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

Diagnosis: Chronic Kidney Disease. 
Treatment: Kidney Transplant. 

The insurer denied: Kidney Transplant. 
The denial is upheld. 

This is an adult male patient being considered for a renal transplant.  The health plan's denial letter stated that a renal transplant was denied for no glomerular filtration rate (GFR) documented, and this patient was smoking marijuana.  A letter from the Transplant Coordinator claims a glomerular filtration rate (GFR) of 13 and recreational marijuana as not an absolute contraindication. 

The proposed treatment, renal transplant, is not medically necessary for it would not meet applicable and generally accepted practice guidelines. 
As per the letter of denial, "[T]he following criteria must be met - your provider must send documentation of the following: 1. recent blood test indicating your kidney function (eGFR) 2. documentation that you are in a doctor-prescribed program to help you stop using marijuana, and that you will stop using marijuana during the transplant and immediate time period after the transplant." 

As per the United Network for Organ Sharing (UNOS) National Guidelines: For an adult: A patient to receive a renal transplant must have glomerular filtration rate (GFR) of 20 or less documented or must be on some form of dialysis. No such documentation was submitted; there is no primary documentation of this patient's glomerular filtration rate (GFR) submitted. 

In addition, marijuana smoking has replaced cigarettes for this patient who is smoking marijuana five times per day seven days per week.  This is not recreational but habitual.  Substance abuse consultation may be indicated.   As per the Milliman Care Guidelines (MCG) National Guidelines: No contraindications can be present including: No ongoing substance use disorder that affects decision making.  This criterion is met as the patient has excessive use or marijuana which is of concern.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell anemia
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient is a female with a history of sickle cell anemia. She was seen in the emergency department with a history of fever at home. She was found to have a temperature of 99 degrees Fahrenheit, and a hemoglobin of 6.7. A chest X- ray did not show evidence of acute chest syndrome. Blood and urine cultures were negative. She was admitted to the hospital and received a blood transfusion. 

"Acute painful episodes are the most common reason for emergency department visits among patients with sickle cell disease (SCD). Early and aggressive pain management is a priority. Emergency providers (EPs) must also diagnose other emergent diagnoses in patients with SCD and differentiate them from vaso-occlusive crisis. EPs should be aware of cognitive biases that may misdirect the diagnostic process. Administration of intravenous fluids should be used judiciously. Blood transfusion may be considered. Coordination of care with hematology is an important part of the effective emergency department and long-term management of patients with SCD". (Lovett, P. B., et al., 2017).

"Pain is the leading cause of emergency department (ED) visits for individuals living with sickle cell disease (SCD). The care that is delivered in the ED is often cited by patients with SCD as the area of health care in greatest need of improvement. In 2014, the National Heart, Lung, and Blood Institute released guidelines for the care of SCD, including recommendations for the management of acute sickle cell pain in the ED". (Glassberg J. A., 2017).

"Sickle cell disease (SCD) complications begin with the polymerization of sickle hemoglobin (HbS). Thus, SCD therapies are focused on preventing HbS production or reducing the circulating amount of HbS". (Meier E. R. 2018). 

The inpatient hospital admission is not considered medically necessary. The medical records indicate that the patient has sickle cell anemia and had a history of fever and required a blood transfusion. This service could have been provided at a lower level of care. There is no documentation of acute chest syndrome, stroke, sepsis or splenic sequestration which required acute care hospitalization. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical records indicate that the patient has sickle cell anemia and had a history of fever and required a blood transfusion. This service could have been provided at a lower level of care. There is no documentation of acute chest syndrome, stroke, sepsis or splenic sequestration which required acute care hospitalization.
The insurer's denial of coverage for hospital inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholestasis. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female, gravida-3, para-2, at 31 weeks estimated gestational age with twin pregnancy who was admitted to the hospital for cholestasis. She had reported intermittent pruritis during the pregnancy, and had an abnormal bile salts lab done a couple weeks prior to this. She had been referred on the day of admission to the hospital after complaining of pruritis. Admission was recommended for "monitoring". 

The physician notes state the patient was placed in the hospital for "monitoring", but there are no interventions reported. The physician notes do not demonstrate any goals of the admission, or particular needs to support placing the patient in the hospital. Standard of care, per American College of Obstetricians and Gynecologists (ACOG), is outpatient fetal surveillance. The appeal reports that the elevated liver enzymes were a reason for admission. First, moderate elevation of liver enzymes is common in cholestasis. Second, the labs reported in this case (viral tests) are generally send-out labs with lengthy turnaround times. These tests are routinely done in the outpatient setting when investigating the lengthy differential diagnosis attached to liver disease. 
Therefore, the inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Stelara 90MG/ML (milligrams/milliliter) SC (subcutaneous) SOSY (solution prefilled syringe) every 4 weeks. 

