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

Diagnosis: Right flat foot, foot pain
Treatment: Hospital admission
The insurer denied the hospital admission.
The determination is upheld.

The patient has a right flat foot and complains of pain. The admitting history and physical states that she has failed non-operative treatment; however, no details of this treatment are given. There are no office notes that might indicate the time over which non-operative treatment was used, the duration or severity of the symptoms, how the symptoms limited her functional activity, or whether custom or off-the-shelf orthotics were used. There is no record of any other diagnosis such as tarsal coalition or neuromuscular disease, conditions sometimes associated with flatfoot. The patient underwent surgery recommended and carried out by her podiatrist to address her flatfoot, surgery which consisted of calcaneal and medial cuneiform osteotomies. At issue is whether an inpatient stay was medically necessary.

An inpatient stay was not medically necessary. Although the degree of swelling and pain after surgery of this type can be substantial, there is little risk of neurovascular compromise or compartment syndrome. Patients generally keep the foot elevated for a few days at home and are then able to resume ambulation with crutches. Oral analgesics are generally satisfactory to control pain. This type of surgery is generally well-tolerated on an outpatient basis, with postoperative care (elevation and oral analgesics) being provided at home. The procedure could have been done at a lower level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Constipation.
Treatment: Motegrity.
The insurer denied: Motegrity.
The denial is: Overturned.

The patient is a female under evaluation for chronic constipation. The patient has tried and failed Linzess at both the 145 and 290 microgram (ug) dose and lubiprostone 24 micrograms (mcg) twice daily (BID). The patient has also failed therapy with Miralax, lactulose, Dulcolax, and stool softeners. Formulary alternative treatments applicable for this patient would include lubiprostone.
The patient used office samples of Motegrity and had a beneficial response. The patient's provider has now recommended continued treatment with Motegrity.

The health plan's determination is overturned.

The patient has followed the plan's pharmacy pathway and used the plan's preferred drugs. These medications were ineffective. Motegrity has a unique mechanism of action different from the formulary alternatives and is beneficial for the patient (more beneficial than the formulary medications). This reviewer concludes that this drug would be the most appropriate and the patient should be approved.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

Multiple attempts have been made to obtain a copy of the medical records. The review of this case was based on a summary of the hospital care that was provided. The patient presented with left flank and abdominal tenderness. She had mild hypertension. There was no documentation of peritoneal signs. A computed axial tomography (CAT) scan showed small renal calculi. Cystourethroscopy with stent placement was performed. Intravenous (IV) fluids and pain medications were given. 

Clinical indications for admission for Undiagnosed Abdominal Pain (Milliman Clinical Guidelines M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions. 

Clinical indications for admission for Renal Colic and Kidney Stones (Milliman Clinical Guidelines M-320) include hemodynamic instability, acute renal failure, bilateral obstruction, severe vomiting, and the need for further postoperative care that could only be done on an inpatient basis. The patient did not have these conditions.

This patient had renal stones and required placement of a ureteral stent. This is a procedure that could have been done on an ambulatory basis. She did not meet Milliman Clinical Guidelines (MCG) criteria for admission for either Undiagnosed Abdominal Pain or Renal Colic and Kidney Stones. 

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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis. 
Treatment: Otezla. 

The insurer denied Otezla. The denial is upheld. 

The patient is an adult female with psoriasis. She has been treated with methotrexate, Cimzia, topicals and Cosentyx. Her provider is requesting to initiate Otezla in conjunction with Cosentyx. The health plan denied coverage of the combination of Otezla with Cosentyx. The denial is being appealed. 

The requested Otezla is not medically necessary. 

Up to 30% (percent) of patients with recalcitrant psoriasis are placed on combination therapy, typically anti-TNFa (tumor necrosis factor alpha) with methotrexate, in spite of limited data on the combination of biologics with MTX (methotrexate), cyclosporine or acitretin. The use of combination therapy with apremilast is increasing, despite the fact that only a few reports on its use exist. A case series of 4 patients showed no safety concerns and achievement of near PASI100 (100% reduction in Psoriasis Area and Severity Index score) in all patients in the case series. 

