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

Diagnosis: Cat bite
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female who was admitted to an acute care setting with a cat bite to her left fifth digit.  The patient was seen on an outpatient basis and had received a one-time dose of oral anti-infective therapy.  

On admission, the patient was hemodynamically stable and afebrile.  She was admitted for intravenous antibiotics.  Labs were otherwise unremarkable with the exception of mild leukocytosis.  The patient was seen by orthopedic providers who deemed no need for surgical intervention.  She remained clinically stable and was subsequently discharged.  This case was previously denied as it did not meet the medical necessity criteria.

No, the proposed treatment was not medically necessary.
In this instance, the inpatient level of care was not medically necessary.  There was no evidence of hemodynamic instability, hypoxia, hypercapnia, failure of outpatient management demonstrated by at least 48 hours of anti-infective therapy.  There was no evidence of bacteremia, immunosuppression, infection over a prosthesis or an implanted device.  There was no need for surgical intervention.  There were no active comorbidities.  There was no food/medication intolerance, renal failure, electrolytes necessitating inpatient monitoring.  There was no evidence of bleeding.  The inpatient level of care was not medically necessary.

In this instance, the services could have been rendered in a less intensive setting such as observation secondary to the following: There was no evidence of hemodynamic instability, hypoxia, hypercapnia, failure of outpatient management demonstrated by at least 48 hours of anti-infective therapy.  There was no evidence of bacteremia, immunosuppression, infection over a prosthesis or an implanted device.  There was no need for surgical intervention.  There were no active comorbidities.  There was no food/medication intolerance, renal failure, electrolytes necessitating inpatient monitoring.  There was no evidence of bleeding.  The inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis. 
Treatment: Taltz. 

The insurer is denied coverage for Taltz. 
The denial is overturned. 

This female patient has a history of psoriasis. 

Based on the submitted clinical notes, Taltz is medically necessary for the treatment of the patient's psoriasis.  The patient has failed numerous topical therapies as well as wide range of systemic options including methotrexate. TNF inhibitors, and Otezla.  She has had a positive response in the past to Taltz.  It is within the standard of care to treat with Taltz based on the submitted documentation. 

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

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

Diagnosis: Respiratory System. 
Treatment: Home Health Care. 
The insurer denied Personal Care Aide 84 hours per week. 
The denial is upheld.

The patient is a female requesting Personal Care Aide hours and has a previous diagnosis of chronic obstructive pulmonary disease (COPD), asthma, hypertension, and anemia. The patient is requesting 84 hours per week for personal care aide hours. The patient's physician sent an appeal letter which also requested 84 hours per week for the above diagnoses. The subject under review is whether the requested 84 hours is medically necessary for the patient.

The requested service of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week for a total of 84 hours per week is not medically necessary for this patient. Community assessment (Uniform Assessment System [UAS]) performed showed that maximal assistance was needed with meal preparation, shopping, and transportation, total dependence needed for housework, extensive assistance needed for managing medication. Maximal assistance is also needed for all activities of daily living (ADL) performance. Per client task sheet, the patient was calculated to require 52.5 hours per week. The original calculated hours of 52.5 would be reasonable.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Pain management, injection (62323). 

The insurer is denied coverage for pain management, injection (62323). 

The denial is upheld. 

This male patient has a history of back pain. 

An Epidural steroid injection (ESI) is indicated for the management of back/radicular pain syndromes. The injection is recommended if a course of conservative treatment had been completed. There should be functional limitations.  The injection is provided to one site. 

The records show the patient has back pain for several years. There is no documented functional loss. He has not completed a course of conservative treatment of 6 weeks. His pain pattern is subjective. There is no evidence of objective radiculopathy. The practitioner has prescribed 2 injections. 

It is also important to note the patient has instability patterns on his flexion extension views. He has abnormal motion of a specific segment. This would more than likely be the source of his pain generator. An injection will have little effect on the listhesis. 

There are no indications for the ESI at this time. 

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

The carrier's denial of coverage for pain management, injection (62323) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dermatitis.
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Dupixent. 
The health plan's determination is overturned.

