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

Diagnosis: Obstructive sleep apnea

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is overturned.

This is a male child with a history of obstructive sleep apnea, mild hearing loss, and speech delay. The patient presented to the hospital for an elective tonsillectomy, adenoidectomy, and bilateral myringotomy tube placement. The procedure was uncomplicated. Per anesthesia note, the patient had some gurgling when he awoke and there was concern for mild uvula swelling. The patient was admitted to the Intensive Care Unit (ICU) for postoperative management. The patient's diet was advanced until he was tolerating soft foods. The patient's pain was controlled with oral Tylenol and he continued on Ciprodex drops in each ear twice a day. There were no acute events. At the time of his discharge, the patient was tolerating his diet, ambulating and stable with his pain well controlled.
  
Based on the review of the medical record and literature, inpatient admission is considered medically necessary for this patient. The patient had a diagnosis of sleep apnea (moderate to severe) and underwent a tonsillectomy, adenoidectomy and bilateral myringotomy tube placement. During the immediate postoperative period, it was noted that the patient had some gurgling respiratory sounds and his uvula was edematous. Literature review indicates that admission following adeno-tonsillectomy is recommended for children with sleep apnea due to the higher incidence of respiratory complications in the first 24 hours of post-operative period. In addition, in this case, there were clinical findings concerning for airway edema (i.e., gurgling and uvular swelling) that required close observation in a monitored unit. An inpatient level of care is particularly important in this case, for this patient was a child and may not be able to adequately communicate evolving symptoms of airway compromise. Considering this patient's clinical findings concerning for airway compromise, an inpatient level of care and admission was medically necessary for this patient.

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 should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Appendicitis

Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission.

The denial was overturned.   

This is a male patient who presented by ambulance to the Emergency Department (ED) with complaints of abdominal pain x 1 day associated with non-bilious, non-bloody vomiting x 2 episodes and anorexia. There was no fever, dysuria, bleeding or chills. The patient also reported sore throat, abdominal pain with jumping and generalized body aches. The patient's presenting vital signs were: Pulse 123, Temperature 98.6 F, Respiration 33, Blood Pressure 114/64 and Oxygen Saturation of 100% on room air. The patient developed a fever to 101.8 F. The patient's admitting weight was 45.8 kilograms and his height was 143 centimeters. The patient's physical exam was notable for a well-developed, well-nourished male with 6/10 abdominal pain. The patient had moist mucosa, normal skin turgor, normal cap refill and warm skin. His lungs were clear. His cardiac exam was unremarkable. In the ED, the patient received intravenous (IV) normal saline bolus. An abdominal computed imaging (CT) scan was performed that showed a thickened appendiceal wall and hyperemia of the tip of the appendix suggestive of acute appendicitis. Surgery was consulted with recommendations for admission for hydration, intravenous antibiotics, serial exams and possible appendectomy. The patient received IV Tylenol and 5 doses of cefoxitin. The patient remained afebrile and his pain and vomiting resolved. The patient was discharged on oral antibiotics for outpatient follow-up.

Based on the review of the medical record, this patient appeared to have acute appendicitis by presenting symptoms, physical exam, laboratories and imaging. According to a review of the management of acute appendicitis in children from UpToDate, "Well-appearing patients with an appendiceal mass or phlegmon may initially be managed nonoperatively or undergo appendectomy." It recommends that "Intravenous (IV) hydration and analgesia should be provided." The literature further states, "Although appendectomy for early appendicitis remains the treatment of choice, nonoperative treatment of early appendicitis has been proposed and may be an option in selected children with early, uncomplicated appendicitis depending upon caregiver preference. Specifically, it may be safe and effective for older children who can better describe their symptoms (over six years of age) and have features of early appendicitis as follows: (1) Abdominal pain for <48 hours; (2) White blood cell (WBC) count less than or equal to 18,000/microL; (3) Normal C-reactive protein; (4) No appendicolith present on imaging; (5) Appendix diameter less than or equal to 1.1 cm on imaging; (6) No preoperative concern for rupture based upon clinical findings.

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

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent
The insurer denied the Dupixent.
The denial is overturned. 

The patient is a man with atopic dermatitis for whom Dupixent is requested. He has severe atopic dermatitis affecting greater than (>) 30% BSA (body surface area), and including sensitive areas. He has tried and failed multiple topical and oral steroids in the past.