The article by AbuHilal et al. examined a total of 81 patients with plaque psoriasis were treated with apremilast in combination with at least 1 other therapy (NB-UVB [narrow band ultraviolet B], methotrexate, acitretin, cyclosporin, etanercept, adalimumab, infliximab, or ustekinumab). Fourteen patients (17%) discontinued treatment before completion of 12 weeks of apremilast therapy. Sixty-seven patients continued on drug past 12 weeks. Of these patients, 81% achieved PASI-75 (75% reduction in Psoriasis Area and Severity Index score) at week 12 after apremilast was added to an existing therapy. 

There are several case reports outlining successful treatment with Humira and Otezla, as well as with Cosentyx. The 2021 review (Ivanic et al.) included 17 studies of 617 patients. 15 of those studies demonstrated beneficial results with excellent safety and efficacy or apremilast combination therapy. The drug's simple dosing schedule with mild side effect profile makes it a practical option for patients as combination therapy. The remaining two studies did not show the combination to be more effective than apremilast monotherapy. 

However, this patient has only tried and failed one other biologic therapy (Cimzia) and switching to a different class of biologics as monotherapy is also within standard of care and is likely more appropriate in a female of childbearing potential (monotherapy is favored over combination therapy). Therefore, the request for Otezla is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental pain/bleeding
Treatment: D2752 Porcelain Crowns - tooth #12 and #13
The insurer denied the D2752 Porcelain Crowns - tooth #12 and #13.
The health plan's determination is upheld. 

The patient is a female who presents for evaluation and treatment of teeth #12 and #13. Provided for review are letters of appeal and denial, panoramic radiographic images and single bitewing and periapical images, a narrative from the patient, consents to release of records, clinical notes, and two pages of dental claim forms.

The requested Porcelain Crowns - tooth #12 and #13 are not medically necessary for this patient based on the provided documentation. From the notes provided, there is not any decay on the restorations nor their margins. Based on the provided radiographs, there is not any decay noted nor any issues with the contours of the crowns. Therefore, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abnormal uterine bleeding; pelvic pain.
Treatment:  Inpatient Hospital Admission.

The insurer denied: Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult female with abnormal uterine bleeding, fibroids, and pelvic pain.  She was admitted for an elective robotic assisted laparoscopic hysterectomy, bilateral salpingectomy, ureteral stents, and cystoscopy.  The procedure was uncomplicated.  Estimated blood loss was 100 milliliters (mL).  The patient was admitted post-surgery to inpatient status.  She was given intravenous fluids, pain medications as needed, antiemetics as needed, sequential compression devices, Lovenox, and her home medications.  She did not have a Foley catheter.  On post operative day number 1 the patient's pain was controlled, she was ambulating, tolerating diet, and voiding.  Her post operative hemoglobin was 10.6.  She was discharged home.
The inpatient hospitalization was denied.  This is being appealed.

The proposed inpatient hospital admission was not medically necessary.

According to the American College of Obstetricians and Gynecology (ACOG), "The ERAS (Enhanced Recovery After Surgery) principles represent an evidence-based approach to surgical management that challenges traditional surgical management paradigms. The use of ERAS pathways has resulted in more rapid surgical recovery, shorter length of stay, greater patient satisfaction... when compared with traditional approaches. These benefits have been replicated across the spectrum of gynecologic surgeries, including open and minimally invasive approaches and benign and oncologic surgeries. The implementation of the ERAS program requires collaboration from all members of the surgical team. Successful ERAS pathway implementation across the spectrum of gynecologic care has the potential to improve patient care and health care delivery systems, and the use of ERAS pathways should be strongly encouraged within institutions."

An outpatient observation bed is an alternate level of healthcare compromising of short stay encounters for patients who require close nursing observation or medical management.  It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient.  The distinction between inpatient versus observation status is not always clear-cut. Patients undergoing short hospital stays may be treated similarly to inpatients but classified as outpatients receiving observation services.

The patient in question was taken to the operating room and underwent an uncomplicated procedure.  She required observation and nursing care to assist with her pain management, ambulation, and routine post operative management.   There were no operative complications or post operative complications that necessitated inpatient care.  She was hemodynamically stable.  By post operative day number 1 the patient was ready for discharge requiring less than a 24 hour stay.  Therefore, the patient did not require an acute inpatient stay, as the same care could have been provided under an observation status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left trans radial amputation secondary to trauma.
Treatment is replacement upper extremity (arm) prosthetic.
The insurer denied coverage for a replacement upper extremity (arm) prosthetic.
The denial is overturned.