The health plan denied the Stelara 90MG/ML SC SOSY every 4 weeks. 
The reviewer has overturned in whole the health plan's determination. 

This is a review for the use of Stelara (ustekinumab) to treat severe Crohn's disease (CD). This adult male patient has severe ileocolonic Crohn's disease. He has previously tried and failed steroids. He was started on Stelara but did not achieve mucosal healing. He has evidence of active inflammation, and his inflammatory markers (fecal calprotectin) are elevated. Hence the attending gastroenterologist is requesting the use of Stelara at the escalated dose of 90 milligrams (mg) subcutaneous (SC) every 4 weeks to treat this patient's severe Crohn's disease. 

The requested health service/treatment of Stelara 90mg/ml every 4 weeks is medically necessary for this patient. Dose escalation is the standard of care in patients with inflammatory bowel disease who are on biological therapy and not responding to standard dose of the medication. 

Since this patient was not responding to standard dosing of Stelara, it is reasonable to increase the dose of Stelara to 90mg every 4 weeks. Dose escalation in biologic therapy used in inflammatory bowel disease can be done either based on clinical symptoms or laboratory markers or endoscopic or radiological features with or without therapeutic drug monitoring. Dose escalation is done either by increasing the dose of the medication or shortening the interval between doses or sometimes a combination of both. There are only a finite number of biological agents used to treat inflammatory bowel disease and the standard of care is to optimize dose of the biological agent before switching to another agent. Therefore, it is medically necessary to use Stelara 90mg SC every 4 weeks to treat this patient's severe Crohn's disease.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Testicular Hypofunction
Treatment: Testosterone Gel.
The health plan denied the requested medication, Testosterone Gel as not medically necessary.
 The health plan's determination is upheld.

The patient is a male with testicular hypofunction. He has been treated with Androgel. Testosterone level was 1410. The patient is being treated with Testosterone Gel 1%.
At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

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

The patient has failed Androgel 1.62% but has not failed or been intolerant to Testosterone solution or Androderm. Neither of these agents is contraindicated. These formulary drugs have not been and will not be ineffective, would be effective as the non-formulary drug, and would not have adverse effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: giant cell arteritis (GCA)

Treatment is Actemra ACTPen 162MG (milligrams)/0.9ML (milliliter) SC (subcutaneous) SOAJ (solution auto injector).

The insurer denied coverage for Actemra ACTPen 162MG/0.9ML SC SOAJ
 
The denial is overturned.

The patient is diagnosed with giant cell arteritis (GCA). The patient is taking prednisone and the treating provider is requesting approval for Actemra, which is under review.

Actemra ACTPen 162MG/0.9ML is considered medically necessary for this patient. The patient is diagnosed with GCA. She also has a history of congestive heart failure (CHF) and hypertension (HTN), so she should not be on steroids, and is currently taking prednisone. The patient needs a steroid sparing agent. Actemra is the only FDA (food and drug administration) approved drug for the treatment of GCA.

"Giant cell arteritis (GCA) is the most frequent primary large-vessel vasculitis in individuals older than 50. Glucocorticoids (GCs) are considered the cornerstone of treatment. GC therapy is usually tapered over months according to clinical symptoms and inflammatory marker levels. Considering the high rate of GC-related adverse events in these older individuals, immunosuppressive treatments and biologic agents have been proposed as add-on therapies. Methotrexate was considered an alternative option, but its clinical impact was limited. Other immunosuppressants failed to demonstrate a significant favorable benefit/risk ratio. The approval of tocilizumab, an anti-interleukin 6 (IL-6) receptor inhibitor brought significant improvement. Indeed, tocilizumab had a noticeable effect on cumulative GCs' dose and relapse prevention" (Regent, A., & Mouthon, L. 2022).

Based on a review of the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations, the health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient. 

The patient is diagnosed with GCA. The patient is taking prednisone. The treating provider is requesting treatment with Actemra, which is the only Food and Drug Administration (FDA) approved treatment for GCA. The plan is requesting that the patient try methotrexate. However, methotrexate is not FDA approved for the treatment of GCA. Furthermore, Up to Date in a comparison of methotrexate vs (versus)  tocilizumab when added to prednisone noted that methotrexate showed mixed results in studies and required higher doses of prednisone when used in combination. Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Actemra ACTPen 162MG/0.9ML SC SOAJ services is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Brain Metastases.
Treatment: 5 Treatment sessions of Multi-Fraction Cranial Stereotactic Radiosurgery (SRS) (Using Photons).
The insurer denied: 5 Treatment sessions of Multi-Fraction Cranial Stereotactic Radiosurgery (SRS) (Using Photons).
The denial is upheld.

