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

Diagnosis:  Respiratory syncytial virus (RSV).
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.
 
This is an infant, who was having a cough and nasal congestion for four days.  He had fever and a decrease in oral intake and urine output. He also had post tussive vomiting. He was taken by his mother to urgent care the day prior to the admission and was diagnosed with RSV and influenza virus. He had a chest x-ray, which documented a left lower lobe pneumonia, and he was sent home. On the day of admission, the mother noted that his oxygen saturation was in the 80s, so she brought the child to the pediatrician, who documented hypoxemia with a pulse oximeter reading of 91 -92% and he recommended that the child be taken to the emergency room (ER).

Upon arrival in the ER, he was noted to have coarse breath sounds and increased work of breathing.  On physical examination he was described as tired appearing with dry lips and mouth. He was noted to have a right otitis media, coarse breath sounds and decreased breath sounds over the left lower lobe. He was treated with an intravenous (IV) bolus of normal saline, nebulized albuterol and IV ceftriaxone. A chest x-ray showed evidence of left middle and lower lobe pneumonia. His blood testing was significant for an elevated Blood urea nitrogen (BUN) of 34, low hemoglobin of 8.6 and low bicarbonate of 18. Because of the clinical and lab evidence of dehydration and x-ray documenting pneumonia the decision was made to admit the child to the hospital with a diagnosis of dehydration and left lower lobe pneumonia for IV antibiotics and IV hydration. 

The medical record documents that the patient had pneumonia, a low oxygen saturation and laboratory evidence of dehydration. There was a history of post tussive vomiting and a decrease in both oral fluid intake and urine output. The BUN was elevated, and the serum bicarbonate was low. The documentation of the medical care administered in the ER does support the need for hospitalization to treat pneumonia with IV antibiotics and IV fluids for dehydration. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Wilson Disease

Treatment: Trientine, CAP 250 mg (milligrams), (120 per 30 days)

The insurer denied coverage for trientine, CAP 250 mg, (120 per 30 days)
The denial is overturned.
 

The patient was diagnosed with Wilson disease. He has a low ceruloplasmin level, abnormal liver histology, and elevated liver enzymes. His copper level is elevated. His physician is requesting to start treatment with trientine for the Wilson disease. 

The American Association for the Study of Liver Diseases has published a guideline in Hepatology September 23, 2022 titled "A multidisciplinary approach to the diagnosis and management of Wilson disease: 2022 practice guidance on Wilson disease from the American Association for the Study of Liver Disease." Treatment options are discussed. D-Penicillamine has been used to treat this disorder although 30% (percent) of patients need to discontinue it due to side effects. Treintine is an alternative and effective treatment for Wilson disease with fewer adverse effects. 

Up To Date has an article titled "Wilson disease: Treatment and Prognosis." Both D-Penicillamine and trientine are listed as recommended treatments. Side effects of Penicillamine include nephrotic syndrome, glomerulonephritis, bone marrow toxicity, polymyositis, aplastic anemia, and a lupus-like syndrome. The article states that trientine has fewer side effects. The summary recommendation in this article is that the evolving consensus has been to use trientine because of its relatively safe side-effect profile.

This patient has Wilson disease and now requires being started on treatment. The medical literature supports the use of both penicillamine and trientine.  However, the literature is clear that trientine is a safer drug and has many fewer associated serious adverse effects as compared to penicillamine. As the UpToDate article states, the evolving consensus is that trientine should be used due to its safety profile. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for trientine CAP 250 mg, (120 per 30 days) is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 1 Diabetes
Treatment: Humalog Kwikpen
The insurer denied the Humalog Kwikpen.
The denial is upheld.

This is an adult female diagnosed with type 1 diabetes mellitus. 

This request is for Humalog. The provider states she needs Humalog Vial and Kwikpen; she is insulin dependent and has been on Humalog for some time. She is currently pregnant so she cannot use Fiasp. She is on OmniPod 5 pump. She has tried Novolog, but her glucose control on Humalog is better than with Novolog.

