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


Diagnosis: acute myelogensous leukemia.
treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

This patient is a female with relapsed acute myelogensous leukemia. The patient underwent a biopsy demonstrating relapsed disease. She was previously diagnosed and underwent induction therapy with cytarabine+idarubicin+gemtuzumab ozogamicin. She also received consolidation HiDAC (high dose cytarabine) +gemtuzumab ozogamicin. The patient had developed neurologic symptoms and neck pain and was diagnosed with leptomeningeal disease.
She was admitted for inpatient care. 

The inpatient hospital admission was medically necessary.
Although this patient had a prolonged hospitalization, it was a complicated course due to recurrent infections in the setting of neutropenia necessitating intravenous (IV) anti-infectives and line changes. The patient had refractory cytopenias while being treated for relapsed/refractory acute myelogenous leukemia. The patient required regular blood products. She patient was receiving peripheral and intrathecal chemotherapy for active acute leukemia. The patient required IV fluids with close volume management. Significant nursing supportive care was provided. Not infrequently, any one of the issues this patient was being treated for could require inpatient care but in total, they present a significant threat to the patient's life. Evidentiary support for inpatient management of this patient during this admission is present throughout the peer-reviewed literature, by the authors of UpToDate, Infectious Diseases Society of America guidelines, and in the National Comprehensive Cancer Network (NCCN) Guidelines.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Psoriasis

Treatment: Sotyktu

The insurer denied coverage for Sotyktu

The denial is upheld. 

The patient is an adult with a diagnosis of psoriasis of the hands and feet affecting 20% (percent) of the total body surface area (TBSA).  The patient has failed multiple topical steroids and calipitriol topical.  The request is for Sotyktu oral therapy.

Based on the submitted documentation and the standard of care Sotyktu is not medically necessary.  The patient has no true contraindications to numerous appropriate available formulary treatment modalities which would make the use of Sotyktu medically necessary.  There are no definitive, comparative, controlled head-to-head studies showing that Sotyktu has a superior efficacy or safety profile to reasonable alternatives such as Humira, Enbrel, Cosentyx, Skyrizi, Tremfya, or phototherapy-all of which are formulary treatment options.  According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient.  

There is no documentation to suggest that Sotyktu would be more effective than available formulary alternatives or that the patient has an absolute contraindication to a preferred medication which would specifically necessitate Sotyktu.    

The formulary drugs are not expected to cause adverse effects.

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non- formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Sotyktu to treat psoriasis is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: RElA Deficiency (p65)
Treatment: Xeljanz
The insurer denied Xeljanz. The health plan's determination is overturned. 

The patient is a female with a rare, newly characterized hereditary systemic autoinflammatory disease in the "relopathy" family. Her specific relopathy has been recently proven by genetic testing to be RElA (p65) deficiency, a monogenic disorder causing abnormality of the NF-KB (nuclear factor kappa light chain) pathway. The clinical conditions caused by this deficiency are multisystem and heterogeneous.

Xeljanz was medically necessary for this patient. The medical records well describe the patient's significant and unusual disease and its clinical burdens, the past treatment failures, and the superb response to the denied medication. The letter of medical necessity elaborates on this. This literature describes the systemic autoinflammatory diseases, the relopathies, including the patient's RElA deficiency, and describes the successful treatment with anti-TNF (tumor necrosis factor) agents.
The available literature on these newly characterized entities suggests successful treatment with anti-TNF agents. The only anti-TNF agent the plan has available that is not part of an Indication Based Coverage (IBC) appears to be adalimumab. The medical records and letter of medical necessity clearly state the patient tried and failed the adalimumab.
The patient tried and failed the only anti-TNF agent that would be covered by the health plan. It is, therefore, medically necessary that the patient try a different covered anti-TNF agent. One such available anti-TNF alternative is tofacitnib. The medical records and letter of medical necessity clearly state that the patient has responded very favorably to this agent. Her joint pain and disfiguring skin condition have improved and she has been able to come off systemic steroids.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Other - removal of gastric band
Treatment: Inpatient admission
The health plan denied: Inpatient admission
The determination is: Upheld

This patient is a female who presented to the emergency room (ER)with a history of prior lap band with complaints of abdominal pain, nausea, and vomiting. A decision was made to remove the lap band, and the patient underwent diagnostic laparoscopy removal of the lap band with findings of a posterior gastric slip and no complications of the stomach noted. The patient was discharged home after the procedure.