The patient is an adult male with stage IV (four) small cell carcinoma with brain metastases status post two prior courses of SRS (stereotactic radiosurgery). He now presents with three progressive brain lesions. The request is for approval of repeat SRS (stereotactic radiosurgery). 

The health plan should not cover the requested Stereotactic Radiosurgery.
The requested Stereotactic Radiosurgery is not more beneficial than any standard treatment for the insured's condition or disease. 

The standard of care for multiply progressive brain metastases secondary to small cell carcinoma is whole brain radiotherapy rather than SRS (stereotactic radiosurgery). SRS (stereotactic radiosurgery) is not proven to yield superior clinical outcomes in the patient's setting. Its use would be considered experimental, as there are insufficient publications to support its use for multiply progressive small cell cancer brain metastases.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major fall from a staircase resulting in rib fracture. 
Treatment: Inpatient Hospital Admission. 

The insurer denied the inpatient hospital admission. 
The denial is upheld. 

The patient is an adult male with history of liver transplant on immunosuppression, and diabetes. The patient has had previous falls with broken ribs and presented to the emergency department with a major fall from a staircase resulting in rib fracture. The patient had a complete trauma work up performed in the emergency room and was admitted for monitoring and pain control. The inpatient hospital admission was denied due to lack of medical necessity. This denial is being appealed. 

The proposed inpatient hospital admission was not medically necessary. 

The patient was admitted after a fall with a broken rib. The patient did not have severe pain. The patient was hemodynamically stable. The patient was at baseline within 24 hours of admission. The patient was awaiting physical therapy evaluation and disposition to rehab center. The proposed treatment is not medically necessary.  The patient's treatment course would have been expected to be safe and effective at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Breast Cancer. 
Treatment: Trastuzumab and Pertuzumab in combination with Docetaxel and Carboplatin. 

The insurer denied Trastuzumab and Pertuzumab in combination with Docetaxel and Carboplatin. 
The health plan's determination is overturned in part. 

This is a female with left breast cancer. Neoadjuvant therapy with trastuzumab + pertuzumab + docetaxel + carboplatin is under review.

The use of trastuzumab +docetaxel + carboplatin is medically necessary. 
The provider makes a point of stating that she was treating this patient based on data from the TRYPHAENA trial. To be eligible for this trial patients had to have a T2 or larger primary breast cancer with or without lymph node involvement. Based on the results of this trial, the Food and Drug Administration (FDA) granted accelerated approval for the addition of pertuzumab to neoadjuvant chemotherapy (NACT) and trastuzumab for patients with HER2-positive locally advanced, inflammatory, or early-stage (either greater than 2 centimeters (cm) in diameter or node-positive) breast cancer. This patient did not meet these criteria. Support for the use of pertuzumab is not present in national guidelines nor the peer-reviewed literature. For these reasons, the medical necessity for pertuzumab cannot be established. 
It should be noted, however, that non-anthracycline-containing neoadjuvant breast cancer regimens with trastuzumab are indicated for patients with 0.6 cm or larger lesions. Numerous trials have demonstrated a benefit in this setting and for these reasons, the National Comprehensive Cancer Network (NCCN), the authors of Up-To-Date, and the peer-reviewed literature support the use of trastuzumab + docetaxel + carboplatin.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cystic Fibrosis.
Treatment: Kalydeco.
The insurer denied the Kalydeco.
The determination is overturned.

This is a patient with cystic fibrosis with multiple complications, including significantly diminished lung function and life-shortening pulmonary infections, for whom insurance coverage for the CFTR channel modulator Kalydeco (ivacaftor) has been requested. The member's cystic fibrosis transmembrane regulator (CFTR) genotype is W1282X/W1282X. Coverage for this medication has been denied as the mutation does not appear on the list of mutations for which ivacaftor is indicated. This denial is being appealed. At issue is the medical necessity of Kalydeco.

The requested treatment is medically necessary for the patient. It is likely to be effective and therefore to improve lung function (among other benefits), quality of life, and longevity. Although the patient's mutations do not appear among those for which ivacaftor is indicated, additional mutations/genotypes for which it is effective are occasionally discovered. The patient's genotype is among those mutations. As medicine is constantly changing, coverage criteria may occasionally be outdated, as is the case here. Given the member's significant disease burden, a reasonable and sound decision made in the best interest of the patient would be a time-limited trial of ivacaftor.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Post procedure monitoring- cardiac catheterization.
Treatment: Inpatient admission.
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld.