The health plan should not cover the proposed treatment. 

There are no studies demonstrating superiority of one rapid acting insulin analog over another [1-7]. There is no evidence of a contraindication or adverse reaction to the formulary alternatives Fiasp and Novolog. There is no documentation supporting failure of Novolog. The patient now has a hybrid closed-loop system with the OmniPod 5. Novolog is not expected to be less effective or have adverse effects for the patient. There are insufficient studies on using Fiasp in pregnancy to determine safety. The patient can retry Novolog. Based on this, Humalog is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: atopic dermatitis.
Treatment: Dupixent.
The insurer denied Dupixent.
The denial is: Upheld.

The patient is a female with moderate to severe atopic dermatitis and concomitant alopecia areata who has previously failed topical therapies including hydrocortisone and triamcinolone, as well as oral prednisone. The prescriber is requesting for coverage of Dupixent 300 milligrams (mg) for the treatment of moderate to severe atopic dermatitis. The prescriber intends for the patient to use Dupixent 300mg weekly, which the prescriber documents as an off-label dose. The subject under review is the medical necessity for Dupixent.

The requested treatment of Dupixent is not medically necessary for this patient. Dupixent may be considered medically necessary for the treatment of atopic dermatitis in a patient who has failed two different classes of topical therapies among medium or higher topical corticosteroids, a topical calcineurin inhibitor, and Eucrisa. Review of the medical documentation shows that the patient has only failed therapy with a medium topical corticosteroid in triamcinolone. There is no documentation that this patient has tried therapy with higher potency topical corticosteroids, or non-steroidal topical therapy with either topical calcineurin inhibitors or Eucrisa, nor documentation of an intolerance or clinical contraindication to these other topical therapies. Higher potency topical corticosteroids, topical calcineurin inhibitors, and Eucrisa are first-line topical therapies for atopic dermatitis and may have improved efficacy compared to low- and medium-potency topical corticosteroids such as hydrocortisone and triamcinolone. Therefore, this patient has not yet failed all standard topical therapy for the treatment of atopic dermatitis. Furthermore, the prescriber intends to use Dupixent at an off-label dose of 300mg weekly. This dose exceeds the Food and Drug Administration (FDA)-recommended maximum dose for Dupixent in the treatment of atopic dermatitis. Review of the medical literature does not show published clinical studies evaluating the safety and efficacy of Dupixent 300mg weekly in the treatment of atopic dermatitis. For these reasons, the request for Dupixent for this patient's atopic dermatitis is not considered medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: psoriasis.
Treatment: Tremfya
The insurer denied Tremfya. 
The health plan's determination is upheld. 

The patient is a male with moderate to severe psoriasis (6% body surface area involvement) located on the elbows, knees, and shins. The patient has tried and failed topical clobetasol and calcipotriene. 

Tremfya is not medically necessary for this patient.
The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, Acitretin, and/or Phototherapy. Particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, these preferred agents are as appropriate for the treatment of this patient's clinical scenario.
Modern dermatology literature supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Tremfya, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and the literature recommends use of these preferred agents as appropriate for this patient's clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease, anxiety, depression, weight loss, hypertension, GERD (gastroesophageal reflux disease), insomnia and neuroglia
Treatment: Initiation of Personal Care Aide Services (PCA)
The insurer denied: Initiation of Personal Care Aide Services (PCA)
The denial is upheld

This adult female is requesting initiation of personal care aide services (PCA). The request was denied due to lack of medical necessity noting that the member is independent with activities of daily living and has durable medical equipment and voluntary supports when needed. She has medical conditions including anxiety, COPD (chronic obstructive pulmonary disease), depression, weight loss, hypertension, GERD (gastroesophageal reflux disease), insomnia and neuroglia. Uniform Assessment System evaluation completed 2 months ago shows independent cognition and independent with all ADLs (activities of daily living) and IADLs (instrumental activities of daily living). She is continent of bowel and bladder. 