Yes, the treatment with Dupixent is medically necessary.

The patient has severe atopic dermatitis affecting multiple areas of the body. He is a candidate for systemic therapy, as the BSA is too large for reasonable control with topical medications. Topical calcineurin inhibitors (tacrolimus) are not appropriate therapy for severe, widespread atopic dermatitis, affecting sensitive areas, which should be treated with systemic therapy. 

Dupilumab is a monoclonal antibody that inhibits IL-4 and IL-13 signaling by blocking the shared IL-4Ra and originally demonstrated efficacy in phase 2 clinical trials. In  2017, it was approved by the US Food and Drug Administration (FDA) for adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. It is a subcutaneous injection administered initially at a dose of 600 mg and then every two weeks thereafter.

Approval of dupilumab was based on clinical trials investigating dupilumab as monotherapy (SOLO 1 and SOLO 2) and in concomitant administration with topical corticosteroids (CHRONOS). Results from the SOLO 1 (n=671) and SOLO 2 (n=708) trials showed 36-38% of patients who received dupilumab had scores of 0 or 1 (clear or almost clear) on the Investigator's Global Assessment scale compared with placebo (8-10%) (P< .001). Additionally, improvement from baseline to week 16 of at least 75% on the Eczema Area and Severity Index (EASI) was reported in significantly more patients who received each regimen of dupilumab than in patients who received placebo (P < .001).

Given its unprecedented efficacy, dupilumab is emerging as a first-line therapeutic for moderate-to-severe AD (atopic dermatitis). The patient has failed topical steroids, calcineurin inhibitors, and systemic steroids. Additionally, topical calcineurin inhibitors are not indicated for severe disease.

Phototherapy is not appropriate for sensitive areas (scalp, face) and impossible to obtain during the COVID-19 (Novel Coronavirus Disease 2019) pandemic. Cyclosporine, azathioprine, and methotrexate are not FDA-approved for use in atopic dermatitis (Insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulating medication. Strength of Recommendation: B Level of Evidence: I or II, depending on agent), while Dupixent is. Systemic steroids and cyclosporine are not a reasonable long-term treatment for moderate to severe atopic dermatitis due to their severe side effect profile.

Therefore, given the above, the treatment with Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Nursing Services (including Private Duty Nursing)

Diagnosis: CVA
Treatment: Personal Care Services, Level 2: 24 Hours per Day, 7 Days per Week (Live-In) 
The insurer denied Personal Care Services, Level 2: 24 Hours per Day, 7 Days per Week (Live-In). The health plan's determination is upheld. 

The patient is a female with a past medical history significant for coronary artery disease, diabetes, dementia, osteoarthritis and history of cerebrovascular accident (CVA) with residual left-sided weakness. The patient requests an increase in personal care service hours to 24 hours a day 7 days a week live in service. 

The Personal Care Services, Level 2: 24 Hours per Day, 7 Days per Week (Live-In) is not medically necessary for this patient. There are no additional medical services which cannot be provided during the allotted time period. Additional service hours for safety monitoring in the absence of specific activities of daily living (ADL) or Instrumental activities of daily living (IADL) are not indicated.  There are no additional medical services which cannot be provided during the allotted time period. Additional service hours for safety monitoring in the absence of specific activities of daily living (ADL) or Instrumental activities of daily living (IADL) are not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Seizure 
Treatment: Inpatient Hospital Stay 

The insurer denied the inpatient hospital stay. The determination is upheld. 

The patient has a history of depression and was in her usual state of good health. While at school, she drank alcohol-containing rum from her water bottle and became intoxicated. She vomited several times. While intoxicated, she had a generalized seizure at school with a duration of 4-5 minutes. The seizure stopped spontaneously. She was taken by ambulance to the emergency room. Her blood sugar was normal at 145. In the emergency room, she was lethargic, but arousable and was able to answer questions. Her blood alcohol level was in the intoxicating range at 179.8. A urine drug screen was negative and a head computed tomography (CT) scan was normal. In the emergency room, she was treated with Zofran and IV fluids. She was admitted to the hospital at an acute level of care. In the hospital, she underwent an electroencephalogram (EEG) and a magnetic resonance imaging (MRI) scan of the brain, both of which were normal. Throughout the hospitalization, she was able to eat and drink and had a normal neurological exam. She was discharged the following day. At issue is the medical necessity of an inpatient stay. 

