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

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

The patient is an adult woman who presented to the hospital ED (emergency department) with abdominal pain, nausea, and vomiting.  Comorbid health conditions included hyperlipidemia and obesity (BMI [body mass index] 38 kg/m2 [kilograms per meters squared]).

At the time of presentation, the patient was without fever, and vital signs showed a normal heart rate and blood pressure.  She was tender in the right upper abdomen.  The WBC (white blood cell) count was 10.9 K (thousand).  The complete metabolic panel identified normal serum transaminases, bilirubin, and alkaline phosphatase.  Ultrasound and CT (computed tomography) scan showed gallstones, no thickening of the gallbladder wall and a dilated common bile duct (CBD) at 10-mm (millimeters).  She was initially treated with IV (intravenous) fluid, pain medications and antiemetics.  MRCP (Magnetic Resonance Cholangiopancreatogram) was ordered, but was not tolerated and was refused by the patient.  She was treated with laparoscopic cholecystectomy with cholangiogram. The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy procedure.

The patient was treated with post-surgical monitoring, IV (intravenous) fluid, IV (intravenous) analgesia, and antiemetics.  The immediate post-surgical recovery was uncomplicated.  Following surgery, the patient had stable vital signs.  Pain was controlled.  The diet was advanced.  The patient remained clinically stable and was discharged from the inpatient setting.  Under review is the inpatient hospitalization.

No, the inpatient admission was not medically necessary.

This patient was admitted to the hospital with the diagnosis of cholelithiasis/cholecystitis.  Her pre-surgical assessment and the indication for surgery was established on day 1.  However, surgery was not performed until 4 days later and the perioperative period was uncomplicated.  She remained stable and was discharged from the hospital on the first post-surgical day. 

The indication for cholecystectomy was established as of day 1 in this case.  The medical record supports that the patient could have been reasonably and appropriately treated with an observation level of care.  An observational level of care would have provided for ED (emergency department) assessment, surgical assessment, imaging with ultrasound and CT (computed tomography) scan, perioperative care and monitoring, provision of IV (intravenous) fluid and medication, and overnight care.  As such, the inpatient admission level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: HTLV-positive lymphoma/leukemia
Treatment: Prevymis (letermovir) 480mg or tabs, pre-service
The insurer denied the Prevymis (letermovir) 480mg or tabs, pre-service.
The denial is upheld. 

The patient in this case is a woman with a history of HTLV (human T-cell lymphotropic virus)-positive lymphoma/leukemia.  She was diagnosed over two years ago, and within the last year she underwent allogeneic stem cell transplantation.  Earlier this year, she underwent colonoscopy and upper endoscopy and biopsies revealed changes consistent with mild to moderate graft versus host disease.  Stains revealed some CMV (cytomegalovirus)-positive cells, and there was suggestion she had superimposed CMV colitis.  She was treated with gancyclovir for that issue.  Now, her physician has recommended secondary prophylaxis with letermovir to prevent future CMV reactivation.

No, the requested Prevymis (letermovir) is not medically necessary.

Letermovir has not been well-studied for secondary prophylaxis against CMV infection in post-transplant patients beyond 100 days, and it is not currently considered a standard drug for that indication.  The issue in this case is secondary prophylaxis following CMV infection.  At the present time, there is only limited evidence supporting a role for letermovir in the secondary prophylaxis of CMV reactivation following treatment of CMV infection.  Therefore, based on lack of sufficient supporting evidence, it is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative colitis
Treatment: Humira 40 milligrams (Pre-Service)
The insurer denied the Humira 40 milligrams (pre-service).
The denial is overturned.

The patient is a male with moderate to severe ulcerative colitis. He has failed treatment with mesalamine, steroids, immunosuppressives and Remicade, and was started on Humira 40 milligrams every other week. He did well initially, but then symptoms flared with diarrhea, bleeding and elevated inflammatory markers. Humira was increased to 40 milligrams weekly and the patient has done well. The provider is requesting continuation of Humira 40 milligrams weekly.

Yes, the proposed weekly Humira is medically necessary.

