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

Diagnosis: chest pain
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This woman presented to the emergency department (ED) complaining of chest pain and dyspnea that was precipitated by cocaine use. Her medical history was remarkable for nonischemic cardiomyopathy, heart failure with reduced ejection fraction, biventricular implantable cardioverter defibrillator implantation, chronic obstructive pulmonary disease (COPD), hypertension and hyperlipidemia.

Based on the documentation provided an inpatient level of care was not medically necessary.

This patient presented with chest pain after cocaine use. She was hemodynamically stable. Her electrocardiogram showed ventricular pacing; Sgarbossa criteria for acute infarction were not met. While her serum troponin level was minimally elevated, there was no significant delta troponin. She did not require intensive monitoring or continuous infusion of intravenous cardioactive medications. No acute intervention was deemed necessary. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be both safe and effective and is in accordance with current guidelines.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lichen planopilaris. 
Treatment: Xeljanz 10 milligram (mg) tablet. 
The insurer denied coverage for the Xeljanz 10 mg tablet. 
The denial is upheld. 

This patient has a diagnosis of Lichen planopilaris/frontal fibrosing alopecia (FFA). 

Per Abrahim Abduelmula et al "A total of 15 studies, with a total of 60 instances of Janus Kinase Inhibitors (JAK) inhibitor therapy across 56 patients (multiple JAK inhibitor use in 4 patients), were included in this review. In the patients with reported data, 73.3% (44/60) of instances with JAK inhibitor use achieved partial or complete resolution, and 26.7% (16/60) achieved no resolution of Lichen planopilaris (LP) following their course of JAK inhibitors therapy.

The number of participants in each study included varied, which makes it challenging to offer an accurate comparison between the different JAK inhibitors. Furthermore, there were no randomized controlled trials included in the study, which affects the level of evidence included. This also makes it more challenging to provide more generalizable data, as the differences in patient characteristics as well as confounding factors may have not been effectively accounted for. Another limitation in this study is the lack of uniformity in outcome measures utilized. As alluded to previously, the studies varied in their choice of outcome measure used to quantify the utility of JAK inhibitors. Such heterogeneity adds another challenge in comparing the objective effects of the therapeutic agents in treating LP. Notably, 50% (28/56) of the patients included were also receiving concurrent systemic therapies."

Further studies are warranted and necessary before any consensus can be made with regards to the use of Xeljanz particularly as monotherapy in treating this patient population.  Additionally, it is not known what the optimal dosing would be or what the duration of treatment would be.  

In summary, the denial of Xeljanz 10 milligram (mg) tablet for a date yet to be determined and filled at a network specialty pharmacy and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lichen planopilaris. 
Treatment: Xeljanz 10 milligram (mg) tablet. 
The insurer denied coverage for the Xeljanz 10 mg tablet. 
The denial is overturned. 

The patient has a diagnosis of Lichen planus with Lichen planopilaris/frontal fibrosing alopecia (FFA). The patient has failed therapy with topical, oral, and intralesional steroids, hydroxychloroquine, as well as Xolair. The patient is also on metformin and Minoxidil oral therapy. The request is for Xeljanz for the treatment of lichen planus with FFA. 

Based on the submitted documentation, the patient has eruptive lichen planus with lichenplanopilaris and FFA. There are no Food and Drug Administration (FDA) approved therapies for these conditions. The patient has failed therapy with multiple systemic agents commonly used to treat his skin conditions. Scientific evidence supports the improvement in health from the use of Xeljanz. No medications are currently FDA approved for the patient's conditions, including Xeljanz. The patient may be a good candidate for Xeljanz as numerous commonly used therapies have been exhausted without success. No contraindications to Xeljanz use are noted in the documentation.  The adverse side effects of Xeljanz are not expected to be increased compared to standard systemic therapies. The use of Xeljanz is expected to be more beneficial than any other standard therapy for this patient. The decision is overturned. 

In summary, the denial of Xeljanz 10 milligram (mg) tablet for a date yet to be determined and filled at a network specialty pharmacy and coverage for the requested treatment should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pain in the right ankle and joints of the right foot and pain in the left ankle and joints of the left foot.