The inpatient stay was not medically necessary. The patient was intoxicated with ethanol. As a result, she had a generalized seizure. It is very common for acute alcohol intoxication to induce seizures in teenagers. When an alcohol-intoxicated patient arrives in the emergency room following a seizure, it is necessary to ensure that the patient's vital signs are stable, that the patient has no serious electrolyte imbalances or signs of infection, and that the patient has no intracranial hemorrhage. All of these things were done for this patient in the emergency room. Following that, the patient could be kept in the emergency room until the patient she was no longer intoxicated. It was not medically necessary or customary to admit such a patient at the acute level of care. During the hospitalization, the patient underwent an EEG and an MRI scan of the brain. These tests could have been obtained at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Inpatient hospital

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

The patient is a female with history of hypertension, diabetes, and stroke who presented to the emergency department (ED) with a complaint of dizziness. The dizziness was described and lightheadedness and spinning of the room which began one day prior and was associated with two episodes of vomiting. The patient also had elevated glucose level, which was in the 400's. Vital signs were blood pressure (BP) 142/61, pulse 92, temp 98.2 F, respirations 20, and pulse oximetry 100%. Physical examination was unremarkable. 

The Inpatient Hospital Admission was not medically necessary for this patient. This patient presented with dizziness and hyperglycemia. There was no evidence of a new or severe neurologic deficit on physical examination or brain imaging. The patient was hemodynamically stable without evidence of acidosis. There was no evidence of a severe heart rate or rhythm abnormality. This patient could have been monitored and treated at a lower level of care with subsequent outpatient follow-up. Further testing could have been performed at a lower level and did not require inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Vascular Accident 
Treatment: Acute inpatient admission 

The insurer is denied coverage for acute inpatient admission. The denial is overturned. 

This is a female patient with a history of asthma and low blood pressure case. She presented to the Emergency Department (ED) with complaint of numbness in her left arm and leg. The patient denied facial numbness as well as slurred speech, headache, vomiting or other acute complaints. The patient's physical examination revealed a heart rate of 77 bpm with a blood pressure of 104/67. The patient's oxygen saturation was 100% on room air. On examination it was noted that the patient had mild to moderate sensory loss and scored 1 on the NIH stroke scale. The patient's laboratory studies did not reveal any significant abnormalities. The patient's calcium was 8.1. The patient's computed tomography (CT) scan of the head revealed sinus mucosal thickening and an otherwise unremarkable head CT. The patient underwent an electrocardiogram (EKG) revealing a heart rate of 70 bpm. The patient had a normal sinus rhythm. The patient was admitted for further treatment. Neurology and cardiology were consulted. An echocardiogram was performed that revealed normal results. A magnetic resonance angiograph (MRA) was dome that showed artifact versus focal stenosis at the A1 segment of the left anterior cerebral artery and focal stenosis of the proximal M2 segment of the left middle cerebral artery. The patient was discharged with instruction to follow-up. 

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient presented to the hospital with left arm and leg numbness, suggestive of a right hemispheric stroke. A stroke is a clinical diagnosis, and can have a normal computed tomography (CT) scan and normal magnetic resonance angiograph (MRA). Therefore, while the patient did not initially present with clinical findings and imaging verifying a stroke, the admission was justified as strokes can progress and worsen, leading to severe disability. Therefore, the inpatient stay was appropriate given the ability to continue monitoring and perform intervention if needed. 

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

Based on the above, the medical necessity for the acute inpatient admission is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vitiligo 
Treatment: Compounded tofacitinib cream 

The insurer is denied coverage for compounded tofacitinib cream. The denial is overturned. 

This is a male patient with a history of vitiligo. The patient had tried and had an inadequate response to light therapy, Excimer laser therapy and topical Protopic. Compounded tofacitinib 2/5 cream was discussed at the office visit. 

As per Damsky & King (2017), "New molecularly targeted therapeutics are changing
dermatologic therapy. Janus kinase-signal transducer and activator of transcription (JAK-STAT) is an intracellular signaling pathway upon which many different proinflammatory signaling pathways converge. Numerous inflammatory dermatoses are driven by soluble inflammatory mediators, which rely on JAK-STAT signaling, and inhibition of this pathway using JAK inhibitors might be a useful therapeutic strategy for these diseases. Growing evidence suggests that JAK inhibitors are efficacious in atopic dermatitis, alopecia areata, psoriasis, and vitiligo." And as per Craiglow & King (2015), "Recent advances in the understanding of the pathogenesis of vitiligo suggest that Janus kinase inhibitors may be a therapeutic option" and this study suggested "that tofacitinib and other Janus kinase inhibitors may be effective in the treatment of vitiligo." 