The proposed treatment is not medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This member has multiple chronic conditions. She is appealing denial of initiation of personal care aide services (PCA). The request was denied due to lack of medical necessity noting that the member is independent with activities of daily living and has durable medical equipment and voluntary supports when needed. Uniform Assessment System evaluation completed 2 months ago shows independent cognition and independent with all ADLs (activities of daily living) and IADLs (instrumental activities of daily living). PCA (personal care aide) is not indicated for supervision or when no tasks are being performed. This member does not have medical needs for PCA (personal care aide) services. The proposed PCA (personal care aide) services is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anxiety, tremor and Lewy body dementia.

Treatment: Personal Care Services, 12 hours a day, 7 days a week.

The insurer denied coverage for Personal Care Services, 12 hours a day, 7 days a week.

The denial is overturned.

This is a geriatric patient with a diagnosis including anxiety, tremor and Lewy body dementia. The patient lives alone in a 1-bedroom apartment in a senior living community. The patient has Personal Care Services 8 hours per day, 7 days per week and the request is for 12 hours per day, 7 days per week, which is under review.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as Moderately impaired. The patient is totally dependent for much of the Independent Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient also requires maximal assistance for bathing, lower body dressing, locomotion, ambulation (uses a walker) and toilet transfer/use. The patient is frequently bladder incontinent and occasionally incontinent of bowel. Extensive assistance is needed for upper body dressing and eating. Limited assistance is needed for personal hygiene and bed mobility. The patient's cognitive status continues to decline. This physician would agree the patient is incontinent and requires maximal assistance with toilet use which is further complicated by wandering and history of frequent falls which will be exacerbated by the need to use the toilet.  Based on the enclosed documents reviewed, attention to the patient's physical needs cannot be appropriately provided and maintained by the currently approved Personal Care Services 8 hours/day, 7 days/week, totaling 56 hours/week.  

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

From a physical medicine and rehabilitation perspective, an increase in Personal Care Services, 12 hours a day, 7 days a week is medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for increase Personal Care Services, 12 hours a day, 7 days a week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

 
The patient had a history of cardiac disease and had an orthotopic cardiac transplant. She presented with abdominal pain and myalgias. She was recently discharged after being treated for pneumonia and pyelonephritis. She reported having a fever at home but was afebrile at the hospital. There was no abdominal rebound or guarding. She did not have an acute chest infiltrate. The Infectious Disease consultant advised to stop the antibiotic. She had acute kidney injury (AKI) and her diuretic was held. Intravenous (IV) hydration was given. Her troponin was slightly Increased but that was her baseline. She received treatment for gout with colchicine, stool testing was ordered. She was treated with a proton pump inhibitor (PPI) twice a day. Her diarrhea and vomiting resolved. 

Clinical indications for admission for Undiagnosed Abdominal Pain per Milliman Care Guidelines (MCG M-05) include hemodynamic instability, peritoneal signs) bacteremia, bowel perforation or ischemia, and the inability to maintain oral hydration after observation care. The patient did not have these indications. 

This patient had a history of cardiac disease, pneumonia and pyelonephritis but these conditions were stable for outpatient care at this time. She was having abdominal pain and diarrhea and required a workup including stool testing and treatment with a PPI. This could have been done with observation care. IV hydration and antiemetics could have been given in the emergency room (ER) as an outpatient. She did not meet MCG criteria for admission for Undiagnosed Abdominal Pain.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is a young child with a history of asthma, one previous admission to the Pediatric Intensive Care Unit (PICU) for status asthmaticus and several emergency room (ER) visits for asthma. He is taking Pulmicort twice daily (BID) and montelukast daily to control his asthma. He was sick with an upper respiratory infection for 2 days and he developed difficulty breathing on the night before admission. He was treated with several treatments of albuterol at home with no improvement, so his mother brought him to the ER for additional treatment.