Treatment: additional Physical Therapy visits.

The insurer denied coverage for additional Physical Therapy visits.

The denial is overturned.
 

The patient is seeking coverage for physical therapy treatments.

The patient presented for an evaluation related to pain in the right ankle and joints of the right foot and pain in the left ankle and joints of the left foot.  The patient was on visit #7. The patient had a history of a stroke.  The patient reported that they were still recovering and had balance impairment.  Due to balance impairment, the patient had pain in the ankles.  The patient had difficulty going up and down more than 2 flights of stairs, difficulty with sit-to-stand transfer, and difficulty with walking for more than 2 blocks.  The patient rated their pain 4-6 out of 10 which had improved from the initial assessment of 8-10 out of 10.  The patient's lower extremity functional scale score was 36 out of 80 and was previously 19 out of 80.  There was an objective improvement in the range of motion of the bilateral ankles.  There was an objective improvement of strength in the bilateral ankles.  However, there continued to be functional deficits in strength and range of motion.  There was a plan to continue physical therapy 3 times a week for 8 weeks.

Per the cited references, rehabilitation is recommended for patients with lower extremity soft tissue dysfunction.  Extension of treatment is recommended when functional progress has been made during initial therapy when goals of therapy are not yet met, when the patient is actively participating in treatment sessions, and when the patient is adherent to the plan of care.  In this case, the patient had 2 prior strokes and was participating in physical therapy.  The documentation indicated that the patient had new bilateral ankle symptoms related to ongoing dizziness and balance issues.  The patient had been recommended for physical therapy for the bilateral ankles.  The documentation detailed that the patient had made functional gains, was participating in physical therapy, and was adherent to the plan of care, but had ongoing deficits in which the goals of therapy had not yet been met.  Although the documentation indicated that the patient had extensive physical therapy for prior stroke symptoms, continuation of the treatment is reasonable for this patient.  The patient appears to have new bilateral ankle symptoms that have not been adequately addressed.  The patient had objective functional improvement with prior treatment but continued to have deficits.  The patient has not plateaued with treatment, and the patient will likely have further functional gains with the requested treatment at the current level of care.  

Based on the above, the insurer's denial must be reversed. 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 physical therapy treatment is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee Injury

Treatment: Knee surgery (procedure code 29876) performed in an outpatient  hospital setting

The insurer denied coverage for knee surgery (procedure code 29876) performed in an outpatient  hospital setting

The denial is overturned.

This is a child who reported injury to their left knee. The date of the original accident requiring the patient to be on crutches was several months ago. Further injury was reportedly sustained a few weeks later. The patient reported ongoing pain, swelling, catching, giving way and weight bearing. The patient had undergone two magnetic resonance imaging (MRI's)  which were inconclusive. The patient had received courses of physical therapy (PT) which did not help, and their physical examination was significant for mild patella glide and several areas of tenderness. The most recent MRI showed sprain pattern anterior cruciate ligament (ACL) and synovitis. Consideration of complex regional pain syndrome (CRPS) was noted and a cortisone injection provided. The patient's electromyogram (EMG) was normal. The patient returned to their physician and reported transient relief. The physician reported positive (+) Apley sign. Surgery was discussed and then completed.

Intra operative findings showed mild chondromalacia, synovitis and attenuated ACL. The patient's physician performed a thermal shrinkage procedure and synovectomy. The patient's post-surgical course was satisfactory. 

Surgical indications were met. The records showed need to define a pain generator. Conservative treatments had been provided with no improvement. There were ongoing subjective complaints and reports of mechanical symptoms. There were positive physical findings for occult meniscal pathology (Apley test). 

The physician also considered CRPS. The injection provided temporary relief which would support the intra articular portion of the knee as pain generator. It would now be important to directly view the interior with an arthroscopic examination. The physician performed a complete and extensive examination. He found thickened inflamed synovium in several locations. This is a pathologic finding and is treated with synovectomy. 

The patient also found an attenuated ACL. 

In conclusion, the finding of symptomatic pathologic synovium requires surgical management. 