At issue is the medical necessity of the inpatient admission.

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

The requested health service/treatment of inpatient admission was not medically necessary for this patient. The patient presented with abdominal pain and a history of a lap band with question of a possible slip. The patient was taken the following day for removal of the lap band, which was uncomplicated. The patient was discharged home from the recovery room. Diagnostic laparoscopy and band removal is considered an ambulatory or observation level of procedure when uncomplicated, according to current standard of care. Therefore, the patient could have been treated at an alternate level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: back pain
Treatment: Percutaneous Laminotomy/Laminectomy (Spine Surgery)
The insurer denied Percutaneous Laminotomy/Laminectomy (Spine Surgery). The health plan's determination is overturned. 

This is a female who has spinal stenosis with neurogenic claudication. She has low back pain with diffused bilateral low extremity pain. Her pain level is 7.5/10. She has increased pain with walking and standing. She has tried home exercise, chiropractic manipulation, pain medications, and epidural injections without adequate pain relief. Magnetic resonance imaging (MRI) showed moderate to severe stenosis at L (lumbar) 3/4 and L4/5 with ligament flavum hypertrophy and grade 1 L4-5 spondylolisthesis. 

Percutaneous Laminotomy/Laminectomy (Spine Surgery) is medically necessary for this patient.
This patient has severe pain from spinal stenosis. She had failed extensive conservative treatments. Her pain is severe. Further treatments are medically necessary to improve her pain and function. There are multiple well-designed clinical trials that showed long-term improvement in pain and function for patients with spinal stenosis from ligament flavum hypertrophy. The alternative surgical option is lumbar decompression and fusion, which is a major spine surgery, associated with significant risks and complications.
This patient has spinal stenosis with neurogenic claudication. Her magnetic resonance imaging (MRI) showed ligament flavum hypertrophy with resultant moderate to severe stenosis at L3/4 and L4/5. Current clinical trials supported the effectiveness of the requested procedure for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ovarian Cancer. 
Treatment: Inpatient hospital admission. 
The health plan denied the inpatient hospital admission. 
The determination is: Overturned. 

The patient is a female admitted to the hospital. She was noted to have a left ovarian mass with a history of left low malignant potential tumor of the right ovary. An operative report indicates the patient underwent a laparoscopic bilateral salpingo-oophorectomy, lysis of adhesions, removal of pelvic mass, and left ureterolysis. Operative findings were remarkable for dense intra-abdominal adhesive disease, a 10-centimeter (cm) left adnexal mass, and metastatic disease to the uterus with a metastatic implant on the right colon. The operative report goes on to state that the patient actually underwent an exploratory laparotomy with a midline vertical incision. A postoperative check again noted the patient to have undergone exploratory laparotomy with lysis of adhesions, left salpingo-oophorectomy, excision of left ovarian mass, and tumor debulking. 
The patient was seen on postoperative day #1, at which time a plan was made for a voiding trial and to discontinue the patient-controlled analgesia. She was again noted to have a midline vertical incision. The discharge summary indicates the patient was discharged home after having undergone an exploratory laparotomy with lysis of adhesions, and left salpingo-oophorectomy with excision of left ovarian mass debulking.
At issue is the medical necessity of the inpatient stay. 
The health plan's determination of medical necessity is overturned in whole.
The inpatient stay was medically necessary for this patient. 
Despite the error in the header of the operative report, the patient underwent an exploratory laparotomy (open surgery), with debulking of her ovarian cancer. This is universally appropriate for the inpatient level of care as postoperatively the patient will have some needs and complexity as to compel the inpatient level of care. 
It appears that the determination regarding the inpatient level of care was made based upon the reported procedure in the header of the patient's operative report. There was a transcription error, and the patient was then noted to have undergone a laparoscopic bilateral salpingo-oophorectomy. In reality, when reviewing the body of the operative note, as well as all of the subsequent progress notes and discharge summary, this patient underwent an exploratory laparotomy with an extensive lysis of adhesions, removal of pelvic mass, and left ureterolysis. 
This patient with exploratory laparotomy and tumor debulking was appropriate for inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bardet Biedl Syndrome