In the ER he was noted to be in respiratory distress with suprasternal and intercostal retractions and tachypnea. His pulse oximeter reading was 92% (percent). He was treated with 3 doses of DuoNeb, dexamethasone, magnesium sulfate and an intravenous (IV) bolus of normal saline. There was continued increase in his work of breathing and wheezing following treatment in the ER.

Following treatment in the ER, the decision was made to admit the child to the hospital with a diagnosis of status asthmaticus for continued treatment with albuterol every 2 hours.

The patient was treated appropriately in the ER for an acute episode of wheezing, and difficulty breathing. When the child failed to improve with treatment in the home and he continued to have persistent retractions in the ER following aggressive therapy for asthma, it was appropriate and consistent with the standard of care to admit the child to the hospital with a diagnosis of status asthmaticus for ongoing albuterol every two hours. He was not stable enough to be safely discharged. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crohn's disease.
Treatment:  Infliximab-Dyyb, Biosimilar, (Inflectra).

The insurer denied Infliximab-Dyyb, Biosimilar, (Inflectra).  The health plan's determination is overturned.

This patient is a male with a history of newly diagnosed Crohn's disease. His disease is complicated by perianal involvement and growth failure.

Infliximab-Dyyb, Biosimilar, (Inflectra) is medically necessary for this patient.
Anti-tumor necrosis factor alpha (TNF-a) (such as infliximab) are considered the standard treatment for pediatric Crohn's disease. The clinical practice guidelines recommend early biologic therapy for selected children with high risk for poor outcome such as patients with upper gastrointestinal (GI) involvement, growth delay, perianal disease or stricturing diseases (Ruemmele FM et al.).

Furthermore, there is growing scientific evidence supporting the early use of biologics in the treatment of pediatric Crohn's disease. Many peer-reviewed literature reports showed superior efficacy and less disease complications when biologics are used early in the disease course.

Finally, infliximab is Food and Drug Administration (FDA) approved for pediatric Crohn's disease. However, the proposed "conventional therapies", such as azathioprine and methotrexate, are not FDA approved for pediatric Crohn's disease and are associated with major side effects.

This child has severe and extensive disease, involving the perianal area. He has growth delay and is considered at high risk for poor outcomes. Therefore, the early use of infliximab in this case is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis (OA) and rheumatoid arthritis (RA)

Treatment: 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week of Personal Care Worker (PCW) services

The insurer denied coverage for 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week of Personal Care Worker (PCW) services

The denial is upheld

According to the medical records, the patient is an elderly female who lives at home. The patient has chronic knee and shoulder pain due to osteoarthritis (OA) and rheumatoid arthritis (RA). The patient had a left total knee arthroplasty (TKA) and currently has a caregiver at night; it is noted the patient is up most of the night with toileting, at least hourly and at times every 15 minutes. It is noted the patient has shoulder osteoarthritis, anxiety, hypertension (HTN) and generalized anxiety disorder. The request is for coverage for seven days per week, 24 hours per day, continuous care by more than one person; 168 hours per week of Personal Care Worker (PCW) services, which is under review.

There is no documentation provided which would support that the patient requires 24 hour care for the diagnosis of shoulder and knee osteoarthritis. The patient was seen by a physician who travels to her home. The patient is not bed bound and it is unclear why she cannot do short distance ambulation or feed herself.

Generally, adult diapers are used for urinary frequency and or an indwelling catheter, if absolutely necessary. Hourly voids and taking the patient to bathroom every 15 minutes is likely due to a psychogenic and non physiologic condition; water should not be provided at night. There is no documentations of conservative measures, such as adult diapers or medications prescribed for urinary frequency, nor any urodynamic studies provided for review. The provided medical records do not support complete bed debility. As such, the denial is upheld.

Urinary incontinence is a common problem that is often under-reported due to the embarrassing nature and social stigma attached. Urinary incontinence can have a considerable effect on an individual's quality of life, but can be significantly improved with correct assessment, treatment and management. Conservative treatment options, including pelvic floor exercises, bladder retraining and fluid modification, are recommended before referral to secondary services.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week of Personal Care Worker (PCW) services is not substantiated.