The patient is a female with atopic dermatitis and asthma, treated successfully with Dupixent. Prior to Dupixent the patient had 80% body surface area (BSA) and had tried and failed topical steroids, Eucrisa and Protopic. Her asthma is also well controlled on Dupixent. The provider requesting continuation. The subject under review is the medical necessity for the Dupixent. The health plan's determination is overturned.

While cyclosporine and methotrexate can be used in atopic dermatitis, they are not Food and Drug Administration (FDA) approved and are not the most appropriate agents for this patient. She has already responded favorably to this FDA approved medication. Discontinuing this medication will result in destabilization of both her asthma and her atopic dermatitis. Furthermore, according to the multidisciplinary review (Gresham et al., 2021), vaccine efficacy may be reduced in patients receiving systemic immune-targeting therapies because of the impaired immune response in these patients. There is a trend toward a decreased immune response and vaccine immunogenicity in patients on systemic immunotherapies, particularly patients receiving azathioprine, cyclosporine, methotrexate, mycophenolate mofetil, or Janus kinase (JAK) inhibitors. Therefore, it would not be advisable to use a systemic therapy in this patient that can decrease vaccine efficacy and place this patient at higher risk of Covid-19 complications when a safer alternative is available. Covid vaccines only just received approval in this age group and therefore she is likely not yet vaccinated. Therefore, Dupixent continuation is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Inpatient Hospital 
The insurer denied the inpatient stay. 
The denial is upheld in whole. 

This patient is a female with a history of asthma, who presented to the hospital emergency department (ED) with complaints of vomiting for 5 hours. Her vital signs were a temperature at 96.0 degrees Fahrenheit, pulse was 89, blood pressure (BP) was 142/90, respiration rate was 16 and pulse oximetry was 100% (percent) on room air. The physical examination revealed the patient to be drowsy and was otherwise unremarkable.

Her abnormal laboratory values included a hemoglobin at 8.5, hematocrit was 30.6, potassium was 3.3, glucose was 153, phosphorus was 1.6, and positive for tetrahydrocannabinol (THC). The urinalysis showed greater than (>) 80 ketones. The chest x-ray did not reveal any acute disease. A computed tomography (CT) scan of the head was unremarkable. A CT scan of the abdomen and pelvis showed a small hiatal hernia, enhancing lesion at pancreatic tail, and a small renal cyst. An electrocardiogram (EKG) showed normal sinus rhythm.

The patient was admitted and treated with intravenous fluids and electrolyte replacement. She was made nothing by mouth (NPO) and seen by Gastroenterology. Her diet was advanced, and she was deemed medically stable for discharge.

At issue is the medical necessity of the inpatient stay.

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

The requested health service/treatment of inpatient stay was not medically necessary for this patient.

This patient presented to the hospital with vomiting and mild electrolyte imbalance. The patient was hemodynamically stable. There was no evidence of acute renal failure. There was no evidence of severe electrolyte imbalance. There was no evidence of acute abdominal pathology. There was no evidence of acute findings on imaging studies. The patient did not require any surgical procedures. Symptoms were thought to be due to marijuana use. Based on current standards of care, the patient did not have any alarm symptoms that would have warranted an inpatient level of care. The patient did not have symptoms such as an altered mental status or gastrointestinal bleeding. The patient did not require frequent monitoring or telemetry. The inpatient stay was not medically necessary for this patient.

Therefore, the requested health service/treatment of inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Radiation Therapy. 
The insurer denied proton beam therapy. 
The denial is upheld.

The patient is a male with history of clinically localized high risk prostate cancer diagnosed on transurethral resection of the prostate (TURP). He has an indeterminate lesion in his left iliac bone. Request is for approval of definitive proton beam radiation therapy with curative intent. The subject under review is the medical necessity for the requested therapy.

The health plan's determination is upheld in whole.

