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

Diagnosis: Tear of lateral collateral ligament, subsequent anterior cruciate ligament (ACL) tear
Treatment: Physical therapy (PT) evaluation moderate complexity, CPT code 97162 
The insurer denied PT evaluation moderate complexity, CPT code 97162.
The determination is upheld.

The patient has diagnoses of tear of lateral collateral ligament, subsequent anterior cruciate ligament (ACL) tear, gait abnormality, pain and muscle weakness. Records provided show that a physical therapy evaluation code 97162, evaluation of moderate complexity was denied noting that a nonparticipating physician is seeking coverage for repeat evaluation of moderate complexity. The provider did not obtain prior authorization pretreatment. It was noted that coverage for moderate complexity evaluations were denied as a physical therapy evaluation was previously billed for the same condition and an initial evaluation should not be billed on each visit. Appeal letters from the physical therapist stated that the patient was seen regarding lateral collateral ligament tear, subsequent ACL tear, gait abnormality, pain and muscle weakness. The patient was noted to be a runner, running multiple marathons. The provider stated that the patient was progressing in physical therapy but still had some deficits and was appealing for further therapy. At issue is the medical necessity of the physical therapy evaluation-moderate complexity, current procedural terminology (CPT) code 97162.

The requested health service/treatment of physical therapy, CPT code 97162 was not medically necessary for this patient. Records indicate the patient had a history of lateral collateral ligament tear and subsequent ACL tear with abnormality of gait, pain and muscle weakness. The patient was participating in physical therapy services and records show that the patient underwent an initial physical therapy evaluation, moderate complexity billed as CPT code 97162. The provider then requested retrospective coverage for physical therapy services, which were medically necessary and were approved. However, the provider also billed for moderate complexity evaluation on additional dates. This is not medically necessary as they were for the same condition. There was no documentation of an exacerbation or a new episode of care that would require a new evaluation. The requested health service/treatment was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Psoriasis.
Treatment:  Skyrizi.

The insurer denied Skyrizi. The health plan's determination is upheld.

The patient is a male with diagnoses of moderate to severe psoriasis (involving the upper and lower extremities) and psoriatic arthritis. The patient has tried and failed topical clobetasol, triamcinolone, fluocinonide, hydrocortisone, and calcipotriene, as well as phototherapy, Enbrel, and Cosentyx.

Skyrizi is not medically necessary for this patient.

The patient has no documented treatment failure with, or true medical contraindication to the time-tested, standard, and plan-preferred first-line biologic therapy Humira. Humira's efficacy is significantly higher than the previously-failed Enbrel (50% psoriasis area and severity index (PASI) 75 reduction score at four months), despite their mechanisms of action being similar with respect to inhibiting Tumor Necrosis Factor. Particularly for a patient with this particular history of biologic psoriasis therapy previously utilized, this preferred agent (Humira) is as appropriate for the treatment of this patient's clinical scenario as is the requested Skyrizi. Therefore, Skyrizi is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Dysphagia and chronic reflux
Treatment POEM (Peroral Endoscopic Myotomy) procedure
The insurer denied the POEM procedure.
The determination is overturned.

The patient has suspected achalasia type 3. She has had dysphagia and chronic reflux despite omeprazole 40 milligrams (mg) twice daily with famotidine 40 mg at bedtime. She had regurgitation, chest pain, nausea, and unintentional weight loss in the past. Esophageal manometry  showed an elevated integrated relaxation pressure, distal contractile integral, intact peristalsis, and gastroesophageal outlet obstruction; the findings were suggestive of achalasia type 3. She had an Eckardt score of 10. She had an upper endoscopy with esophageal dilation. At issue is whether the POEM Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Peroral endoscopic myotomy (POEM) is likely to be more beneficial than any standard treatment or treatments for the treatment of the enrollee's achalasia (type 3). The American Gastroenterological Association best-practice for peroral endoscopic myotomy states that "if the expertise is available, POEM should be considered as a treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes" (Kahrilas, et al). The American Society for Gastrointestinal Endoscopy has recently published a statement based on available evidence, recommending POEM as the preferred treatment of type 3 achalasia (Khashab, et al). Clinical studies and trials have shown comparable efficacy with surgery when expertise in POEM is available (Barbieri, et al; Schlottmann, et al). However, despite comparable efficacy, POEM is significantly less invasive than surgical intervention, resulting in less postoperative pain and a more rapid recovery (Docimo S, et al). In this patient, with symptoms including dysphagia, the use of POEM is supported by current medical literature and guidelines. For these reasons, POEM should be considered likely to be more beneficial than any standard treatment or treatments for the patient's type 3 achalasia.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Dysphagia and chronic reflux
Treatment POEM (Peroral Endoscopic Myotomy) procedure
The insurer denied the POEM procedure.
The determination is overturned.