This case involves a male with a history of chronic systolic heart failure with severe left ventricular (LV) systolic dysfunction, hypertension (HTN), chronic renal disease, diabetes type 2, and severe mitral regurgitation (MR). The patient was referred for left heart catheterization (LHC) for evaluation of exertional chest pain and abnormal stress test showing infarcts involving the inferior wall, inferoseptum, and apex with minimal ischemia. Records demonstrate that the patient underwent LHC showing occlusive mid left anterior descending (LAD) disease which required 1 drug coated stent via right radial approach without complications. Left ventricular end diastolic pressure (LVEDP) was elevated, 30 millimeters of mercury (mmHg). The patient was admitted under inpatient level of care overnight for monitoring. Telemetry remained stable showing normal sinus rhythm (NSR). The patient remained hemodynamically stable, asymptomatic and was discharged home the following day. 

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

Inpatient level of care was not medically necessary because the patient underwent elective percutaneous coronary intervention (PCI) without complications and remained hemodynamically stable post procedure, able to be discharged the following day.
Given the patient underwent elective PCI without complications and remained hemodynamically stable post procedure, inpatient level of care was not medically necessary. Rather, an alternate level of care would have been medically appropriate and safe in this case, and is supported by expert consensus guideline recommendations on discharge criteria following percutaneous coronary interventions. [1,2]
I recommend that the health plan's determination be upheld on the grounds the patient underwent elective PCI without complications and remained hemodynamically stable post procedure, making an inpatient level of care medically unnecessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with vaginal bleeding that had resolved. She presented to the emergency room with pelvic pain for the last two weeks that had worsened. She also had nausea, vomiting and dizziness. Pelvic ultrasound showed a ruptured ectopic pregnancy in the right adnexa. She had a laparoscopic right salpingectomy and evacuation of 800cc of hemoperitoneum. Estimated blood loss from the surgery was 200cc. She was admitted as an inpatient after surgery. After surgery, hemoglobin was 6.2 which was down from 8.7. She received 2 units of packed red blood cells and her hemoglobin was 8.2. She did well postoperatively, and met all milestones. She was discharged home.

The Inpatient Hospital Admission is not medically necessary for this patient.
The patient had an ectopic pregnancy that was treated with laparoscopy. She had anemia that was treated with a blood transfusion; however, her vital signs were not hemodynamically unstable. She did not have continued hemorrhage and the anemia was secondary to the hemoperitoneum evacuated during surgery. She had no concerns postoperatively about continued bleeding. She had no postoperative complications such as infection or dehiscence. She had no pulmonary nor anesthesia complications. She had no renal, hepatic or cardiac concerns. The surgery she had is considered an outpatient surgery and she could have been monitored under outpatient or extended care after surgery until she was clinically ready for discharge. There was no need for acute, high level inpatient care. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thoracic level spinal cord injury
Treatment: Ultra-lightweight wheelchair and wheelchair component carbon fiber side guards (codes K0005, K0108)
The insurer denied coverage for ultra-lightweight wheelchair and wheelchair component carbon fiber side guards (codes K0005, K0108)
The denial is upheld.

According to the clinical documentation provided for review, the patient has the medical diagnosis of thoracic level spinal cord injury. The patient has suffered a thoracic level spinal cord injury.  The patient presents with impaired mobility and function. The patient has a wheelchair (w/c), now reported to be too large. 

The treating team is requesting a new, ultra-lightweight wheelchair to address mobility and ambulatory deficits. The patient has intact cognition and lives in an accessible home. The treating provider ordered ultra-lightweight wheelchair and wheelchair component carbon fiber side guards, codes K0005 and K0108. The treating provider is requesting plan approval for treatment with ultra-lightweight wheelchair and wheelchair component carbon fiber side guards, codes K0005 and K0108.

The treating provider is requesting plan approval for treatment with ultra-lightweight wheelchair and wheelchair component carbon fiber side guards, codes K0005 and K0108.  While a new chair is necessary, there is no indication that an alternative device, lightweight wheelchair (w/c) as an example, is incapable of meeting this patient's mobility and mobility-related activities of daily living (MRADL) needs.  

To summarize, medical necessity for this model over another standard lightweight model is not substantiated.

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 ultra-lightweight wheelchair and wheelchair component carbon fiber side guards (codes K0005, K0108) services is not substantiated.