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

Diagnosis: Altered Mental Status
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with end-stage renal disease on hemodialysis and hypertension. He was admitted with altered mentation following completion of outpatient dialysis.

Computed tomography of the brain and the chest x-ray demonstrated no acute process.  Laboratory indices were notable for a white blood cell count 7.39, hemoglobin 11.7, glucose 156, BUN (blood urea nitrogen) 31, creatinine 6.4, bicarbonate 26 and potassium 3.8.  The patient was afebrile with a blood pressure 140/90 and pulse 88.  Nephrology consulted.  Neurology consulted and noted that the patient had recently self-decreased home dosing of Subutex.  Subutex was continued.  The patient's mentation improved.

No, the Inpatient admission was not medically necessary.
The patient's altered mentation was not accompanied by evidence of a focal neurologic process, acute cerebrovascular accident, acute demyelinating condition, or seizure activity.  There was no evidence of drug or alcohol withdrawal.  The patient's mentation normalized within an observation timeframe.  There was no evidence of delirium preventing performance of life-sustaining functions such as speeding or hydration.  Computed tomography of the brain demonstrated no acute process.  The patient remained hemodynamically stable and afebrile without evidence of infectious process.  The patient did not have hyperkalemia, uremia, acidosis or volume overload.  In summary, inpatient admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cardiac arrest
Treatment: Wearable Cardioverter Defibrillator (K0606)
The insurer denied the Wearable Cardioverter Defibrillator (K0606).
The denial is upheld.

The patient is a male. He has a past medical history significant for AVRT
(atrioventricular reentrant tachycardia), status post ablation of a concealed
accessory tract, and PAF (paroxysmal atrial fibrillation). He was admitted to the
hospital following an episode of VF (ventricular fibrillation) cardiac arrest in the field.
He was initially intubated, started on Amiodarone drip. He was successfully
extubated.

The patient's echocardiogram revealed normal LV (left ventricle) systolic function.
Cardiac catheterization revealed non-obstructive CAD (coronary artery disease).
The patient was discharged home with Zoll LifeVest Wearable Cardioverter
Defibrillator with a plan to return for a permanent AICD (automatic implantable
cardioverter defibrillator) implantation.

No, the health plan should not cover the wearable cardioverter defibrillator.
No, the requested therapy is not likely to be more beneficial for the enrollee than
any available standard therapy.
The patient presented for a VF (ventricular fibrillation) cardiac arrest. He was found
to have no reversible cause, and thus had Class I indication for implantation of an
AICD (automatic implantable cardioverter defibrillator) for secondary prevention of
SCD (sudden cardiac death). There was no evidence of acute MI (myocardial
infarction), need for coronary revascularization, acute infection, bleeding disorder or
any other condition necessitating a delay in AICD (automatic implantable
cardioverter defibrillator) implantation. Therefore, there is no evidence that the
requested therapy is likely to be more beneficial for the enrollee than any available
standard therapy, i.e. implantation of permanent AICD (automatic implantable
cardioverter defibrillator), and there is no medical reason for the delay and use of
temporary wearable device as a bridge therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cardiac arrest
Treatment: Wearable Cardioverter Defibrillator (K0606)
The insurer denied the Wearable Cardioverter Defibrillator (K0606)
The denial is upheld.

The patient is a male. He presented with out-of-hospital cardiac arrest secondary to VF (ventricular fibrillation). He was intubated initially, but evidenced full recovery.

The patient's echocardiogram showed normal LV (left ventricle) function. He met criteria for implant of permanent ICD (implantable cardioverter defibrillator), but was delayed at least 10 days due to "scheduling issues." The decision was made to discharge patient with placement of WCD (wearable cardiac defibrillator) and readmit for an elective ICD (implantable cardioverter defibrillator) implant.

No, the health plan should not cover the wearable cardioverter  defibrillator.

There was no medical contraindications to placing the ICD (implantable cardioverter defibrillator) at the initial hospital admission. While he could not be discharged without a defibrillator, scheduling issues cannot be considered an exception to the guidelines for implanting a permanent ICD (implantable cardioverter defibrillator). Also, the permanent device is medically superior to a wearable unit, including pacing capabilities, and 24-hour protection.