The patient has a history of chronic heartburn and dysphagia. The patient underwent manometry and upper endoscopy which documented changes most consistent with severe esophagogastric junction (EGJ) outflow obstruction. Achalasia has been ruled out; this is confusing as her original gastroenterology (GI) doctor felt confident she had achalasia. The patient failed to respond to a proton pump inhibitor (PPI) and histamine type 2 (H2) blocker therapy. Her dysphagia is severe and significantly affects her quality of life.
The patient's provider is requesting approval for the peroral endoscopic myotomy (POEM) procedure. At issue is whether it is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes. The POEM procedure is a "third space" endoscopic procedure which results in a myotomy of the LES (lower esophageal sphincter) via an endoscope. It achieves remarkable relief of dysphagia in achalasia and several other motility disorders including spastic disorders of the esophagus and EGJ outflow obstruction. In head-to-head trials for achalasia, using the Eckardt dysphagia scoring system, the results are equivalent between POEM and Heller myotomy. POEM is far less invasive with fewer side effects. The POEM procedure is likely to be more beneficial than a Heller Myotomy for the insured's achalasia/EGJ outflow obstruction. This is because it is a non-operative way, that is far less invasive, to cut the lower esophageal sphincter and markedly improve the patient's swallowing difficulties.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent SOSY (solution prefilled syringe) 300mg (milligrams) per 2ml (milliliters). 

The insurer denied: Dupixent SOSY (solution prefilled syringe) 300mg (milligrams) per 2ml (milliliters). 
The denial is overturned. 

The patient is a toddler aged female with atopic dermatitis, treated with topical medications, antihistamines and emollients. The patient has severe disease with over 60% BSA (body surface area). The provider is requesting Dupixent. The health plan denied coverage of the request because it requires the use of Eucrisa or Opzelura.

The requested Dupixent is medically necessary. 

Eucrisa is indicated only for mild to moderate atopic dermatitis, and Opzelura is only approved for ages 12 and up. This patient has severe disease. Dupixent is now FDA (United States Food and Drug Administration) approved for ages 6 months and up. Given the disease severity and failure of other appropriate topicals, Dupixent is medically necessary. 

The randomized, double-blind, placebo-controlled, parallel-group, phase 3 trial (Paller et al) was conducted in 31 hospitals, clinics, and academic institutions in Europe and North America. Eligible patients were aged 6 months to younger than 6 years, with moderate-to-severe atopic dermatitis. At week 16, significantly more patients in the dupilumab group than in the placebo group had IGA (Investigator's Global Assessment) 0-1 (23 [28%] vs three [4%]), and EASI [Eczema Area and Severity Index]-75 (44 [53%] vs eight [11%]). No dupilumab-related adverse events were serious or led to treatment discontinuation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: congestive heart failure, respiratory failure with hypoxia and hypercapnia on bilevel positive airway pressure (Bipap), cardiorenal syndrome with renal failure.

Treatment is CDPAS 24 hours a day, 7 days a week (split shift)

The insurer denied coverage for CDPAS 24 hours a day, 7 days a week (split shift)
 
The denial is overturned

This is an older adult with multiple medical problems including congestive heart failure, respiratory failure with hypoxia and hypercapnia on bilevel positive airway pressure (Bipap), cardiorenal syndrome with renal failure. The patient is bedbound and is currently approved by the insurer for consumer directed personal assistance services (CDPAS) 24 hours a day, 7 days a week (live-in); an increase in services to 24 hours a day, 7 days a week (split shift) is requested and is currently under review. 

