymph nodes which by report cannot be biopsied, this scenario has not been rigorously studied in a clinical trial.  Fluciclovine PET scan shows promise as an initial staging agent, and there are several ongoing clinical trials.  The latest addition of the National Comprehensive Cancer Network mentions that fluciclovine PET could be considered in cases where bone scan is equivocal.  In this specific scenario described here, and my clinical opinion, the fluciclovine PET is not considered medically necessary.

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

The carrier's denial of coverage for Positron Emission Tomography and Computed Tomography (PET CT) Imaging should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plaque Psoriasis
Treatment: Otezla 30mg Tablet
The insurer denied the Otezla 30mg Tablet.
The denial is overturned. 

The patient is a female with psoriasis on trunk and extremities for whom Otezla is requested. She has tried and failed topical steroids and phototherapy. She has been on Otezla since the end of last year and is doing well.

Yes, the treatment with Otezla is medically necessary.
The health plan offers alternatives that are not appropriate for the patient.

The patient is not a good candidate for conventional systemic medications due to childbearing age. Therefore, a biologic medication or small molecule like Otezla are medically appropriate. Additionally, she has been on Otezla for several months with good results. Discontinuation of treatment may result in a flare.

Otezla, an inhibitor of phosphodiesterase 4 (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.  (Celgene)  Otezla is an oral small molecule inhibitor of phosphodiesterase 4 (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA) as well as the treatment of patients with moderate to severe plaque psoriasis. (Celgene)

The patient has moderate to severe psoriasis for which therapy with Otezla is appropriate and medically necessary.

In view of the above, and since the patient has initiated therapy with Otezla, is doing well, and has not reported any adverse events, it is medically appropriate and necessary to continue the treatment.

Since the patient has initiated therapy with Otezla, is doing well, and has not reported any adverse events, it is medically appropriate and necessary to continue the treatment. For the patient, this is a continuation of therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness status post diverticulitis exacerbation and influenza; Multiple Sclerosis.
Treatment: Continued Stay Acute Rehabilitation Facility.
The insurer denied the Continued Stay Acute Rehabilitation Facility.
The denial is upheld. 

The patient is a male with history of general weakness after acute exacerbation of diverticulitis along with influenza requiring acute admission. He has history of debilitating Multiple Sclerosis. He is incontinent of bladder and bowel.

Prior to admission, the patient had limited household ambulation with an assistive device, and limited ambulation at his office with an assistive device. He had a power WC (wheelchair) for long distance and outdoor mobility and was previously using a scooter. He lives alone in an apartment with his son staying with him on alternating weeks.

The patient was ambulating 100 feet x 2 with rolling walker and supervision, modified independent with grooming, feeding, rolling, required supervision with upper body dressing/bath, supine-to-sit, transfers, minimum assistance with lower body dressing/bath.

No, the Continued Stay Acute Rehabilitation Facility was not medically necessary.

The patient has not met all the criteria for acute rehabilitation care INTERQUAL Criteria for Acute Rehabilitation in a patient with General Debility and weakness and with no major ongoing clinical issues. He was ambulating 100 feet x 2 with rolling walker and supervision, modified independent with grooming, feeding, rolling, required supervision with upper body dressing/bath, supine-to-sit, transfers, minimum assistance with lower body dressing/bath.

The plan was to discharge him home with home care service.

Based on not meeting the above requirements, the patient has not met the criteria for continuing further intensive acute inpatient rehabilitation.

The patient was ambulating 100 feet x 2 with rolling walker and supervision, modified independent with grooming, feeding, rolling, required supervision with upper body dressing/bath, supine-to-sit, transfers, minimum assistance with lower body dressing/bath.

The plan was to discharge him home with home care service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever
Treatment: Continued inpatient admission
The insurer denied the Continued inpatient admission.
The denial is upheld. 