The requested proton beam radiation therapy is not medically necessary for this patient. There are currently insufficient high quality clinical outcomes published in the peer reviewed medical literature to allow one to make definitive conclusions regarding the relative safety/efficacy of proton radiotherapy in the patient's case, as compared to standard of care photon-based radiotherapy in the form of intensity modulated radiation therapy (IMRT). Proton radiation therapy is the subject of ongoing clinical trials for management of prostate cancer (e.g., the COMPPARE study). The American Society for Radiation Oncology (ASTRO) Model Policy for proton radiation does not support its use in this case outside the context of a clinical trial. There are no extenuating circumstances in this case that would necessitate the use of proton beam therapy (e.g., prior receipt of pelvic radiation necessitating reduction in treatment overlap or presence of a comorbid/genetic condition which increases the patient's risk for normal tissue toxicity). The provider has not supplied a proton/photon plan comparison to show why the patient cannot be treated safely with IMRT (the provided plan comparison information is from a representative case control and not this actual patient).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer 
Treatment: Pharmacy/Prescription Drug. 
The insurer denied Tibsovo. 
The denial is upheld in whole.

The patient is a male with a low grade oligoastrocytoma. The patient has undergone resection but has progressed despite adjuvant radiation and temozolomide. The tumor is isocitrate dehydrogenase (IDH1) mutated. Ivosidenib (Tibsovo) has been recommended and is under review for medical necessity.

The health plan's determination is upheld in whole.

The treatment with Tibsovo is not medically necessary. Ivosidenib, a mutant-IDH1 inhibitor approved in the United States for advanced acute myeloid leukemia, was well tolerated with no dose-limiting toxicities in a phase I trial in 66 patients with advanced IDH1-mutant astrocytoma, oligodendroglioma, or glioblastoma (Mellinghoff IK, et al). Among 35 patients with progressive non-enhancing gliomas, a partial response or stable disease was observed in 3 and 86 percent of patients, respectively, with a median progression-free survival of 13.5 months. There were no objective responses in enhancing tumors, although a decrease in volumetric growth rate was observed in some patients.
Lacking more definitive data, neither the authors of UpToDate nor the National Comprehensive Cancer Network (NCCN) recommends the use of these agents in this clinical scenario; the former labels the use of ivosidenib an investigational approach. The agent remains the subject of ongoing investigation in this clinical scenario. For these reasons medical necessity cannot be established for this service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Skyrizi
The insurer denied Skyrizi. 
The health plan's determination is upheld. 

The patient is a male with a diagnosis of psoriasis vulgaris. Body surface area affected is greater than 20%. He has failed clobetasol ointment, hydrocortisone ointment, and triamcinolone ointment. The medication under review is Skyrizi.

Skyrizi is not medically necessary for this patient.

There is no documentation that the patient has tried and failed, has a contraindication to, or intolerance to the preferred therapies such as methotrexate, Cimzia, Humira, Stelara, or Tremfya.
According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines Humira and Stelara are effective treatments for the management of psoriasis. Within the peer-reviewed literature, according to Burness et al., "well-designed randomized clinical trials demonstrated that adalimumab 40 milligrams (mg) effectively reduced the signs and symptoms of psoriasis and improved dermatology-specific and general measures of health-related quality of life, with these benefits sustained during long-term treatment". Langley et al., write, "Treatment with ustekinumab for up to 5 years was safe and effective". The preferred agents are appropriate agents for the treatment of the patient's psoriasis. The formulary medications should be tried and failed prior to initiating Skyrizi.
It is noted that the patient has failed numerous therapies. However, there is no documentation provided that would justify the patient requiring treatment with Skyrizi prior to the formulary alternatives such as Humira or Stelara. There is no proof or documentation provided the patient has tried these preferred drugs and had an adverse effect or proof that these formulary tried drugs did not work for the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain.

Treatment: 22899, unlisted procedure, spine (Intracept); C9752, destruction of intraosseous basivertebral nerve [BVN], first two vertebral bodies, including imaging guidance (e.g.) fluoroscopy, lumbar/sacral.

The insurer denied coverage for 22899, unlisted procedure, spine (Intracept); C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g.) fluoroscopy, lumbar/sacral.

The denial is upheld.

The patient has a history of low back pain. Basivertebral ablation treatment is under consderation. The magnetic resonance imaging (MRI) of lumbar spine shows L [lumbar[5-S1 listhesis.  The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

There are no long term data suggesting benefit with this procedure especially in patients with lumbar listhesis. More studies are needed showing clinical benefit. Becker et al noted "Ablation of the BVN for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period."

Urits, I., et al. note, "Further reproducible large clinical studies are needed to study BVN(basivertebral nerve) ablation before clinicians can confidently apply this treatment in their practice."      