This is a patient who underwent a left trans-radial amputation secondary to trauma. Under review is the request for a replacement upper extremity (arm) prosthetic.

From a physical medicine & rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, based on the clinical information available for review, the patient's left upper extremity prosthesis is clearly in dire need of replacement.  He was initially provided this prosthesis well over a decade ago. The current prosthesis no longer properly fits and has damaged hardware and fraying/tearing of soft components. Contrary to the assertion of the insurer; replacement of the current prosthesis is not merely for the sake of convenience, appearance, or comfort. The patient's poorly fitting prosthesis has resulted in decreased left upper extremity function as well as nerve irritation and overuse injury of the contralateral limb. Replacement of the current prosthesis will result in the patient's ability to resume his prior functional ability.   

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

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the requested replacement upper extremity (arm) prosthesis is medically necessary.  

The insurer's denial of coverage for a replacement upper extremity (arm) prosthetic is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Class I occlusion.
Treatment: braces/monthly visits.
The insurer denied braces/monthly visits. 
The health plan's determination is upheld.

The patient in question is a  male with a Class I occlusion with a 5-millimeter (mm) deep overbite and 4mm overjet. He has maxillary and mandibular crowding. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion. This is under review.

Braces and monthly visits are not medically necessary. There is no medical reason to correct his malocclusion with braces. While the patient has moderate crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID-19.
Treatment is an inpatient admission.
The insurer denied coverage for an inpatient admission. 
The denial is upheld.

The patient is a male with no significant history (other than some mild childhood asthma) who presented to the hospital with complaints of fever, cough, body aches, and some palpitations. The patient had recently had a positive Covid test at a pharmacy. The patient denied chest pain (CP) or shortness of breath (SOB). Vital signs at presentation were, Temperature 103 F (Fahrenheit), heart rate (HR) 121, respiratory rate (RR) 18, blood pressure (BP) 122/67. Oxygen saturation (O2 sats) was 95 % on room air (RA). The patient was in no acute distress (NAD). Lungs were clear. Cardiovascular systems were normal. 

Labs: white blood count (WBC) was 8.5K (thousand), hemoglobin (Hb) 14.8.
Electrolytes were within normal limits (WNL) other than potassium (K+) which was 3.1 Blood urea nitrogen (BUN)/ creatinine (Cr) 10/0.9 were normal.

Procalcitonin was 0.4. An electrocardiogram (EKG) showed normal sinus rhythm (NSR), and there were no acute changes. The chest x-ray (CXR) revealed some patchy infiltrates in the right upper lobe (RUL) and left lower lobe (LLL).

The patient was treated with intravenous (IV) Fluids, Intravenous (IV) pain meds, Tylenol, Magnesium, and K+ replacement. The patient was also given 1 dose of steroids. The patient was also given Rocephin and oral (PO) Levaquin.

His admitting diagnosis was Covid, and atypical pneumonia (PNA). 

This patient improved with treatment and remained stable after admission. He effervesced quickly and was discharged home on PO meds with an outpatient follow-up.

This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient became afebrile quickly a few hours after admission. Repeat vital signs later that day were as follows: T 98, HR 105, RR 19, BP 115/74.
O2 sats were 96% on room air. The patient was in no acute distress. The patient was in NAD with few crackles on his lung exam. He was awake and alert.

This patient was not hypoxic, was hemodynamically stable, and was tolerating oral intake.
His CURB 65 (confusion, urea, respiratory rate, blood pressure, and age >=65 years) score was zero. His pneumonia was mild and could have been treated in an outpatient setting after a period of observation. His Covid did not need an inpatient hospital stay.

The patient was stable for a discharge home by the next day.

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

The insurer's denial of coverage for full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Dupixent
The insurer denied: Treatment with Dupixent
The denial is: Upheld

The patient is a female with asthma. She has been on Advair and Singulair and has poor compliance. Her Eosinophil count was 220. She has a cough, and wheezing. There are no details given as to the frequency. The subject under review is the medical necessity for Dupixent.

The health plan's determination is upheld.