Treatment: Imcivree 10 milligrams / milliliter (mg/ml)

The insurer denied coverage for Imcivree 10 mg/ml

The denial is overturned

The patient has a rare genetic syndrome called Bardet Biedl. This disease results in obesity, blindness, and kidney problems. Her body mass index (BMI) is 52.8. In a clinical trial, she received setmelanotide and had improvement in her weight and quality of life. Her physician states that without this medication she will have a significant decline in her health.

The Food and Drug Administration (FDA) has approved a treatment for weight management in patients with Bardet Biedl Syndrome. It has an orphan drug designation and is approved for chronic weight management. Imcivree is the first drug approved specifically tor chronic weight management in patients with this rare genetic disorder. The safety and effectiveness of Imcivree was evaluated in a 66 week trial of patients with Bardet Biedl Syndrome and a BMI greater than 30. After treatment, the patients taking Imcivree lost on average 7.9% of their BMI. 

Up To Date has a review on ''Setmelanotide: Drug information". The drug is approved for patients with obesity for certain rare genetic disorders. Bardet Biedl Syndrome is listed as an indication for this medication. 

This patient has a rare genetic disorder which has resulted in massive obesity. The FDA has approved with an orphan-drug designation the use of setmelanotide specifically for Bardet Biedl Syndrome. The Up To Date review of this medication also supports the use of setmelanotide for patients with Bardet Biedl. The health care plan did not act with sound medical judgement or in the best interest of the patient. Imcivree is a medically necessary treatment for this patient. 

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 Imcivree 10 milligrams / milliliter (mg/ml) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Short stature

Treatment: Genotropin 0.8mg/0.25 Syringe [Inject 0.17-0.24 mg/kg body weight every week, x 1 year]

The insurer denied coverage for Genotropin 0.8mg/0.25 Syringe [Inject 0.17-0.24 mg/kg body weight every week, x 1 year]

The denial is upheld 

 
This is child diagnosed with growth hormone deficiency. This request is for Genotropin. His height velocity is reported to be 4.4 centimeters per year (cm/yr). His growth hormone (GH) stimulation test with arginine and glucagon peaked at 4.9 and 9.2 respectively. His insulin like growth factor (IGF1) was 247 (page 45).  The year prior his testes and pubic hair were at tanner 1. His magnetic resonance imaging (MRI) was normal. His weight was 28.10 kilograms (kg) Chart page 43.  His height was 135.2 cm (-1.12 standard deviations (SDS)) and later was 137.2 cm (-1.11 SDS) with height velocity over 5 months of 4.3 cm/yr. His mid parental height is 170.3 cm (-0.91 SDS). His predicted adult height is 169.44 cm (-1.03 SDS)

The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:

The patient did not meet height and height velocity criteria as pretreatment height and height velocity are normal. GH stimulation testing peaked at less than 10 nanograms per milliliter (ng/ml).

The pediatric endocrine Society recommends that growth hormone deficiency is not diagnosed based solely on failed growth hormone stimulation testing.

The patient does not have a pretreatment height less than or equal to -2.25 SD. The patient therefore does not meet idiopathic short stature criteria. 
The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.
The request does not meet the standard of care and is therefore not medically necessary. 

The health care plan acted reasonably and with sound medical judgement. 

Genotropin 0.8mg/0.25 Syringe [Inject 0.17-0.24 mg/kg body weight every week, x 1 year] is not considered medically necessary for this patient.