The 22899, unlisted procedure, spine (Intracept); C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g.) fluoroscopy, lumbar/sacral does have final approval from the appropriate regulatory bodies for this diagnosis.     

This patient is not a good candidate for 22899, unlisted procedure, spine (Intracept); C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g.) fluoroscopy, lumbar/sacral. The requested service is not the best available treatment for this patient at this time. Standard treatments include physical therapy, pain management, and acupuncture.     
  
Given this treatment has not been shown to be safe and effective particularly in patients with listhesis the adverse risks are increased over standard treatment/services.     

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.                                                    

The carrier's denial of 22899, unlisted procedure, spine (Intracept); C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g.) fluoroscopy, lumbar/sacral should be upheld. It is not more beneficial than any other standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain.
Treatment: 22899, unlisted procedure, spine (Intracept); C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g.) fluoroscopy, lumbar/sacral.
The insurer denied coverage for 22899, unlisted procedure, spine (Intracept); C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g.) fluoroscopy, lumbar/sacral.
The denial is upheld.

This patient was seen for a follow-up complaining of low back pain for approximately 11-1/2 months.  She also complained of intermittent left leg radiation that has worsened.  She was seen via telehealth and indicated she has undergone a lumbar medial branch block with an unclear response.  She continued to have significant axial low back pain.  Physical examination revealed 5/5 strength.  The physician referenced prior imaging and indicated she has tried multiple conservative care modalities to include chiropractic care, medications most recently injections.  It was recommended she proceed with the requested intercept procedure.  It was also recommended she undergo acupuncture.  An MRI [magnetic resonance imaging] indicates there is multilevel lumbar degenerative disc and facet disease with grade 1 degenerative spondylolisthesis at the L [lumbar]4-5 and L5-S1 level with mild central stenosis at L4-5.  There was grade 1 degenerative spondylolisthesis and a disc herniation at L5-S1 without stenosis or nerve root compression.

Thermocoagulation of the basivertebral nerve (CPT [current procedural terminology] code 22899) is supported by the available literature including randomized clinical trials. It is an FDA [food and drug administration] approved procedure. However, the patient does not meet medical necessity. This procedure has shown to be effective for patients with axial low back pain and Modic changes on magnetic resonance imaging (MRI). It has not been shown to be effective in patients with radiating low back pain and grade 1 degenerative spondylolisthesis as is the case in the patient. It is not the best available treatment for this patient at this time.

The adverse risks of the procedure are not increased over standard treatment/services. The requested service has not been shown to be more beneficial than other treatments in patients with spondylolisthesis. The patient should continue with physical therapy.

The carrier's denial of 22899, unlisted procedure, spine (Intracept); C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g.) fluoroscopy, lumbar/sacral should be upheld. It is not more beneficial than any other standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male. He was admitted following an accident with atrial fibrillation and active use of Eliquis. He was weak, had palpitations and felt the care and communication of the initial hospital was inadequate. His work up included history of atrial fibrillation, normal echocardiogram.

Once admitted, the patient denied chest pain, palpitations or dizziness. He arranged transfer per patient's preference. His enzymes were negative. His vital signs were stable. His exam was normal except for known atrial fibrillation.

No, the Inpatient admission was not medically necessary.
Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care.

There was no clinical need for any inpatient level of care. The patient was hemodynamically stable. His atrial fibrillation had a controlled ventricular response, with no evidence of ischemia or infarction. The patient's care, including all testing and treatment, would have been appropriate and safely performed in a lower level of care.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diarrhea
Treatment: Octreotide Acetate
The insurer denied the Octreotide Acetate
The denial is upheld

The patient is a female with Crohn's disease and refractory entero-cutaneous fistula, with diarrhea. She has failed biologics, and is TPN (Total Parenteral Nutrition)-dependent. The provider is requesting treatment with Octreotide.

No, the Octreotide Acetate is not medically necessary.
While some studies suggest a possible benefit of the use of Octreotide in the management of enterocutaneous fistulas, literature continues to be inconclusive. Therefore, the requested Octreotide is not clinically appropriate, accepted standard of care or medically necessary in this patient.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
As it is not medically necessary, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying