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

Diagnosis: Aneurysm

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient with a past medical history of aneurysm, smoking, hypertension, and obesity who initially presented as a transfer from a secondary hospital with a grade 2, subarachnoid hemorrhage secondary to ruptured anterior communicating artery (Acom) aneurysm. The patient had a prior history of a successful endovascular coil embolization of the ruptured anterior communicating artery (Acom) aneurysm. She was most recently status post diagnostic cerebral angiogram which demonstrated an approximately 2 millimeters residual versus recurrent neck of previously coil embolized, previously ruptured anterior communicating artery (Acom) aneurysm. The patient was noted on admission with no current complaints. She underwent a diagnostic cerebral angiogram with embolization with pipeline embolization device (PED) of residual possible growing neck of anterior communicating artery (Acom) aneurysm. The patient was stable post-procedurally. The patient was discharged on day 2 of admission in stable condition.  

Based on the review of the medical record and literature, the inpatient hospital admission was not medically necessary for this patient. The patient underwent a cerebral angiogram and pipeline embolization. The patient was asymptomatic and was clinically stable post-operatively. The literature does not support the need for the inpatient admission. 

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

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Degenerative arthritis of the left knee.
Treatment:  Inpatient admission.

The insurer denied coverage for the inpatient admission.  The denial is upheld. 

This is a female patient with history of arrhythmia, gastroesophageal reflux disease (GERD), osteoarthritis, ventricular trigeminy, hypertension, obesity, and arthritis of the left knee, who presented to the hospital for scheduled total knee replacement due to bilateral knee pain, worse in the left than the right.  It was exacerbated by walking, climbing stairs, rising from a seated position and bending and squatting.  The patient had corticosteroid injections, gel injections, physical therapy, activity modification, pain medications and surgery in the past without relief.  The patient's X-ray showed mild bilateral hip joint space narrowing, mild pubic symphysis arthrosis, severe bilateral medial femorotibial compartment osteoarthritis with bone to bone apposition, marginal osteophyte formation and genu varus deformity, bilateral lateral joint line osteophytes, severe bilateral lateral patellofemoral compartment osteoarthritis with bone to bone apposition, subchondral sclerosis and cystic change, and marginal osteophyte formation.  The patient was diagnosed with degenerative arthritis of the left knee.  The patient underwent a left primary cemented total knee replacement with neuraxial/combined spinal/ epidural block.  After surgery, the patient was transferred to the post anesthesia care unit (PACU) for close monitoring.  After treatment, the patient was cleared for discharge to home with follow-up with primary care.

The patient's medical record demonstrates a non-complicated post-surgical course.  The operation was approximately 1 hour with limited blood loss.  The progress notes show no problem with the patient's surgical site, and she had motion.  On Post-Operative Day 1 (POD #1), the physician progress report was: "doing well and stable, knee pain well controlled, discharge planning."  The patient's vital signs were stable.  There was no evidence of bleeding.  The patient was able to tolerate oral medications.  The patient did not require treatment for an underlying medical condition.  The patient had adequate pain relief, and she had made progress with physical therapy.  These clinical findings do not substantiate necessity of the inpatient admission.  A lower level of care would be appropriate.  Literature review indicates that inpatient admission was not medically necessary for this patient. 

The inpatient admission is not considered medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease; exertional angina
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This male with known coronary artery disease (CAD) was hospitalized for exertional angina. Treatment included cardiac catheterization with coronary angiography and successful percutaneous coronary intervention (PCI) with stent to the left circumflex second obtuse marginal branch on the same day. Blood pressure was initially elevated and otherwise, vitals were stable. There were no procedural complications, the patient was observed overnight and was discharged the following day. This is an appeal of the denied claim that inpatient level of care was medically necessary for this patient.

No, the proposed inpatient admission was not medically necessary.

There was not a medical need for the acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. There was no hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, acute myocardial infarct (MI), hypertension requiring inpatient hospitalization, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, pneumonia or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care the patient received, including urgent cardiac catheterization with successful percutaneous coronary intervention (PCI) like in this patient's case, is routinely provided safely and effectively at a lower level of care. In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. Therefore, based on the submitted information and the current published medical literature, the proposed treatment was not medically necessary and the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia, COVID
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient in this case is a female. She presented to the emergency department (ED) with anemia. She had been found to have a hemoglobin of 5.4 grams per deciliter (g/dl) and was sent to the ED by her outpatient physician. She was noted to have a history of heavy menses. She had no significant symptoms at the time of initial presentation. She was noted to be hemodynamically stable at the time of admission.