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 Genotropin 0.8mg/0.25 Syringe [Inject 0.17-0.24 mg/kg body weight every week, x 1 year] is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headaches and Problems with Vision
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male, who presented to the emergency ward with the complaint of headache and bilateral blurred vision and decreased vision. At presentation, computed tomography (CT) of the brain was normal and neurological examination was normal. National Institute of Health (NIH) stroke scale score was zero. The patient was admitted to the acute inpatient level of care for possible transient ischemic attack (TIA) or stroke.

The proposed treatment was not medically necessary.

The patient reported transient bilateral blurred vision (triage note at presentation) and bilateral decreased vision associated with headaches. These symptoms are not consistent with transient ischemic attack or stroke, as there was no loss of vision or diplopia and visual complaints were bilateral. Therefore, risk of stroke at the time of presentation or in next 90 days was low (Mendelson and Prabhakaran, 2021). The patient could have been safely and effectively managed at a lower level of care (Campbell et al., 2019).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld

 
This patient presented to the hospital complaining of chest pain radiating to the neck associated with shortness of breath. Pain began one day earlier following a computed tomography (CT) scan with contrast. Of note the patient had an allergy to contrast agents and was pretreated with steroids and Benadryl. She also complained of dysuria and vaginal discharge on arrival to the hospital. Past medical history was relevant for Lynch syndrome, colon cancer status post hemicolectomy, chemotherapy, and hypertension. Upon arrival to the hospital vital signs were stable (BP (blood pressure) 142/72 and Pulse 118). Physical examination revealed mild lower abdomen tenderness without rebound or distension. 12 lead electrocardiogram (ECG) revealed normal sinus rhythm without ischemic ST (interval on an ECG) or T (interval on an ECG) wave abnormalities. Serum blood testing revealed an elevated serum troponin, white blood cells (WBC) of 21 and white blood cells on urinalysis. The patient was admitted to the hospital for monitoring and treatment. Echocardiogram revealed a preserved left ventricular ejection fraction (LVEF) of 55% (percent) without wall motion or valvular abnormalities. An exercise ECG test was attempted but the patient developed chest pain with exercise and was unable to complete the test. The patient was treated for a urinary tract infection and discharged with plans for outpatient cardiac work up. 

This patient presented with chest pain and a past medical history of hypertension. Her pretest probability of coronary artery disease was low. Utilizing the HEART score (history, ECG, age, risk factors, troponin). She was considered low risk. Utilizing the Thrombolysis In Myocardial Infarction (TIMI) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al (and others). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.

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: Back pain and suicidal thoughts

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
This adult male was admitted to worsened back pain, at level 9/10. He could not walk, and his hemoglobin and hematocrit were low and he reportedly had depressive symptoms including depressed mood and expressed suicidal ideation with a plan to overdose or jump out a window. He had elevated liver function test's (LFT's) and ammonia levels. He reportedly had a long history of alcohol dependence and had liver cirrhosis, peptic ulcer disease, pancreatitis, hypertension, and diabetes mellitus in addition to severe back pain. The psychiatric consultant was called, and the patient was on 1:1 observation due to suicidal thoughts. 

The medical records provided enough specific evidence to support that the patient required this level of care.  The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors, reports that patients with suicidal plan or intent or suicide attempts are in need of hospital treatment. This patient was considered at risk for suicide as it was reported that he expressed 2 suicidal plans and had depressed mood, so he was considered an imminent risk of harm to self and in need of 24-hour hospital treatment. He was seen by the psychiatric consultant and was on 1:1 for suicide. The patient reportedly had a long history of alcohol dependence and had liver cirrhosis, peptic ulcer disease, pancreatitis, hypertension, and had diabetes mellitus in addition to the severe back pain and reportedly was in treatment with a psychologist weekly and was recently started on Effexor for depression. The psychiatric consultant recommended possibly switching from Effexor to Duloxetine as it also could target pain in addition to depression. The APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports also that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital.

This patient had severe back pain as well which worsened his depression and had a past history of alcohol dependence with medical consequences to alcohol use. Even though he was in a medical hospital, he required and received active psychiatric treatment and he was on 1:1 observation and was seen by the psychiatric consultant and behavioral health. 

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 admission is substantiated.