No, the wearable cardioverter defibrillator is not likely to be more beneficial. The permanent device is medically superior to a wearable unit, including pacing capabilities, and 24-hour protection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: advanced dementia and associated cognitive impairment.
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week.
The insurer denied the Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week.
The denial is overturned. 

The patient is a female with a history of advanced dementia and associated cognitive impairment. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 168 hours/week Personal Assistance Services to offer increased ADL support.

The proposed treatment of 168 hours/week Personal Assistance Services is deemed medically necessary.
This is a female with a history of advanced dementia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Although an assessment of the patient's functionality and ability to perform ADLs was completed and revealed that the currently approved plan of 45.5 hours/week Personal Assistance Services is sufficient to meet the patient's current needs; the patient's family and medical providers have indicated this reduced schedule leaves her home alone, completely unassisted for numerous hours/day. This is problematic as her cognitive impairment continues to worsen, resulting in increased memory loss, failure to thrive and continuous decline in her mental status, placing her at high risk for falls and other injuries if forced to attempt to complete her ADLs without assistance. 

Hence, provision of 168 hours/week Personal Assistance Services can reasonably be expected to be beneficial for the patient and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 168 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis. 

Treatment: Dupixent. 

The insurer denied coverage for Dupixent. 

The denial is upheld. 

This the case of a male patient with a medical history of atopic dermatitis (AD) with pruritus affecting 80% total body surface area (TBSA). The patient has failed therapy with triamcinolone ointment, hydrocortisone cream, and prednisone. The patient's Dermatologist is requesting coverage of Dupixent to treat the patient's atopic dermatitis.

Within the peer-reviewed literature, in 2018, Gerbens et al writes "Methotrexate (MTX) and azathioprine (AZA) seem to be effective and safe as maintenance treatments in moderate to severe AD up to 5 years." (3) Shah et al 2018 writes "Methotrexate is an effective treatment for moderate to severe atopic dermatitis with an acceptable safety profile. A low dose can be used to control the disease for prolonged periods without significant risk." (4) There are several published studies that show that methotrexate is effective and safe for moderate-severe atopic dermatitis. (5-8)  

According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the conventional medications such as Protopic, Elidel, and methotrexate are effective treatments for the management of atopic dermatitis. (1, 2)

The requested medication, Dupixent, is not medically necessary for this claimant's condition. There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Dupixent for this patient's condition as an accepted standard of practice in the United States compared to alternative therapies.  

The patient has no true contraindications to the conventional medications commonly used for atopic dermatitis. The conventional medications, such as methotrexate, should be tried and failed prior to initiating Dupixent. The requested medication Dupixent is not medically necessary based on the standard of care, and there are no unique clinical circumstances to this particular individual in the documentation provided that would make it medically necessary. 

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for Dupixent is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma.
Treatment: Nucala 100mg/ml SC SOSY, Pre-service.
The insurer denied the Nucala 100mg/ml SC SOSY, Pre-service.
The denial is overturned. 

The patient is a male child with medical history significant for premature birth at 36 weeks' gestation, environmental allergies, and severe persistent asthma. He was recently prescribed Nucala after having ongoing poorly controlled symptoms with Symbicort, montelukast, loratadine, and albuterol. He experienced several exacerbations, including need for systemic steroid use. He has significant wheezing day and night, exacerbated by exercise.

The patient's laboratory evaluation revealed IgE (immunoglobulin E) greater than 5000, and eosinophil count 1000. Per his mother, he has been on Symbicort and montelukast for over a year with ongoing poorly controlled symptoms.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Mepolizumab (Nucala) is a type of biologic therapy, a monoclonal antibody against the IL-5 (interleukin 5) receptor on eosinophils, reducing eosinophilia and associated asthmatic symptoms. In the appropriate patient population, it is quite effective in decreasing need for recurrent courses of systemic corticosteroids.