The patient in this case is a woman being treated for breast cancer.  She was treated with dose dense AC (Adriamycin + Cyclophosphamide) chemotherapy and Neulasta. She called the office saying that she had a fever of 102.1 the night before.  She was sent to Urgent Care for evaluation.

The patient's vital signs were unremarkable and temperature was 99.9. Symptoms included rhinorrhea, sinus congestion and sore throat.  She had cough with clear mucous.  She had started a Medrol dose pack and Augumentin the day before presentation. Labs were notable for white cell count 0.7 and absolute neutrophil count less than 500 (it was listed as 0). She was diagnosed with neutropenic fever without pneumonia.  She was admitted and treated with Zosyn and blood cultures were obtained.

The patient had continued rhinorrhea and congestion.  She had no other symptoms.  White cell count was up to 1.2.

The patient had further improvement in white cell count.  She had a fever the night before.  She had worsening throat pain.  She was continued on IV (intravenous) antibiotics given continued fever.

The patient was noted to have not had any further fevers or neutropenia. Blood cultures had been negative.  She was felt to most likely have a viral infection.  She was continued on Zosyn and kept in the hospital.  It was noted that she would be kept in the hospital until afebrile with negative cultures for 48 hours.

No, the Continued inpatient admission was not medically necessary.

This patient had been afebrile and was no longer neutropenic.  Blood cultures had been negative since the time of admission. Records clearly and consistently indicated that she was not considered to have an active bacterial infection.  Given that neutropenia and fever had both resolved and blood cultures were negative, and also given lack of hemodynamic instability or organ dysfunction, she did not require continued inpatient hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain, Bowel Disease And Uveitis.
Treatment: Hyperbaric Oxygen (CPT 99183 x 30) .
The insurance denied the Hyperbaric Oxygen (CPT 99183 x 30).
The denial is overturned. 

The patient is a male. He suffers from Crohn's disease, ankylosing spondylitis, and uveitis. A colonoscopy indicated significant erosions and chronic inflammation of the illeocecal valve. The patient has not responded to Humira and Methotrexate and was recently placed on Remicade.

A progress note indicated the patient has three bowel movements daily with bleeding and joint pain.

The provider recommended hyperbaric oxygen therapy three times per week for 30 sessions over several months to improve mucosal healing and avoid emergent surgery.

Yes, based on the chronicity of symptoms, severity of disease and failure of biologics and DMARDs (disease-modifying antirheumatic drugs), the request for non -pharmacoptherapy is medically necessary. The HBO (hyperbaric oxygen) therapy as requested is medically necessary.

The patient has failed a biologic (Humira) and Methotrexate. Remicade is the same class medication as Humira. There is growing evidence in the literature that hyperbaric oxygen is beneficial for moderate to severe Crohn's that is refractory to biologics and first-line medications. Since Crohn's can be significantly debilitating and result in multiple surgeries, the request for adjunct HBO (hyperbaric oxygen) therapy is medically necessary.

The health plan's decision to deny hyperbaric oxygen therapy did not take into account the growing evidence in the literature that hyperbaric oxygen is beneficial for moderate to severe Crohn's that is refractory to biologics and first-line medications. The request for hyperbaric oxygen in this patient with refractory Crohn's is reasonable and consistent with the standard of care in the hyperbaric medicine community.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, CAD, Hypertension and GERD
Treatment: Increase Consumer Directed Personal Assistance A Total Of 70 Hours Per Week
The insurer denied the Increase Consumer Directed Personal Assistance A Total Of 70 Hours Per Week.
The denial is overturned. 

The patient is a female with a history of Alzheimer's dementia, Coronary Artery Disease (CAD), Hypertension and GERD (gastroesophageal reflux disease). 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 was requested for potential approval of 70 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 70 hours/week Personal Assistance Services is deemed medically necessary.