Humira was denied as the dose is higher than the Food and Drug Administration (FDA) approved dose. Medical literature supports dose intensification of Humira in patients who do not respond to FDA approved dosing. Twenty to twenty-five percent of patients with ulcerative colitis treated with Humira require dose intensification. Humira has been found to be safe and effective at doses as high as 80 milligrams weekly. This patient had loss of response with Humira 40 milligrams every other week, and has done well on Humira 40 milligrams weekly. Therefore, the requested dose and frequency is supported by current peer-reviewed medical literature and clinical practice guidelines, and is standard of care. Humira should be approved at 40 milligrams weekly.

As per the rationale above, the request is medically necessary. The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient by denying Humira 40 milligrams weekly.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchenne or Becker muscular dystrophy

Treatment: inpatient subacute rehabilitation

The insurer is denied coverage for inpatient subacute rehabilitation

The denial is overturned. 

This male patient has a history of Duchenne or Becker muscular dystrophy, spondylolisthesis, lumbar region, hypertension, paroxysmal atrial fibrillation, gastroesophageal reflux disease, anxiety, and depression.

The patient was an appropriate candidate for subacute rehabilitation at a Skilled Nursing Facility (SNF) (1, 2, 3). He has physical impairments amenable to subacute rehabilitation. He was able to ambulate approximately 90 feet with a wheeled walker, requiring stand by assistance. He was also able to climb 18 steps with standby assistance. He has 23 steps with right handrail to get into his home. Activities of daily living (ADL) tasks such as bathing, dressing and toileting varied from set-up to minimal assistance. Due to his underlying muscular dystrophy, the patient's functional progress would have been slower than anticipated.
Subsequent notes document continued functional improvement.  He was able to ambulate 100 feet with a wheeled walker. He was also able to "ascend/descend 20 steps using bilateral handrails and non-reciprocal gait pattern with only stand by assist (SBA) of 1." Given his continued improvement and underlying muscular dystrophy, this physician would have recommended subacute rehabilitation for an additional 10 days.
Taken into consideration were the clinical standards of the plan, information provided concerning the patient, 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, as well as within a reasonable degree of medical certainty, based on the enclosed clinical records, continued inpatient subacute rehabilitation admission was supported as medically necessary.

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 the inpatient subacute rehabilitation is overturned.  The medical necessity is substantiated
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral infarction due to an embolism, memory deficit, dementia. 
Treatment: Personal care services, level 2 of 10 hours per day, 7 days per week for a total of 70 hours per week. 

The insurer denied coverage for personal care services, level 2 of 10 hours per day, 7 days per week for a total of 70 hours per week. 

The denial is overturned. 

The patient has a past medical history of cerebral infarction (due to an embolism), memory deficit, dementia (after cerebral infarction), impaired mobility, depression, and type two diabetes mellitus. She lives alone in a studio apartment. She is totally dependent for meal preparation and ordinary housework. The patient needs maximum assistance with managing stairs, shopping, and transportation. She needs extensive assistance with managing finances and medications, bathing, dressing her upper and lower body, walking, locomotion, toilet transfer, and toilet use. The patient is frequently bladder incontinent, and occasionally bowel incontinent. She uses pull ups for her incontinence. She uses an assistive device for locomotion. The patient needs limited assistance with phone use, personal hygiene, and eating. An increase to personal care services, level two of ten hours per day, seven days per week for a total of 70 hours per week, is being requested. 

According to an Appeal Letter, "The patient has diagnoses: cerebral infarction (due to embolism), memory deficit (dementia, after cerebral infarction), impaired mobility, depression, and non-insulin dependent diabetes mellitus (NIDDM). The patient requires assistance and prompting when completing her activities of daily living (ADLs). She requires nutritional support, as she has had meals prepared and left for her, which was not eaten, after caregiver left for the day; the patient has also not taken her medications after these meals, which renders her at a risk of decompensation, and further cognitive decline. Assistance is needed with toileting, due to urinary incontinence." 

The patient is receiving 42 hours per week, of personal care assistance. However, it is noted that meals while delivered are not eaten, she is incontinent and needs assistance with toileting. Thus, while she gets two meals delivered per day her other needs require an increase in hours. The tasking tool shows need for assistance with toileting multiple times/day. The patient's needs cannot be met with the number of hours she has. 

Based on submitted information, the health plan did not act reasonably and with sound medical judgment and in the best interest of the patient.   Personal Care Services, Level two of ten hours per day, seven days per week, for a total of 70 hours per week, is medically necessary for this patient. 