According to the Uniform Assessment System (UAS) report the patient's cognition is described as modified independent. However, the patient is totally dependent for bathing, lower body dressing, locomotion and toilet use. The patient is frequently incontinent of bowel and bladder. The patient requires maximal assistance for personal hygiene and upper body dressing. Extensive assistance is needed for bed mobility and eating.  The patient is transferred to and from the bed via a Hoyer lift. Additional needs include adjusting nasal cannula (4 liters/minute) and Bipap machine, as well as repositioning every 2 hours. The currently approved CDPCAS (consumer directed personal care assistance services) 24 hours a day, 7 days a week (live-in) is insufficient to meet the daily/nightly functional needs of the patient. The patient's condition and functional needs are at a level and unpredictable as to require the requested CDPCAS 24 hours a day, 7 days a week (split shift). The patient's health and safety can be more appropriately provided and maintained at home with the requested CDPCAS 24 hours a day, 7 days a week (split shift).

From a physical medicine and rehabilitation perspective, the requested CDPCAS change to 24 hours a day, 7 days a week (split shift) is medically necessary.  

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 consumer directed personal care assistance services 24 hours a day, 7 days a week (split shift) services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pericarditis

Treatment: Kineret 100 mg (milligrams)/0.67 ml (milliliter) syringe

The insurer denied coverage for Kineret 100 mg/0.67 ml syringe.
 
The denial is upheld.

This is the case of an adult female with history of recurrent pericarditis. She initially presented with chest pain following an upper respiratory infection. Physical examination was significant for a pericardial friction rub. Serum blood testing revealed elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) (120 and 200 respectively). She was treated with colchicine and ibuprofen. She returned to the hospital complaining of persistent chest pain and difficulty breathing. ESR and CRP remained elevated. A 12-lead electrocardiogram (EKG) revealed diffuse T wave (interval on a EKG) changes and echocardiogram revealed a small pericardial effusion. Ibuprofen dose was increased, and colchicine continued. Hemoglobin was noted to be 7 grams/deciliter (g/dl) and ibuprofen was discontinued. Prednisone was initiated and symptoms abated. Several days later, tapering of Prednisone from 30 to 20 milligrams (mg) resulted in recurrent symptoms of chest pain. Prednisone dose was increased and interleukin (IL)-1 inhibitor for recurrent pericarditis (Kineret) was ordered. 

This patient presented with viral pericarditis. Following a trial of colchicine and nonsteroidal anti-inflammatory drug (NSAID) therapy, symptoms persisted, and inflammatory markers remained elevated. The patient was treated with Prednisone and tapering from 30 to 20 mg was performed within 2-3 days. Moreover, tapering of Prednisone was rapid in timing and dosage as compared to European Society of Cardiology (ESC) guidelines. (1) Current guidelines for use of Anakinra- IL 1 inhibitor (Kineret) recommends using after relapsing pericarditis that is diagnosed following several weeks of therapy with colchicine and NSAID therapy or colchicine and steroid therapy. (1,2) In this case, steroid treatment was not prescribed for a sufficient period prior to tapering. In conclusion, Kineret is not medically necessary in this case.

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

The insurer's denial of coverage for Kineret 100 mg/0.67 ml (milliliter) syringe for idiopathic pericarditis is upheld. Medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Peyronies disease
Treatment: Xiaflex
The insurer denied Xiaflex.
The health plan's determination is overturned.

The patient is a man with Peyronies disease (PD). He has a palpable plaque. His deflection is 30 degrees. He has intact erectile function but cannot satisfactorily achieve vaginal penetration. The problem has been present for one year. Xiaflex was recommended. It is the topic of review.

The patient has symptomatic Peyronies disease with a palpable penile plaque, 30 degree bend, intact erectile function. The problem has been present for one year or more. For this patient, the use of Xiaflex is indicated based on the guidelines of the American Urological Association (AUA). No alternative drugs exist for the intracorporeal treatment of Peyronies disease.

Per the AUA, "Clinicians may administer intralesional collagenase clostridium histolyticum in combination with modeling by the clinician and by the patient for the reduction of penile curvature in patients with stable Peyronie's disease, penile curvature > [greater than] 30 [degrees] and < [less than] 90, and intact erectile function (with or without the use of medications)."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's disease and Parkinson's-related psychosis, chronic kidney disease, sacral ulcer, DM (diabetes mellitus), and partial blindness.
Treatment:  Increase in CDPAP (consumer directed personal assistance program) services to round the clock home attendant services.

The insurer denied increase in CDPAP (consumer directed personal assistance program) services to round the clock home attendant services.  The denial is overturned.