Recent documentation was received from the patient's medical provider indicates that the patient's functionality and ability to perform ADLs (activities of daily living) has significantly decreased to the point where she is now entirely dependent on others 24 hours per day, seven days per week for assistance with completion of her ADLs (activities of daily living) including feeding, mobility, ambulation and safety monitoring. Hence, the currently approved plan of 49 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 70 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional-Diabetes
Treatment: Inpatient hospital stay
The health plan denied the inpatient admission as not medically necessary. 
The reviewer has upheld the health plan determination in whole.

This is a female patient with type 2 diabetes complicated by neuropathy and hypertension who presented with symptomatic hyperglycemia. Her blood pressure was 169/91 and heart rate 91. She was alert and oriented. Glucose was 958 milligrams per decilitre(mg /dL), bicarbonate18, potential hydrogen (pH) 7.3, and glycated hemoglobin (A1C) 13.4%. She was treated with an insulin drip and intravenous fluids in the Intensive Care Unit (ICU). The patient was seen by endocrinology who noted that the patient's mild acidosis had resolved, and the patient was hungry. They recommended high subcutaneous insulin doses and transition off of the insulin drip. Glucose improved to 179 mg/dL.

Patients with diabetic ketoacidosis can be safely managed in lower level of care units unless they present with severe alteration of mental status or with critical illness such as sepsis [1], which is not documented in this case. This patient presented with hyperglycemia with known type 2 diabetes. She presented with mild diabetic ketoacidosis with an initial pH of 7.3. Her hyperglycemia quickly improved with intravenous hydration. She was hemodynamically stable. This patient did not have alteration in her mental status and the documentation does not support a diagnosis of hyperglycemic hyperosmolar syndrome. Therefore, no, the proposed inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Subacute progression of chronic bilateral lower extremity numbness and weakness.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This patient is a female child who was brought to the emergency department by her mother for subacute progression of chronic bilateral lower extremity numbness and weakness.  The patient has a history of sickle cell trait and lower extremity numbness.  The physician indicated the patient has been having increasing weakness with difficulty walking and multiple falls.  She was alert and oriented on physical examination.  Strength and sensation were intact in the upper extremities.  She was able to sense pressure however no sensation or pain in the lower extremities.  They were unable to perform coordination examination and to assess the gait.  The physician detailed the patient should undergo laboratory diagnostic studies.  The laboratory studies revealed a white blood cell count of 11.1 with 15.3% Red cell distribution width.  The patient also had an elevated alkaline phosphatase of 228.  The recommendation was made to admit the patient for further consultation.  The patient continued with additional treatment that included Magnetic Resonance Imaging (MRI) of the lumbar spine.  The documentation does not detail any significant findings.  She continued with treatment and given improvement without further significant adverse events she was subsequently discharged.

According to the guidelines provided by the InterQual 2019, this acuity of this case is considered to have required observation. Upon arrival, the patient had an extensive workup to exclude structural causes. No worsening was appreciated. The patient did not require an escalated level of care.

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. Within the documentation it was noted the patient presented with gait changes and possible new sensory changes. 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 does not detail any treatment interventions. 

The requested inpatient admission would not be the most appropriate level of care and therefore, the insurer acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission
The denial is overturned. 

This male patient has a history of asthma, anxiety, panic attacks and depression. The patient presented to the Emergency Department (ED) for emergency evaluation of intermittent weakness, lightheadedness, falls, confusion, possible seizure activity with incontinence. The patient was admitted initially to the Psychiatry unit, and was then to the Medicine unit. The patient was evaluated by neurology. The patient was hemodynamically stable, and requested to be discharged. The patient was advised against this. The patient was alert and oriented, and was discharged against medical advice (AMA).

