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

Diagnosis: Stroke and Infection of Lungs (COVID-19). 
Treatment: Continued Long Term Acute Care (LTACH). 

The insurer denied the Continued Long Term Acute Care (LTACH). 
The denial is upheld. 

This female patient with a recent cerebral vascular accident (CVA) with residual aphasia was hospitalized after a fall and findings of C1 (first cervical spine vertebra) cervical fracture.  Her hospital course was complicated by acute hypoxic respiratory failure, COVID-19, percutaneous gastrostomy tube (PEG) dislodgment/infection, and a urinary tract infection.  She was transferred to long term acute care (LTAC). 

The patient's vital signs were stable.  The patient was awake, tracks, but did not respond to verbal commands.  She was COVID positive.  The patient had post-cerebral vascular accident (CVA) dysphagia.  She was nothing by mouth (NPO), and was tolerating tube feeding.  The patient was working with speech therapy, physical therapy, and occupational therapy.  Her hypernatremia had resolved.  Metoprolol and hydration were given for sinus tachycardia.  The patient's current level of functioning is maximal assistance - dependent with bed mobility.  There was no significant change through discharge.

No, the proposed treatment was not medically necessary. 

Long term acute care (LTAC) is indicated for patients needing treatment for a primary complex condition or illness as well as active management of active comorbidities.  In long term acute care, the patient requires services of on-site specialty services, skilled nursing services and daily intervention of a medical practitioner. 

This patient has a history of cerebral vascular accident (CVA) with residual deficits. The patient was recently hospitalized with a cervical fracture and had complications including respiratory failure.  She was transferred to an long term acute care level of care.  As of the dates in question, the patient was clinically stable.  Her percutaneous gastrostomy (PEG) tube feedings and medications had been established. Her medication regimen had been established.  She did not require skilled nursing care for management of active comorbidities.  She continued to require maximal assistance with bed mobility.  Her level of functioning had plateaued.  Continued Long Term Acute Care was not medically necessary because she did not require skilled nursing services and daily intervention of a medical practitioner. 

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

The proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia Areata
Treatment: Olumiant
The insurer denied Olumiant. The health plan's determination is upheld.

The patient is a female with alopecia areata (AA). The scalp and eyebrows are affected. She has tried and failed ruxolitinib 1.5% cream. She has also failed tofacitinib cream, intralesional steroid injections, fluocinolone solution, imecrolimus cream, and fluocinonide solution. 

Olumiant is not medically necessary for this member's alopecia areata. There are no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Olumiant for this patient's condition as an accepted standard of practice in the U.S. There is no documentation the patient has exhausted all topical options, and that it would therefore be medically necessary to start systemic treatment with Olumiant, which would carry a higher side effect profile.

Based on the documentation provided, the patient has not tried and failed all topical therapies available. Topical medications, which have been shown to be effective for the patient's condition, should be tried and failed prior to initiating Olumiant.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult male with asthma and HIV (human immunodeficiency virus). He presented to the ER (emergency room) with worsening SOB (shortness of breath) and wheezing.
The patient was treated with nebulization treatment, oxygen and steroids in the ER (emergency room) for asthma exacerbation. The patient was admitted to acute in hospital level of care for further management of asthma exacerbation.
This admission is denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

The inpatient admission was not medically necessary.
The patient had asthma exacerbation due to viral infection. The patient's condition improved with ER (emergency room) treatment. At the time of admission, the patient was on room air with oxygen levels above 92%. The patient was hemodynamically stable. The patient was not on any invasive drip. The likelihood of receiving treatment that could only be provided at an inpatient level of care was low. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unsteady Gait.
Treatment: Outdoor wheelchair ramp.
The insurer denied an Outdoor wheelchair ramp.
The determination is overturned.