The requested Dupixent is not medically necessary for this patient. In this case, the records do not adequately show poor asthma control. She has a cough and wheezing but no details are given as to frequency.
Dupixent has United States Food and Drug Administration (FDA) approval for adjunct treatment poorly controlled moderate to severe persistent eosinophilic asthma or oral steroid dependent asthma.
Castro et al. conducted a trial of 1902 patients 12 years of age or older with uncontrolled asthma in a 2:2:1:1 ratio to receive add-on subcutaneous dupilumab at a dose of 200 or 300 milligrams (mg) every 2 weeks or matched-volume placebos for 52 weeks. The primary end points were the annualized rate of severe asthma exacerbations and the absolute change from baseline to week 12 in the forced expiratory volume in 1 second (FEV1) before bronchodilator use in the overall trial population. Secondary end points included the exacerbation rate and FEV1 in patients with a blood eosinophil count of 300 or more per cubic millimeter. The annualized rate of severe asthma exacerbations was 0.46 (95% confidence interval [CI], 0.39 to 0.53) among patients assigned to 200 mg of dupilumab every 2 weeks and 0.87 (95% CI, 0.72 to 1.05) among those assigned to a matched placebo, for a 47.7% lower rate with dupilumab than with placebo (Probability value [P] less than [<] 0.001); similar results were seen with the dupilumab dose of 300 mg every 2 weeks. At week 12, the FEV1 had increased by 0.32 liters in patients assigned to the lower dose of dupilumab (difference vs. matched placebo, 0.14 liters; P< 0.001); similar results were seen with the higher dose. Among patients with a blood eosinophil count of 300 or more per cubic millimeter, the annualized rate of severe asthma exacerbations was 0.37 (95% CI, 0.29 to 0.48) among those receiving lower dose dupilumab and 1.08 (95% CI, 0.85 to 1.38) among those receiving a matched placebo (65.8% lower rate with dupilumab than with placebo; 95% CI, 52.0 to 75.6); similar results were observed with the higher dose. Blood eosinophilia occurred after the start of the intervention in 52 patients (4.1%) who received dupilumab as compared with 4 patients (0.6%) who received placebo. the authors concluded that patients who received dupilumab had significantly lower rates of severe asthma exacerbation than those who received placebo, as well as better lung function and asthma control.

In this case, the patient has poor compliance with medications and the notes do not support frequent asthma exacerbations. Dupixent is not supported as medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p back surgery
Treatment: personal care assistance services, a total of 70 hours per week
The insurer denied personal care assistance services, a total of 70 hours per week.
The determination is upheld.

This is a patient with a medical history notable for spinal stenosis status post multiple surgical interventions, amnesia, major depressive disorder, and dementia/memory issues. The patient was approved for 35 hours per week of personal care assistance. The patient requested an increase to 70 hours per week, and this increase was denied by the health plan and is under review.

A letter of support for this appeal was provided by the patient's treating neurologist. The letter states that the patient's health and overall status have been deteriorating gradually. 
A letter of support for this appeal was also provided by the patient's primary care physician. The letter describes the most recent office visit  where she continues to have significant pain related to her back. The letter states that she "needs supervision and assistance to avoid additional complications." There is no specific request for additional hours, or discussion of personal care needs that are not currently being met by her allotment of hours.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was found to be alert and oriented but forgetful. A mini-mental state examination (MMSE) score was 11/30. For her functional status, she requires maximal assistance for meal preparation and housework. She requires extensive assistance for managing finances, managing medications, and shopping. She requires limited assistance for phone use. For her activities of daily living, she requires extensive assistance for bathing and dressing lower body. She requires limited assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. She is independent for bed mobility and eating. She is frequently incontinent of urine and uses 1-2 liners daily. She uses a straight catheter as needed due to a history of neurogenic bladder. She is continent of stool. A task tool associated with the assessment recommended 26.3 hours per week to address her personal care needs.

The requested health service/treatment of personal care assistance services, a total of 70 hours per week is not medically necessary for this patient.

The patient has some functional limitations related to her spinal stenosis and associated mobility issues and chronic pain. These functional limitations are currently being addressed by having personal care assistance for 35 hours per week, which represents a 33% increase over the hours recommended by the tasking tool. There is no demonstrated medical necessity provided for increased hours, or evidence of unmet personal care needs that would necessitate an increase in hours. The health plan recommended skilled nursing for any short term needs related to her post operative state which is appropriate. Additional hours that are intended for safety and supervision alone are not provided by personal care.