Based on the review of the medical record and literature, compounded tofacitinib cream is considered medically necessary for this patient. The patient has tried and failed conservative therapy. The patient would like to avoid immunosuppressive medication and systemic medication that could have an adverse effect. Topical tofacitinib has minimal absorption and much less potential for adverse consequences. Therefore, the request for tofacitinib topical should be approved. 

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

Based on the above, the medical necessity for is substantiated. The insurer's denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial fibrillation
Issue under review: MAZE procedure

Determination:
The health plan should not cover the MAZE procedure.

The patient is an adult male with persistent atrial fibrillation who is being considered for hybrid procedure to correct his atrial fibrillation.

There is no documentation that the patient has failed medical therapy with amiodarone or Tikosyn, and therefore surgical ablation would not be considered medically appropriate per the 2017 STS guidelines.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial fibrillation
Issue under review: MAZE procedure

Determination:
The health plan should cover the MAZE procedure.

The patient is an adult gentleman with a history of recurrent atrial fibrillation (AF), diabetes mellitus, systolic cardiomyopathy and ICD (implantable cardioverter defibrillator).  He underwent catheter ablation of AF on two separate occasions, but had recurrent atrial fibrillation that resulted in rapid ventricular rates and inappropriate ICD shocks.  He was referred for a minimally invasive MAZE procedure for treatment of recurrent AF.

This patient suffers from recurrent atrial fibrillation despite two previous catheter ablations. He was noted to have recurrent atrial fibrillation with rapid ventricular rates that resulted in an inappropriate ICD shock. The MAZE procedure has been demonstrated to be efficacious for the treatment of atrial fibrillation (Reference 1-2).  Heart Rhythm Society joint guidelines list surgical ablation of AF as a class I indication.  Given the fact that this patient failed to respond to catheter based ablation, surgical ablation is likely to be the most beneficial therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial fibrillation
Issue under review: MAZE procedure

Determination:
The health plan should cover the MAZE procedure.

The patient is an adult male with a history of atrial fibrillation. He had undergone two prior catheter based ablations. He has an AICD (automatic implantable cardioverter defibrillator) in place and is shocked when he goes into paroxysmal atrial fibrillation.  The request is for a surgical epicedial/left atrial ablation (MAZE Procedure) via minimally invasive off-pump, so called hybrid procedure (catheter and surgical).

The approach in patients who have had two failed catheter based procedures in within the scope of the standard of care. A minimal approach reduces the risk of cardiopulmonary bypass, enhances recovery. Success rates in the upper 80% conversion to sinus rhythm after one year. The minimally invasive Cox-Maze procedure with CPB support also demonstrated the potential for a higher success rate 12 months following the procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast cancer screening
Treatment: Breast MRI 

Summary:
The patient is a female with lifetime risk of breast cancer of 33% based on Tyrer-Cuzick models.  Her AP (attending physician) perfumed breast MRI.

The Breast MRI was medically necessary. For women with a lifetime risk of breast cancer over 20%, screening MRI is warranted per the NCCN.  Therefore, this patient with a lifetime risk of 33% is eligible for screening breast MRI.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness and nausea
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented to the emergency department with a one-day history of vaginal bleeding. She had a hemoglobin of 12.7 and was discharged but returned with dizziness and nausea. She was given intravenous (IV) ondansetron, tranexamic acid and oral contraceptive tablets. She was admitted and was given oral contraceptive pills (OCPs). She had an ultrasound which showed and ovarian cyst but no ovarian torsion or bleeding. She was seen by hematology who recommending outpatient followup. She was discharged from the hospital without complications.

No, the proposed treatment is not medically necessary. 

The patient had menstrual bleeding with a hemoglobin of 12. She was treated with oral medications only and did not require a blood transfusion or intravenous iron. An ultrasound was done which showed no ovarian torsion or bleeding. She did not require surgical care. The member could have been safely managed at a lower level of care.