The patient has a history of chronic obstructive pulmonary disease (COPD) status/post (s/p) pneumonia with acute respiratory failure, gastroesophageal reflux disease (GERD), and an abdominal aortic aneurysm (AAA) who had been residing at a skilled nursing facility since early 2022. For safe discharge, the Skilled Nursing Facility (SNF) requires an outside home ramp. At issue is the medical necessity of an outdoor wheelchair ramp.

There is medical necessity for an outdoor wheelchair ramp for safe entry and exit from the home. The patient is weak, elderly, and deconditioned and requires minimal assistance with bed mobility and transfers and contact guard ambulating with a rolling walker. He uses a wheelchair for longer mobility and outdoor mobility. Per the health plan's denial letter, the patient can transfer to appointments outside the home with 2 person assistance. The patient has bed mobility and transfers with minimal assistance (min assist), ambulation with min assist using a rolling walker (RW) and he cannot do stairs. According to a letter from is doctor, he is unable to climb 9 steps to enter his home without a handicapped ramp. Therefore, an outdoor ramp is medically necessary for safe entry and exit to the home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Remicade 10 mg/kg (milligrams/kilogram) every 6 weeks 
The insurer denied Remicade 10 mg/kg every 6 weeks . The health plan's determination is overturned. 

This patient is a male with a history of Crohn's disease. He has been controlled on infliximab. He tried and failed lower doses and had a low drug level.

Remicade 10 mg/kg every 6 weeks is medically necessary for this patient. The management of inflammatory bowel disease is very complicated, and the available treatments are limited. It is very common for patients with Crohn's disease to lose response to their biologic over time or to require higher than standard dosing.
There are many peer-reviewed literature reports showing that low infliximab levels were associated with poor clinical response. Dose escalation is often required in order to improve the drug levels and maintain remission. The experience with dose escalation of Remicade has been extensive in both adult and pediatric patients. The available scientific evidence strongly supports the safety and efficacy of this approach.
According to Einarson, Thomas R., et al: "A substantial proportion of patients receiving adalimumab (ADA) or infliximab (IFX) for Crohn's disease require dose escalation after a short period of time".
According to Papamichael, Konstantinos, et al :"In real-life clinical practice, optimization of infliximab therapy can prevent drug discontinuation in approximately 3/4 of patients with antibodies to infliximab (ATI), especially in those with low titers."
This patient failed to adequately respond to the lower doses of Remicade and had low drug levels. He had a good clinical response and an adequate drug level on the requested dose.
Therefore, continuation of Remicade at 10 mg per kg every 6 weeks is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, hypertension and heart disease. 
Treatment: Consumer Direct Personal Aide Service (CDPAS), 7 days times 12 hours times 2 shifts. 

The insurer denied coverage for Consumer Direct Personal Aide Service (CDPAS), 7 days times 12 hours times 2 shifts.  The denial is upheld. 

This is a patient with chronic medical problems including diabetes, hypertension and heart disease. She was hospitalized due to syncope and subsequent clinical work-up. She lives on the 1st floor of a private home, and her daughter lives upstairs. The patient is currently approved for 7 days times 9 hours for a total of 63 hours per week of CDPAS and is requesting an increase CDPAS, 7 days of 2-12-hour shifts, which is currently under review.

According to the Uniform Assessment System (UAS) report, the patient's functional status has not significantly declined compared another UAS report. Her cognitive function is described as "modified independent." The patient requires maximal assistance for lower body dressing. She requires extensive assistance for bathing, upper body dressing, and toilet transfer/use. She is frequently incontinent of bladder and continent of bowel. She uses a walker for ambulation. The patient's functional impairments support the medical necessity of CDPAS 9 hours/day, 7 days/week for a total of 63 hours/week. However, her condition and functional needs are not at a level or unpredictable as to require the requested CDPAS 7 days times 12 hours times 2 shifts. This physician would also agree the patient may require 24-hour monitoring. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the authorized CDPAS 9 hours/day, 7 days/week for a total of 63 hours/week. 

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, Consumer Direct Personal Aide Service (CDPAS), 7 days times 12 hours times 2 shifts are not medically necessary. 