The patient is an elderly male. He has a PMH (past medical history) of chronic kidney disease, sacral ulcer, DM (diabetes mellitus), and partial blindness. He reportedly has Parkinson's disease and Parkinson's-related psychosis. The patient has been having progressive functional decline. He has been having recurrent falls. He is dependent for all his ADLs (activities of daily living). The review is for increase in CDPAP (consumer directed personal assistance program) services to round the clock home attendant services.

The requested health service is medically necessary.

The patient has diagnosis of Parkinson's disease and has progressive functional decline. He has sacral ulcers. The patient is bed-bound and is essentially blind at this time. He has not been able to care for himself or do his ADLs (activities of daily living). He is totally dependent for transfers. The patient has not been able to toilet properly. He has limited mobility and has been having urinary and fecal incontinence. The patient has been having recurrent falls. He does not remember taking his medications on time. Because he is totally dependent for his care and transfers, the plan-approved 63 hours/week are not enough, and he will need round the clock services to ensure safety and prevent fall related complications. He needs help with toileting both during day time and night because of incontinence. He needs reminders for his medications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System - Asthma.
Treatment: Tezspire.

The insurer denied Tezspire.  The denial is upheld.

The patient is a male with persistent asthma with spirometry consistent with this diagnosis. He was on Dupixent but developed joint/bone pain, and it was decided to switch him to Tezspire. He has an absolute eosinophil count which is 100. The patient was on immunotherapy in the past and is on Spiriva.
At issue is the medical necessity of Tezspire.

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

No, the requested health service/treatment of Tezspire is not medically necessary for this patient.

There is no documentation that the patient is on high dose inhaled corticosteroids (ICS). The patient is only on Spiriva. There is no recent asthma exacerbations documented. As there is no documentation of exacerbations, oral corticosteroid rescue, a severe persistent asthma, or unscheduled visits and the patient is not documented to be on a high dose ICS, Tezspire is not medically necessary per the documentation.
Therefore, the requested health service/treatment of Tezspire is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

The patient presented with nausea, vomiting, and diarrhea. In the emergency room (ER) she had a fever which subsequently resolved. The vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. The renal function was normal. Her symptoms were felt to be related to cannabinoid use as well as gastroenteritis. Intravenous (IV) hydration and Reglan were given, and her symptoms improved. 

Clinical indications for admission for Gastroenteritis MCG (Milliman Care Guidelines) include having a suspected severe infection such as bloody diarrhea, severe abdominal pain, peritoneal signs, hemodynamic instability, severe dehydration, severe electrolyte disorders, or an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

Clinical indications for admission for Vomiting include having a severe metabolic derangement, vomiting that persists despite antiemetic treatment, bacteremia, acute renal failure, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had a gastroenteritis that was exacerbated by cannabinoid use. IV hydration, antiemetics, and Pepcid could have been given in the ER with observation status. She did not meet MCG criteria for admission for either Gastroenteritis or Vomiting. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

The denial is upheld. 

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

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

Diagnosis: Chronic low back pain / post-laminectomy syndrome. 
Treatment: Peripheral Nerve Stimulator. 

The insurer denied: Peripheral Nerve Stimulator. 
The denial is upheld. 

The patient is an elderly male with chronic low back pain / post-laminectomy syndrome. He has had multiple injections without any significant improvement. He persists to have low back and leg pain. A Sprint peripheral nerve stimulator (PNS) has been recommended. This was denied by the health plan stating that "This device has not been shown to be effective for your condition.  Treatments that are not shown to be effective are not medically necessary and are not covered benefits under your plan".

The proposed peripheral nerve stimulator is not medically necessary. 

The requested procedure is not a commonly accepted treatment for this condition and has not been shown to be effective in the treatment of chronic low back pain, as shown by high quality randomized control trials (RCT). There is a randomized controlled trial in the setting of chronic pain following amputation, but not this condition. These pathologies are quite different. Other case reports, and observational studies show some benefits in other pain conditions. Other more proven, conventional treatments have been shown to be superior in the literature, such as spinal cord stimulation. Some recent data has shown peripheral nerve stimulation may be effective as an add on therapy to spinal cord stimulator, but not as a standalone therapy. Given the lack of data to support an invasive procedure for this type of condition, the requested peripheral nerve stimulator is not medically necessary.