The patient was admitted and transfused with two units packed red blood cells. She was also found to be coronavirus disease (COVID) positive. The following day she remained without symptoms and was again found to be hemodynamically stable. Hemoglobin had increased from 6.2 g/dl at the time of admission to 8.7 g/dl. She was seen by infectious disease and no treatment for COVID was recommended as she had no symptoms. She was kept in the hospital and discharged the next day.  

No, the proposed treatment was not medically necessary. 

This patient presented with anemia but was hemodynamically stable. She had no symptoms related to her anemia, notably no shortness of breath or dizziness. She did not have active significant bleeding. She required transfusion but that did not necessitate urgent transfusion on an inpatient basis. She could have safely been transfused on a non-urgent outpatient basis. She was also found to be COVID positive but had no symptoms. She required no treatment for COVID given her lack of symptoms. She also did not require inpatient admission on the basis of COVID.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sludge in gallbladder
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She presented to the ER (emergency room) and was found to have sludge in the gallbladder.  She underwent laparoscopic cholecystectomy the next day, had postoperative nausea, and was discharged home the day after surgery.  

No, the Inpatient admission was not medically necessary.

The patient's condition and clinical course did not justify inpatient admission.  The patient did not require therapy other than the usual postoperative medications for nausea and pain.  She did not have difficulty keeping oral intake down.  She did not have any concerning vital sign changes or increasing pain.  Therefore, the Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Home Health Care. 

The insurer denied increase in PCA (Personal Care Assistance) hours to 40 per week. The denial is upheld in whole.

The patient is a female with a past medical history significant for dementia, diabetes, hypertension, chronic pain and previous history of breast cancer. The patient is currently receiving 28 hours per week in Personal Care Assistance (PCA) hours. The letter from the patient's daughter, along with a statement from the patient's physician were reviewed. Additional hours are being requested for supervision and not specifically for additional activities of daily living (ADLs).  
The subject under review is the medical necessity for PCA hours 8 hours a day 5 days a week for a total of 40 hours a week. These services were denied based upon lack of medical necessity.

The health plan's determination is upheld in whole.

No, the requested health service of Personal Care Assistance 8 hours per day/5 days per week (Monday-Friday) for a total of 40 hours a week is not medically necessary for this patient. The services provided are sufficient to meet the patient's needs.
The patient is an older female with past medical history significant for dementia of Alzheimer's type, hypertension, urinary incontinence, gastroesophageal reflux disease, hypertension, anemia, chronic pain, breast cancer history, and diabetes mellitus. Additional services were requested mainly due to the patient's memory impairment and progressive Alzheimer's disease, stating that it is difficult to leave the patient alone.
Denial of the appeal was noted for the following reasons by the health plan. Regulations do not require a personal care assistant services for safety supervision alone, such as may be clinically necessary for someone with cognitive dysfunction. Personal care assistance hours for companion care or for safety supervision without the need for ADLs is not required to be covered under your benefit plan. It is not covered under as a separate or stand-alone function. Coverage will remain for services that support the patient's ADLs such as bathing and dressing toileting and housekeeping related services.
Uniform Assessment System (UAS) State of New York was done by telephonic method secondary to coronavirus. The patient is able to ambulate on her own with a Rollator walker. She is able to transfer. She currently lives alone in her own apartment. She is noted to be occasionally incontinent and does wear pull-ups. It was recommended the patient receive a total of 28 hours a week. These services include mainly homemaking services and the PCA services such as bathing, dressing, personal hygiene. There did not appear to be a significant change in the patient's level of function. There were no new medical conditions noted however it was noted that the patient did have decline in memory. Additional services requested were for safety supervision and not necessarily for other medical needs and are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes mellitus, glaucoma, hypertension and low back pain
Treatment: Consumer Directed Personal Assistance Program (CDPAP): seven hours per day, five days per week; five hours per day, one day per week - for a total of 40 hours per week
The insurer denied the Consumer Directed Personal Assistance Program (CDPAP): seven hours per day, five days per week; five hours per day, one day per week - for a total of 40 hours per week.
The denial is upheld. 

The patient is a female with a history of diabetes mellitus, glaucoma, hypertension and low back pain. 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 40 hours per week Consumer Directed Personal Assistance Program to offer increased activities of daily living (ADL) support.