The insurer's denial of coverage for Consumer Direct Personal Aide Service (CDPAS), 7 days times 12 hours times 2 shifts is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain. 
Treatment: Nerve Treatment (in the spine). 

The insurer denied: Nerve Treatment (in the spine). 
The denial is upheld. 

The patient is an adult female with chronic low back pain, in whom an Intracept procedure has been requested. The procedure was denied as not medically necessary. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, facet injections, home exercises. The patient has failed multiple medications, including potent opiate medications. MRI (magnetic resonance imaging) shows Modic changes.  The patient's physical exam does not reveal any neurological injury.  She has failed previous lumbar spine surgery. 

The requested health service is not medically necessary. 
The patient is an adult female with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied as not medically necessary. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, home exercises. The patient has failed OTC (over the counter) medications. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury, and only tenderness on palpation and facet loading. 

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. The procedure is an FDA (United States Food and Drug Administration)-approved procedure for axial low back pain. It has been shown to be effective in RCT (randomized controlled trials) with five-year results. 

However, the patient in this case has not failed or attempted facet interventions or sacroiliac joint injections, which are common causes of axial low back pain. The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives sacroiliac injections do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Severe Headaches (Migraines)
Treatment: Emgality Pen 120mg/mL (milligrams per milliliter) Pen Injector
The insurer denied: Emgality Pen 120mg/mL (milligrams per milliliter) Pen Injector
The denial is upheld

The patient is a teenage female with migraine headache disorder. The provider has requested Emgality for migraine prevention. The requested medication was denied coverage as patient's age.

The health plan should not cover the proposed treatment.

There are no high quality clinical trials to support the safety or efficacy of Emgality in persons at patient's age. The extent of the medical literature includes only one retrospective trial (Greene et al., 2021). This does not breach the threshold of evidence required to conclude that this medication is effective in this clinical context. The expert opinion piece submitted by the provider to support use is not a clinical trial or clinical guideline (Szperka et al., 2018).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Severe Headaches (Migraines)
Treatment: Emgality Pen 120mg/mL (milligrams per milliliter) Pen Injector
The insurer denied: Emgality Pen 120mg/mL (milligrams per milliliter) Pen Injector
The denial is overturned

The patient is a teenage female with migraines who has tried and failed or has had intolerance to buspirone, Effexor, amitriptyline, and nortriptyline. The patient is currently on Emgality and the provider has requested to continue this medication. The request was previously denied as it was considered experimental/investigative.

The health plan should cover Emgality.

According to the American Headache Society, anti-calcitonin gene-related peptide (CGRP) guidelines in adolescents, it is recommended that anti-calcitonin gene-related peptides be considered in those who have tried and failed at least two different conventional preventative migraine medications. This patient has tried and failed two different oral preventative medications from two different classes and is doing well on Emgality with minimal side effects. 

Furthermore, a clinical trial conducted by Greene and colleagues in 2021 found that monoclonal anti-calcitonin gene-related peptide medication had a safety profile similar to the adult population and benefited adolescents who had failed multiple headache medications. 

For these reasons, continuation of Emgality is medically appropriate and in the best interest of the patient.

Emgality is more beneficial than any standard treatment as the patient has tried and failed at least two different oral conventional medications from two different classes for migraines and therefore is unlikely to benefit from other conventional medications and is already benefiting from Emgality.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Severe Headaches (Migraines)
Treatment: Emgality Pen 120mg/mL (milligrams per milliliter) Pen Injector
The insurer denied: Emgality Pen 120mg/mL (milligrams per milliliter) Pen Injector
The denial is overturned.

The patient is a teenage female who is diagnosed with chronic migraine. Treatment with Emgality is the subject of this review. The patient has tried and failed multiple antidepressants for prevention of migraine including amitriptyline, nortriptyline, venlafaxine and buspirone. Emgality was denied because patient's age. The provider appealed the determination. The provider states that use of Trokendi XR is contraindicated due to depression and it is not covered by the plan.