This patient has severe persistent asthma that is poorly controlled despite maximum medical therapy. He has been using the combination of Symbicort and montelukast for over a year without full benefit, needing multiple courses of systemic corticosteroids. Both IgE (immunoglobulin E) level and eosinophil count are drastically elevated, supporting a diagnosis of severe eosinophilic asthma, a disease process particularly amenable to therapy with IL-5 (interleukin 5) receptor antagonist medications like mepolizumab (Nucala). With his current regimen, he remains significantly symptomatic, negatively impacting his daily functioning. Based on his history, current treatment profile, and severity of illness, mepolizumab is medically necessary and appropriate for him.

Per the health plan's preferences, the following must be met: use of at least a consecutive three-month trial of either budesonide/formoterol (Symbicort), fluticasone/salmeterol (Advair), or Wixela Inhub in conjunction with either montelukast, zafirlukast or spiriva respimat. This patient has met plan criteria, using the combination of Symbicort and montelukast for over a year without sufficient benefit.

Nucala (mepolizumab) is medically necessary and appropriate, consistent with the current standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-dysvascular left transtibial amputation. 
Treatment: Prosthetics. 

The insurer denied Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system as experimental/investigational. 

The denial was overturned. 

This patient is a male with a history of dysvascular left transtibial amputation. He has been ambulating with a shank foot and vertical pylon with suction suspension and vacuum pump. He has lost weight which is causing pistoning within his socket necessitating replacement. 

At issue is whether the addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system is likely to be more beneficial than any standard treatment or treatments. 

The health plan's determination regarding the proposed health service or treatment is overturned in whole. 

The Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system is likely to be more beneficial than any standard treatment or treatments for the insured's condition. 
It is medically necessary and appropriate to have the vacuum pump replaced with his new prosthesis. This patient has a blood disorder which causes fluctuation in volume of the residual limb. Volume fluctuation causes an ill-fitting socket that pistons with activity and causes skin breakdown and gait deviations. The vacuum pump significantly reduces volume fluctuation avoids pistoning within the socket and skin breakdown from a tight fit.
Therefore, the requested health service of addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system is likely to be more beneficial than any standard treatment or treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Adenotonsillar Hypertrophy. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is a male with a history of asthma, obesity, obstructive sleep apnea (OSA), and adenotonsillar hypertrophy. He presented to the hospital for a scheduled intracapsular tonsillectomy and adenoidectomy and the procedure was performed without complications. The patient was admitted for postoperative care. He remained afebrile and hemodynamically stable throughout the admission and was discharged. The insurer denied coverage for the inpatient admission. They stated that the patient presented to the hospital for a procedure to remove the tonsils. There were no reported complications, and the patient was able to go home the next day. After surgery the patient was wheezing. He was started on albuterol every 4 hours as needed for an asthma exacerbation. Pain medication was given for postoperative pain. The patient's condition stabilized, and he was discharged. The requested admission was warranted. 

Tonsillectomy is generally an ambulatory procedure and admission is not indicated. However, there are in this case several documented concerning patient factors that impact even as straightforward a case as tonsillectomy. First, this patient is a brittle asthmatic on multiple agents at baseline. In addition to his asthma and body mass index (BMI) of 34 /weight 203 pounds at his young age, this patient has OSA with saturations below 90 without continuous positive airway pressure (CPAP). This patient is at extremely high risk of post-anesthetic post-obstructive flash pulmonary edema and loss of airway. Indeed, the patient was wheezing post-operatively and required albuterol dosing well into the morning hours of the day following surgery (although albuterol was prescribed every 4 hours as needed, it was needed every four hours for about 12 hours after surgery). Furthermore, his saturations remained in the low 90s and the drop-off can be rapid and severe. When such a case is complicated by these factors, cases of fatal pulmonary edema and airway loss (BMI 34 makes intubation difficult) are reported and there is rapid deterioration after the earliest symptoms. As a result, there was sufficient evidence to support that this inpatient admission was considered medically necessary treatment for the patient's condition. 

The health care plan did not act reasonably, with sound clinical judgement or in the best interest of the patient. 