Based on the review of the medical record and literature, inpatient hospital admission was medically necessary for this patient. This patient presented with encephalopathy and possible seizure. Given seizure concern, electroencephalogram (EEG) is a reasonable test. The specific finding of dysmetria (i.e., inability to perform finger-to-nose task) on exam suggests the possibility of a cerebellar lesion, which is often not visible on computed tomography (CT) scan, and a follow-up magnetic resonance imaging (MRI) is thus, warranted. The patient's clinical picture appeared to have been waxing and waning in severity, and thus regular neuro checks and precautions were also warranted. Thus, inpatient hospital admission was medically necessary for this patent's workup and close monitoring and treatment.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female. She presented to the emergency ward with a three day history of headache.

At presentation, the patient's neurological examination was normal. She had elevated blood pressure and heart rate. She was admitted and treated with parenteral medications for headache.

No, the acute inpatient admission was not medically necessary.

The patient had a normal neurological examination and neuro-imaging at presentation. There was nothing in her clinical history or history of present illness to suggest thunderclap type headache or acute intracranial pathology requiring acute inpatient admission.  There was no documentation provided to support that she had tried and exhausted available outpatient treatment for persistent migraine to warrant acute inpatient admission. The parenteral medications provided for migraine abortive therapy and the management of hypertension could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cramps And Vaginal Bleeding (during pregnancy).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a G2P1 (two pregnancies, one birth) female. She was referred to the hospital at 28 weeks 0 days gestation for some vaginal spotting.  She was observed in OB (obstetrics) triage and discharged the same day.

The patient's FHR (fetal heart rate) tracing was category 1.  Ultrasound was performed revealing 3.1 cm (centimeters) cervical length.  There is no evidence in the medical records of cervical change, advanced cervical dilation on physical exam, or administration of tocolytics or antenatal steroids.

The health plan contends that the admission was not medically necessary due to absence of unstable vital signs, abruption, persistent bleeding, or need to deliver the baby and cites MCG (Milliman Care Guidelines) criteria.  The provider contends that the admission was medically necessary due to risk of preterm labor and cites ACOG (American College of Obstetricians and Gynecologists) practice bulletin on early pregnancy loss.

No, the Inpatient admission was not medically necessary.

The definition of preterm labor is fundamentally established by the finding of cervical change or advanced cervical dilation on physical exam or secondarily by presence of fetal fibronectin in vaginal secretions and/or short cervix in a symptomatic patient.  None of these findings were documented.  Therefore, the admission is not medically necessary to treat preterm labor.

No indication was present that constituted medical necessity for admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer-prostate cancer.
Treatment: Radiation Therapy. 
The insurer denied 45 fractions of IMRT. 
The denial is overturned.

The patient is a male with history of clinically localized favorable intermediate risk adenocarcinoma of his prostate gland. He opted to proceed with a course of definitive external beam radiotherapy with curative intent. Request is for approval of 45 Fractions of intensity modulated radiation therapy (IMRT) Radiation Therapy.
The subject under review is the medical necessity for 45 fractions of IMRT.

The health plan's determination is overturned. 

The requested 45 fractions of IMRT is medically necessary for this patient. Conventional fractionated IMRT (i.e., 45 fractions as requested) is widely utilized and standard of care in the radiation oncology community for similar patients with this patient's clinical presentation. Conventional fractionation is equivalent in terms of short term safety/efficacy for management of the patient's prostate cancer, but there remains a lack of high quality mature data (less than [<] 15 years follow-up) to confirm that hypofractionation (28 fractions or less) will be found to be at least as safe/effective in the long term. Given the patient's relatively young age and otherwise excellent life expectancy, it is medically reasonable and appropriate to deliver conventionally fractionated IMRT as this is the most conservative treatment recommendation.
Conventionally fractionated IMRT in this patient's clinical case is supported by the National Comprehensive Cancer Network (NCCN) Guideline as well as numerous high quality prospective clinical outcomes published in the peer reviewed medical literature. Conventional fractionation is also supported by the American Society for Radiation Oncology (ASTRO) practice guideline for management of prostate cancer. It is frequently utilized outside the context of a prospective clinical trial for patients similar to the patient in this case.