The health plan should cover the proposed Emgality.

The health plan has previously denied Emgality because the patient is not 18 years of age or older. However, the records demonstrate that the patient has chronic migraine that has not responded to multiple antidepressants including amitriptyline, nortriptyline, venlafaxine, and buspirone. The patient has also tried and failed hormone therapy, and topiramate/Trokendi XR is relatively contraindication. Although there is lack of direct evidence showing that injectable calcitonin gene-related peptide (CGRP) inhibitors are effective in pediatric patients, expert recommendations from pediatric headache specialists indicate that injectable calcitonin gene-related peptide inhibitors are reasonable treatment options after failure of oral preventative therapies. This is especially true for post-pubertal patients and this patient is post-pubertal, as the drug has the same mechanism of action in teens as it does in adults. The efficacy is expected to be the same and not age dependent. As the provider notes, there are few if any Food and Drug Administration (FDA) approved medications for migraine prevention in children so all therapies are off-label.

The requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease. Emgality is Food and Drug Administration approved for prevention of chronic migraine. This patient has improved with therapy and the patient has previously tried and failed various oral therapies to prevent migraine.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post ORIF (open-reduction internal fixation)
Treatment: Continued stay at skilled nursing facility
The insurer denied the continued stay at skilled nursing facility.
The denial is overturned.

The patient is an adult male. He had a history of having experienced a fall, whereby he sustained a closed right ankle fracture. He is status post ORIF (open-reduction internal fixation), and he was non-weight-bearing (NWB) for 12 weeks. His surgical wounds were managed and are now well-healed.

The patient's relevant past medical history includes intellectual disabilities, GERD (gastroesophageal reflux disease), and esophagitis.

Prior to admission, the patient lived with his father in a house and with plan to return home. He was independent with ADLs (activities of daily living) prior to injury.

The patient was admitted to SNF (skilled nursing facility) about 3 weeks post operatively. As of 3 weeks post admission and 4 weeks post admission, he was able to ambulate 15 feet with minimum assistance, required supervision for transfers, bed mobility, requires moderate assistance for balance/standing, upper body bathing/dressing, requires maximum assistance for lower body bathing/dressing, clothing management, toilet/commode, personal hygiene, lower limb dressings.

The patient is still having issues with safety awareness and impaired balance and limited activity tolerance. He is NWB (non-weight bearing) right lower limb and is in a CAM (controlled ankle movement) walker boot.

The requested continued stay in skilled nursing facility is medically necessary.

The patient is NWB (non-weight bearing) right leg and has impaired safety and balance. He also has some intellectual disabilities. He was admitted to SNF (skilled nursing facility) 22 days post operatively. As of the third week and fourth week, he was able to ambulate 15 feet with minimum assistance, required supervision for transfers, bed mobility, requires moderate assistance for balance/standing, upper body bathing/dressing, requires maximum assistance for lower body bathing/dressing, clothing management, toilet/commode, personal hygiene, lower limb dressings.

The patient is still having issues with safety awareness and impaired balance and limited activity tolerance. He is NWB (non-weight bearing) right lower limb and is in a CAM walker boot.

Therefore, the stay in SNF (skilled nursing facility) is medically necessary for up to two weeks towards maximizing balance, walking and also safety.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis
Treatment: Personal Care Service Hours: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week
The insurer denied Personal Care Service Hours: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week. 
The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, gout, urinary incontinence, bowel incontinence, hypothyroidism, diabetes mellitus type 2, and osteoporosis who had been assigned PCA (personal care assistant) services.

Personal Care Service Hours: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week are medically necessary for this patient.
There is documentation from the patient's PCP (primary care provider) of the patient's worsening physical functioning. In addition, the PCP documented the need for turning and repositioning every 2 hours as well as overnight assistance needs with activities of daily living (ADL) such that a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. The patient has 24-hour care needs and therefore the insurer should not of utilized a task based tool in calculating PCA hours. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, 7 days/week, split-shift, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.