No, the proposed treatment of 40 hours per week Consumer Directed Personal Assistance Program is not deemed medically necessary. 

This is a female with a history of diabetes mellitus, glaucoma, hypertension and low back pain. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). However, an in-home assessment of the patient's functionality and ability to perform activities of daily living (ADLs) was completed and revealed that the currently approved plan of four hours per day, six days per week, for a total of 24 hours per week Consumer Directed Personal Assistance Program Services is sufficient to meet the patient's current needs. There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment 40 hours per week Consumer Directed Personal Assistance Program is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Muscular Dystrophy
Treatment: Vyondys 53 Injections
The insurer denied the Vyondys 53 Injections. 
The denial is upheld. 

The patient is a male with Duchenne muscular dystrophy (DMD). 

No, the treatment with Vyondys 53 injections is not medically necessary.

There are no clinical trials to support that Vyondys 53 improves outcomes for persons with DMD (Duchenne muscular dystrophy).  This medication was approved based on the ability to increase dystrophin levels in muscle of children with DMD (Duchenne muscular dystrophy). No clinical benefit has been reported in persons treated with this medication. There is no evidence that this medication would improve outcomes for a patient with DMD (Duchenne muscular dystrophy) who cannot ambulate. 

The FDA's (Food and Drug Administration's) initial approval of Vyondys 53 for the treatment of DMD (Duchenne muscular dystrophy) was provisional. They subsequently clarified that there was no evidence to support clinical improvement using this medication. The FDA (Food and Drug Administration) is now requiring evidence of efficacy be provided for continued approval.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (failing restoration, tooth fracture and caries on tooth #5). 

Treatment: Root canal treatment (D3320), crown (D2751) with post and core (D2954) on tooth #5. 

The insurer denied coverage for the root canal treatment (D3320), crown (D2751) with post and core (D2954) on tooth #5. 

The denial is overturned. 

This is a female patient who presented to the dentist with pain in the right maxilla. A failing restoration, tooth fracture and caries were noted on tooth #5 on examination and endodontic therapy was recommended. The insurer has denied these services stating that the services are not medically necessary as the documentation did not demonstrate medical need to support the treatment, or fulfill stated criteria for approval. 

Upon review of radiographs, documentation supports the recommended treatment. The patient's tooth #5 has large carious lesion on the distal aspect encroaching on the pulp radiographically and a failing existing restoration. There is ample coronal structure remaining. This tooth would require endodontic therapy to salvage the tooth. This tooth will have adequate residual coronal structure for support of a post and core and crown and have adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be endodontic therapy for this tooth and subsequent post and core and crown which would have an excellent long-term prognosis with the recommended treatment. 

Thus, the root canal treatment (D3320), crown (D2751) with post and core (D2954) on tooth #5 is considered medically necessary for this patient as the clinical and radiographic documentation supports these services, and these services would be a standard of care in general dental practice. 

The health care 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 root canal treatment (D3320), crown (D2751) with post and core (D2954) on tooth #5 is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Juvenile Idiopathic Arthritis, Enthesitis Related Arthritis.
Treatment: Stelara SQ (subcutaneous) 45MG (milligrams)
The insurer denied the Stelara SQ (subcutaneous) 45MG (milligrams).
The denial is overturned. 

The patient is a female with a diagnosis of Juvenile Idiopathic Arthritis, Enthesitis Related Arthritis.  She has severe disease that has been treatment refractory to multiple medications, including methotrexate, infliximab and etanercept.  Her board-certified pediatric rheumatologist recently started the patient on Ustekinumab (Stelara), and she has had "improvement in her arthritis symptoms," including now bearing weight and out of a wheelchair.  The provider is asking to continue treatment with Ustekinumab for the patient's treatment-refractory disease.  

Yes, the treatment with Stelara is considered medically necessary.

This patient has a rare form of Juvenile Idiopathic Arthritis known as Juvenile Idiopathic Arthritis, Enthesitis Related Arthritis (JIA, ERA).  There are no FDA (Food and Drug Administration)-approved treatments available specifically for JIA, ERA (Juvenile Idiopathic Arthritis, Enthesitis Related Arthritis). Treatment recommendations from the American College of Rheumatology include the following medications: NSAIDs (nonsteroidal antiinflammatory drugs), methotrexate and TNF (tumor necrosis factor) inhibitors.  These medications have already been trialed and failed for this patient as documented by the provider in their appeal letter.  