Based on the above, the insurer's denial must be reversed. 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 knee surgery (procedure code 29876) performed in an outpatient hospital setting is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied: Intracept Procedure
The denial is upheld.

The patient is an adult female. The appeal letter notes that the patient has a history of chronic low back pain due to degenerative disc disease that resulted in development of 
vertebrogenic pain identified by degenerative endplate changes that are noted to be Modic on magnetic resonance imaging (MRI). The patient has pain and failed treatment for greater than six months. Prior treatments include massage, therapy, physical therapy, medication, back brace, home exercises, lumbar epidural steroid injection, and laminectomy.

The health plan should not cover the proposed treatment.

Based on the documentation provided, the requested Intracept procedure is not considered appropriate in this case. Although the patient has a history of chronic low back pain and she had 
tried prior treatment, and counter to what is noted in the appeal letter, there was no documentation of Modic type changes on the magnetic resonance imaging scan provided. As such, the requested procedure is not recommended in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied: Intracept Procedure
The denial is upheld.

The patient is an adult female with low back pain. Past treatments include massage, physical therapy, back brace, home exercise, lumbar laminectomy, epidural steroid injections, Flexeril, ibuprofen, oxycodone, and Tylenol. Her pain ranges from 8/10 to 10/10. Magnetic resonance imaging (MRI) of the lumbar spine shows postoperative change at L5-S1, lumbar spondylosis, degenerative disc disease, and minimal L5 retrolisthesis on S1. The request for Intracept was denied as investigational. The 
denial is being appealed.

The health plan should not cover the Intracept procedure.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.
At this time, there is not enough valid scientific evidence to show that the expected health benefits from the Intracept procedure are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer-reviewed literature and data regarding the long-term outcomes of the procedure. As such, the 
health plan should not cover the Intracept procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied: Intracept Procedure
The denial is upheld.

The patient is an adult female with chronic low back pain for whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as 
experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, massage therapy, and epidural steroid injections. The patient has failed multiple medications, including potent opiate medications. Magnetic resonance imaging (MRI) shows no mention of Modic changes. Physical exam does not reveal any neurological injury. She 
has failed previous lumbar spine surgery.

The health plan should not cover the Intracept procedure.

The requested Intracept procedure is not medically appropriate. The Intracept procedure is not likely to be more beneficial than standard treatments. The patient is an adult female with chronic low back pain for whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, massage therapy, and epidural steroid injections. The patient has failed multiple medications, including potent opiate medications. Magnetic resonance imaging (MRI) shows no mention of Modic changes. Physical exam does not reveal any neurological injury. She has failed previous lumbar spine surgery. The procedure is a United States Food and Drug Administration (FDA)-approved procedure for axial low back pain. It has been shown effective in randomized controlled trials (RCT) with five-year results. The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. 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. However, this patient has not failed or attempted sacroiliac joint injections, or facet interventions, which are common treatments 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 of the denial. Given that the alternative sacroiliac injection does show favorable outcomes in the literature and have lower risk and morbidity, coupled with the fact the magnetic resonance imaging (MRI) shows no Modic changes, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intractable Left Flank Pain.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

 
This patient presented to the emergency department (ED) complaining of chills, nausea, vomiting, severe left flank pain, and hematuria. The patient was status-post left stent insertion. The patient's past medical history revealed stones, asthma, and gastroesophageal reflux disease (GERD). In the ED, the patient's vital signs were as follows: temperature 99.2 Fahrenheit, blood pressure (BP) 127/93. The patient's urinalysis (UA) was positive for bacteria casts. A computed tomography (CT) scan revealed a left stent in position, with punctate renal stones. The patient was given intravenous (IV) fluid bolus and various IV meds. The patient was admitted with intractable left flank pain, status-post left stent insertion. The patient was seen by urology, the stent was removed. The patient was stable for discharge home with outpatient urology follow-up.  The insurer has denied coverage for the acute in-patient admission as not medically necessary. The appeal on behalf of the hospital is noted and read in detail. For Milliman Care Guidelines (MCG) Health (26th) Renal Colic and Kidney Stones, the patient fails to meet clinical indications for admission to in-patient care. These include hemodynamic instability, acute renal failure, bilateral obstruction, urinary tract infection (UTI) identified, etc. Per MCG Health (26th Urologic Surgery or Procedure GRG), the patient meets the GRG discharge parameters within 24 hours post-procedure. 