The insurer's denial of coverage for the inpatient is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute on chronic decompensated diastolic congestive heart failure (CHF). 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is the case of an adult female patient that presented to the hospital complaining of abdominal pain, distension and leg swelling for several weeks. Past medical history was significant for atrial fibrillation, rheumatic mitral stenosis, hypertension (HTN), pulmonary hypertension, heart failure with preserved left ventricular ejection fraction (LVEF) (50% [percent]) and chronic obstructive pulmonary disease (COPD) requiring home oxygen therapy. Upon arrival to the Emergency Department (ED) her blood pressure (BP) was 116/67 and pulse was 82 beats per minute (bpm). Physical examination revealed abdominal distention and 2 positive pitting edema of the lower extremities. B type natriuretic peptide (BNP) was elevated (810) and computed tomography (CT) abdomen revealed ascites. She was treated with Lasix and admitted to the hospital for additional treatment. Echocardiography was performed and revealed severe mitral valve stenosis with moderate regurgitation. Anasarca with fluid overload remained despite intravenous (IV) diuresis. The patient was transferred to another hospital for advanced cardiac care following several days of diuretic therapy. 

This patient presented with acute on chronic decompensated diastolic congestive heart failure (CHF). Following several days of treatment with anti-congestive therapies, the patient remained fluid overloaded. Echocardiography revealed worsening mitral valve stenosis. She required inpatient treatment/follow up. There have been several studies including a meta-analysis of more than 50,000 patients demonstrating poor outcomes for patients that are discharged from the ED after presenting with acute CHF. These findings were true in both systolic and diastolic CHF. (1,2) In conclusion, it was appropriate to manage this patient at an inpatient level of care. 

The health plan did not act reasonably and with sound medical judgement and in the best interest of the patient. Inpatient admission was medically necessary. 

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque Psoriasis. 
Treatment: Otezla. 

The insurer denied coverage for Otezla. 

The denial is upheld. 

The patient is an adult male with a prolonged history of psoriasis, currently affecting 10% (percent) body surface area (BSA). The patient had failed topical steroid therapy. The provider is requesting Otezla. 

According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, phototherapy and methotrexate are effective treatments for the management of psoriasis. Within the peer-reviewed literature, Racz et al. writes, "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated ... Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks." Mehta et al. write that, "Ultraviolet (UV) B phototherapy is most appropriate for patients with >10 % affected body surface area who have not responded to topical treatments ... narrowband (NB)-UVB effective treatment options for psoriasis... Long-term data on NB-UVB indicate that it has a good safety profile." 
 
Additionally, West et al. (2016) conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve Psoriasis Area and Severity Index (PASI75) at primary endpoint. Thus, methotrexate is an effective first-line treatment for the management of psoriasis. 

Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Otezla is not necessary. There is no documentation provided that the patient has tried and/or failed phototherapy or methotrexate. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Otezla medically more appropriate than the other options. 

Based on the submitted documentation, Otezla is not considered medically necessary treatment for the patient's condition. 

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

The insurer's denial of coverage for Otezla is upheld. Medical necessity is not substantiated.
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 a female who had presented to the emergency department (ED) with the report of a sudden onset of right abdominal pain associated with nausea and vomiting. 

While in the emergency department, the patient was afebrile with normal vital signs.  A right upper quadrant ultrasound showed cholelithiasis with gallbladder wall thickening. A computed tomography (CT) of the abdomen and pelvis demonstrated acute cholecystitis. The patient was admitted. On day two, the patient underwent an uncomplicated lap cholecystectomy. The patient tolerated the procedure well. Postoperatively, she was tolerating oral intake (PO), and the pain was well controlled. The patient was then discharged to home. 

No, the proposed inpatient admission was not medically necessary. 

While the care as rendered was appropriate, the level at which the care was rendered was not medically appropriate. 

In the medical records provided, there is no documentation of perioperative complications, hemodynamic instability, or need for reoperation.  Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level. 

While the care as rendered was appropriate, the level at which the care was rendered was not medically appropriate.  The care could have been rendered at a lesser level.