A recent case series article (Mannion et al, see below) shows efficacy and safety of Ustekinumab in patients with JIA, ERA (Juvenile Idiopathic Arthritis, Enthesitis Related Arthritis).  Based on this data, the provider has started the patient on Ustekinumab with improvement in the patient's symptoms.  It is therefore medically necessary to continue treatment of this patient with Ustekinumab.  It would not be in the best interest of this patient to discontinue therapy at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperkalemia/End Stage Renal Disease. 
Treatment: Pharmacy/Prescription Drugs (Veltassa). 

The health plan denied the request for Veltassa. 
The health plan's determination is overturned. 

The patient is a male. The request is for Veltassa for the treatment of hyperkalemia. He also has end stage renal disease status post-transplant. He tried Lokelma without improvement in his potassium level. His potassium level was 4.9 on Veltassa and the creatinine was down to 1.27. 

At issue is the medical necessity of the requested drug, Veltassa. 

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

Yes. The request for Veltassa is medically necessary. It appears that the patient has tried Lokelma and Sodium Polystyrene Sulfonate (SPS). All the formulary alternatives (SPS 454 powder, Kionex suspension and SPS suspension) are the same drug (Sodium Polystyrene Sulfonate). 

In one study, initiation of Sodium Polystyrene Sulfonate in patients with advanced CKD (chronic kidney disease) was associated with a higher risk of severe gastrointestinal (GI) complications as well as the initiation of GI-related medications, particularly when prescribed at per label doses [5]. In addition, there have been many cases of colonic necrosis and perforation associated with administration of SPS [6]. 

Per the current literature, at one-month follow-up, Veltassa had lowered serum potassium by 0.65 to 1.01 meq/L (milliequivalents per liter) in data from three trials.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Acne
Treatment: Dapsone 7.5% gel
The insurer denied Dapsone 7.5% gel
The determination is upheld.

The patient has acne of the face and back. The patient could not tolerate tretinoin on the face because of its drying action, so it was only placed on the back. Aczone is also being used on the face. Oral doxycycline, 100 milligrams (mg)/day and 10% benzoyl peroxide wash are also being used. Dapsone 7.5% gel (Aczone) is under review.

The patient is using both oral antibiotics and benzoyl peroxide wash, so that the use of a topical antibiotic such as Aczone (Dapsone) could be just as effectively replaced with topical clindamycin, sulfacetamide or benzoyl peroxide (a "leave-on" medication, not a wash). Current medical literature [1-5] supports the use of all of the aforementioned agents as both effective and appropriate for this patient's particular scenario, and different oral antibiotics could be used as well. If topical tretinoin is too drying for the patient's face, then topical adapalene cream could be considered as a less drying topical retinoid as well.
Accordingly, the formulary alternatives are not any less effective, appropriate, or with significantly greater side effects compared to the requested Dapsone (Aczone) gel.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Prescription Drugs (Taltz)
The health plan denied the requested prescription Drug (Taltz).
The health plan's determination is upheld.

The patient is a female with a past medical history (PMH) of palmo-plantar psoriasis. The patient has dried pustules, and the palms/soles have desquamating scales. She has tried and failed topical steroids, Cosentyx, Tremfya, Humira, Otezla, Methotrexate, and Soriatane. The patient developed hidradenitis after she stopped Humira. The patient has joint pain and did not achieve relief after starting Cosentyx. The patient has a history of nail psoriasis as well. The provider wants to start Taltz.

At issue is the medical necessity of the requested medication.

The health plan's determination is upheld, in whole.

This patient has tried and failed many conventional DMARDs (Disease Modifying Anti-Rheumatic Drugs) and biologic drugs to treat her palmo-plantar psoriasis. The formulary drug choices available to this patient include: Cimzia, Skyrizi and Stelara. Since she developed hidradenitis after going off Humira, Cimzia may not be the best choice at this time due to the tumor necrosis factor (TNF) mechanism of action (MOA). However, she has tried and failed (IL=Interleukin) IL-17 MOA with Cosentyx and Taltz is another IL-17 drug. She has not tried and failed an IL-23 drug such as Skyrizi or Stelara as of yet, shown an intolerance or had any contraindication to these drugs. Therefore, she must first try and fail either Skyrizi or Stelara before Taltz can be covered. Skyrizi has been shown to be highly effective in the treatment of psoriasis.