The insurer's denial of coverage for the requested Personal Care Services, Level 2 of 10 hours per day, 7 days per week for a total of 70 hours per week is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis	

Treatment Cosentyx Pen Injector 300 milligram (mg) dose [2 pack]

The insurer denied coverage for Cosentyx pen injector 300 milligram (mg) dose [2 pack].

The denial is overturned.

The patient is an adult female with a history of psoriasis involving the scalp and face. The patient has failed multiple topical treatments as well as treatment with methotrexate and Otezla oral tablets. The provider requested narrow band ultraviolet B (NB-UVB) phototherapy, but the insurance denied this according to the appeal letter. The requested medication is Cosentyx.

The patient has failed topical therapy and has been denied light therapy for control and management of her psoriasis diagnosis. Methotrexate and topical steroid therapy have been tried and proven unsatisfactory. The patient has also failed therapy with Otezla. As such, Cosentyx injections are a reasonable alternative which can be administered within the psoriasis care guidelines.  

The requested service is medically necessary, based on the provided medical records and the medical literature. 

The healthcare plan did not act reasonably, with sound medical judgement, or in the best interest of the patient. In this case, based on the provided documentation, Cosentyx is a medically appropriate therapeutic option. 

The insurer's denial of coverage for Cosentyx pen injector 300 milligram (mg) dose [2 pack] to treat psoriasis is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowding; crossbite.
Treatment: Braces and adjustment of braces, treatment visits
The insurer denied the braces and adjustment of braces.
The denial is overturned.

The patient is young male with a class III skeletal relationship, moderate maxillary crowding, mild mandibular crowding, deep bite, anterior crossbite with gingival attachment loss (maxillary left lateral incisor).  The provider is requesting orthodontic therapy (braces) and treatment visits for the adjustment of the braces.

The insurer denied the requested procedures because the patient did not score a 26--the score necessary for orthodontic treatment to be approved on the Handicapping Labio-Lingual Deviation (HLD) Index Report.  The provider appealed because of the severity of the patient's anterior crossbite.

Yes, the requested orthodontic therapy (braces) and treatment visits for the adjustment of the braces are medically necessary.

The patient presents with a significant anterior crossbite on the maxillary left lateral incisor, this is evident in the photo.  Normally, the maxillary lateral incisor sits buccally (in front) of the mandibular incisor, but in a crossbite the lateral incisor will sit lingual (inside) of the mandibular incisor.

This crossbite can cause long term problems for the patient, as it may interfere with proper speech, chewing and hygiene. 

Per the HLD (Handicapping Labio-Lingual Deviation) Index Report, a crossbite with gingival attachment loss is an automatic qualifier for orthodontic treatment (braces).  The severity of the crossbite is supported by the documentation submitted.  Therefore, the orthodontic therapy (braces) and treatment visits for the adjustment of the braces  is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Blood Sugar Levels (diabetes)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with type 2 diabetes, chronic kidney disease, and hypertension. She presented to the emergency department with hyperglycemia and elevated blood pressure after being evaluated by her primary care provider. She endorsed two to three weeks of polyuria and polydipsia.

The patient's BP (blood pressure) was 145/68, heart rate 75, temperature 98.7, respiratory rate 18, and oxygen 99%. She was alert on exam. Her labs revealed elevated glucose of 682, sodium 131, potassium 5.5, BUN (blood urea nitrogen) 39, and creatinine 2.80.  She received fluids and subcutaneous insulin. She received diabetes education, and it was determined that she was not able to read or write. Her insulin regimen was simplified.

The inpatient stay is under review.

No, the Inpatient admission was not medically necessary.
This patient presented with hyperglycemia and dehydration in the setting of known diabetes. She was hemodynamically stable. She had an elevated creatinine in the setting of chronic kidney disease. It was unclear if this elevation was above her baseline. She did not require dialysis. She did not have evidence of sepsis or infection. She did not have acidosis to support a diagnosis of diabetic ketoacidosis. She did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar state. Her glucose improved with hydration and insulin therapy. The documentation does not support that she failed a lower level of care.

Therefore, given the above, no, the patient's admission was not medically necessary.

The inpatient stay was not medically necessary, and it was appropriately denied by the health plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic Short Stature (ISS) and Growth Failure. 	
Treatment: Growth hormone therapy with Zomacton injection 10mg (milligram). 