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: Upheld

Diagnosis: Fevers and Fatigue. 
Treatment: Inpatient admission. 
The insurer denied: Inpatient admission. 
The denial is upheld. 

The patient is an adult male. He has a past medical history of atrial fibrillation, hypertension, cerebral vascular accident (CVA), chronic lymphedema, and endocarditis. The patient presented to the emergency department with a two day history of subjective fever, chills, and fatigue. Prior to this presentation, the patient was admitted for leg cellulitis, and he had recently completed doxycycline as an outpatient. The patient's vitals in the emergency department were temperature 98, pulse 96, respiratory rate 20, blood pressure 157/88, and pulse oximetry 98%. Physical examination showed bilateral edema and tenderness to posterior aspect of leg proximal to the knee without erythema / fluctuation or induration. Labs showed white blood cell count 18.90; international normalized ratio (INR) 1.51; urinalysis was positive for leukocyte esterase, bacteria, and blood. The patient was started on intravenous fluid, Tylenol, and intravenous antibiotic vancomycin. The patient was admitted to the hospital and started on intravenous Zosyn and vancomycin. 
Computed tomography (CT) scan of both lower extremities and infectious disease consult were planned. The patient was continued on intravenous antibiotics and continued to improve. The patient was discharged on oral antibiotics on day #4. 

The inpatient admission was not medically necessary. 

The patient presented with subjective fever, chills, and fatigue. The patient was admitted due to concern for cellulitis, bandemia, and possible sepsis. However, he was afebrile on presentation and had stable vital signs. Labs showed leukocytosis and presence of bands; however, the patient's vital signs were stable, and he did not have any other findings on clinical evaluation / lab results to indicate presence of sepsis / severe sepsis or septic shock. In view of this, inpatient medical admission was not medically necessary for proper and adequate management of this patient. For the duration between this patient was afebrile and had stable vital signs. The patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. The patient was tolerating oral intake and was clinically stable. Physical exam for this duration did not show any new exam findings that would necessitate further workup in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for workup or change in management plan in an inpatient setting. During the above duration, there were no new investigations ordered / workup initiated, and there was no change in management plans that would justify / necessitate continued inpatient stay in the hospital.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Small for gestational age

Treatment: Inpatient hospital

The insurer denied coverage for Inpatient hospital.

The denial is overturned.

Small for gestational age (SGA) female born via repeat cesarean section. Antepartum history was significant for oligohydramnios, intrauterine growth restriction (IUGR), decreased fetal movement, and spontaneous decelerations. Apgar scores were 9 and 9 at one and five minutes respectively. Initial care was Neonatal intensive care unit (NICU) and included continuous cardiorespiratory monitoring, glucose monitoring, oral (po) feeding and provision of appropriate thermal environment, e.g., isolette, due to risk of hypothermia. Subsequently, phototherapy was undertaken for hyperbilirubinemia. The patient remained in an isolette until she was placed in an open crib. Thereafter, her temperature was maintained in a normal range. 

According to the hospital, the basis for "continued hospital stay was ongoing assessment of her thermoregulation was therefore reasonable and medically appropriate to ensure a successful outcome."  

For normal well-newborns, the American Academy of Pediatrics in its Guidelines for Perinatal Care recommends a minimum of 12 hours of stability of vital signs including temperature in an open crib with appropriate clothing.  For High-Risk Newborns, the Guidelines state "The infant is considered ready for discharge if, in the judgment of the responsible physician, the following have been accomplished: The infant has demonstrated adequate maintenance of normal body temperature when fully clothed in an open bed with normal ambient temperature."  According to Milliman Care Guidelines (MCG): Neonatal Facility, Level 1 and Neonatal Facility Level 2, there is a need to demonstrate absence of temperature support for at least 2 consecutive hours with no signs of cold stress. 

In view of the above, it was reasonable to have continued hospitalization with appropriate monitoring in the NICU.

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 continued hospital admission is substantiated.