The insurer denied coverage for growth hormone therapy with Zomacton injection 10mg. 

The denial is overturned. 

The patient is a female who presented at an early age with height of 121.1 centimeters (cm) (-2.46 standard deviation score [SDS], 0.69% percentile), weight was 28 kilograms (kg) (-0.74SDS, 23.02%ile), and a body mass index (BMI) of 19.09 1 kilogram/square meter (kg/m2) (0.85 SDS). Months ago her height was 125.6 cm and height velocity was 6.43 cm/year (-0.21 SDS), but with physical exam on that 2nd visit showing Tanner 2 breast consistent with onset of puberty. Height prediction of 59 inches (in) (-1.93 SDS). Midparental target height was 62.5 in (-0.7 SDS). Thus, height prediction is more than 2 in (inches) (-1.2 SDS) below midparental target height. Laboratory evaluation was benign with growth hormone (GH) stimulation testing showing a peak to 12.2 nanograms/milliliter (ng/ml). The patient was diagnosed as having idiopathic short stature (ISS). Given the extreme short stature, GH therapy was prescribed. The insurer has denied coverage for GH therapy for diagnosis of ISS. 

The patient demonstrates poor linear growth with very short stature that corresponds with the recommendation for treatment according to the consensus guidelines for ISS. (1) Height prediction is at the lower limit of normal and in line with the Food and Drug Administration (FDA) approval for use of GH in children with a diagnosis of ISS. (2, 3) The patient meets the criteria for use of GH therapy as outlined by both the consensus statements and the FDA approval indications. Furthermore, recent Pediatric Endocrine Society guidelines suggest that GH stimulation testing should not be the sole basis of determining need for GH therapy. (4) 

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

The insurer's denial of coverage for growth hormone therapy with Zomacton injection 10mg is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Knee Cellulitis

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is upheld

The patient is a male with past medical history significant for methicillin resistant staphylococcus aureus (MRSA) infection of the right knee who presented to the emergency department with complaints of left knee pain, swelling and fever. 

Vitals on presentation included: Temperature. 98.5, Blood Pressure - 145/64, Pulse - 98, Respiratory Rate - 18, oxygen (O2) saturation - 96% (percent) on room air. Laboratory results included: white blood count (WBC) - 20.78, hemoglobin (Hgb) - 14.2, hematocrit (Hct) - 42.4, creatinine-1.0, glucose-141, c reactive protein (CRP) - 23.17.

The patient was started empirically on intravenous antibiotics (vancomycin and Unasyn) for possible left knee septic arthritis. X-ray of the left knee showed a small metallic foreign body in the tissue near the knee. Magnetic resonance imaging (MRI) of the knee was on hold due to presence of foreign body. Orthopedics consult was also held, until results of arthrocentesis could be obtained from outside facility. Infectious Diseases consulted and recommended antibiotic therapy. Patient remained afebrile, hemodynamically stable. He signed out against medical advice (AMA).

According to documentation, patient presented with a left knee cellulitis versus septic arthritis. On presentation, patient was afebrile, and hemodynamically stable. Laboratory results were notable for only an elevated white blood count. The patient had localized cellulitis with no evidence for a disseminated infection. Moreover, no surgical intervention was necessary. Based on above findings, patient met criteria for observation level of management.     

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: T-Cell Lymphoblastic Leukemia.
Treatment: Darzalex, Pre-service.
The insurer denied the Darzalex, Pre-service.
The denial is upheld. 

The patient is a female. She was initially treated for acute mylogenous leukemia but was then found to have T cell acute lymphoblastic leukemia. She failed standard chemotherapy. The provider is recommending treatment with Darzalex.

No, the requested Darzalex is not medically necessary.
Darzalex has been shown to have efficacy in the treatment of children with relapsed T cell leukemia in several case reports, both as a single agent, and when combined with chemotherapy. The drug is currently under study in a Phase II study in pediatrics. NCCN (National Comprehensive Cancer Network) guidelines for pediatric leukemia do not recommend this drug for the treatment of relapsed T cell ALL (acute lymphoblastic leukemia).

The standard of care for patients such as this includes other recommended regimens.

Therefore, given the above, the Darzalex is not medically necessary.