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

Diagnosis: Chest pain and worsening left shoulder pain. 

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 ischemic heart disease, hypertension, diabetes and transient ischemic attack (TIA) who presented to the hospital with chest pain and a several month history of worsening left shoulder pain. Pain was exacerbated with arm movement. She also noted right arm weakness. On arrival to the Emergency Department (ED), vital signs were stable [blood pressure (BP) 155/79, Pulse 87 beats per minute (bpm)]. Physical exam was notable for increased shoulder pain with left arm movement. Electrocardiogram (ECG) revealed left ventricular hypertrophy with associated ST depressions and T wave inversions. Serum blood testing revealed an elevated glucose (541). Serum troponin was <0.01 on serial measurements. The patient was evaluated by a cardiologist who felt that symptoms were due to musculoskeletal pain. Myocardial perfusion study revealed no evidence of ischemia or infarct and left ventricular (LV) ejection fraction of 60%. The patient was discharged home with follow up. 

Inpatient admission was not necessary for this patient. Although the patient had a history of coronary artery disease and a high pretest probability of coronary artery disease there is clear evidence from the physical exam that pain was reproducible with arm movement.(1) Risk assessment of patients presenting with chest pain was reviewed by Hedayati et al.(2,3) Although this patient had a HEART (History, Electrocardiogram, Age, Risk factors, Troponin) score that placed her at intermediate risk for major adverse cardiac events, the clinical presentation was consistent with an etiology of musculoskeletal pain. The patient was not truly at risk for subsequent cardiac sequelae. Numerous studies have demonstrated that work up for such patients can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care.(4,5) They found no significant difference in outcome at 30 days between the two groups. Fernando Bellolio et al. noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30 day myocardial infarction rates as those admitted to the hospital.(5) 

Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been managed at a lower level of care. 

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

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

Diagnosis: Congenital trans radial amputation
Treatment: Upper Extremity Prosthesis (computerized socket) (L7499)
The insurer denied the Upper Extremity Prosthesis (computerized socket) (L7499). 
The health plan's determination is overturned. 

The patient is a female with a right very short congenital trans radial amputation. She was previously denied a request for L7499 Upper Extremity Prosthesis (computerized socket). This is the subject under review.

The requested upper extremity prosthesis (computerized socket) is medically necessary and appropriate for this patient. This patient is a lifelong amputee. Her current prosthesis is old and beyond repair. Documentation notes that her residual limb is extremely short [3-4 centimeter (cm)] and this, combined with her normal aging muscle atrophy, has resulted in improper fit, pain and inability to successfully complete activities of daily living. Therefore, a prosthetic design with myoelectric control, auto-grip hand, flexible inner socket and the high-fidelity (HiFi) interface system biomechanical socket is medically necessary and appropriate for this patient. It will also provide a more secure fit with precise movements and better energy efficiency, comfort and decreased risk of skin breakdown.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

Diagnosis: Appendicitis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the hospital with a history of progressively worsening abdominal pain. His evaluation included a physical exam, labs, an ultrasound and computed tomography (CT) scan. He was without a fever at the time of presentation. Lab data identified an elevated white blood cell count (WBC) count of 21.8 thousand (K). An abdominal ultrasound and CT scan yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was requested.
The patient underwent a laparoscopic appendectomy. The operative dictation describes a suppurative appendicitis. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. He was provided IV fluid and perioperative antibiotics. The vital signs remained normal throughout the hospitalization without a fever. His diet was advanced and pain management was converted to oral medications. He was discharged home.
At issue is the medical necessity of an inpatient stay.
Inpatient stay was not medically necessary for this patient. The care and treatment provided could have appropriately been rendered with a lower level of care.
This patient presented with abdominal pain. The evaluation with examination, lab data, ultrasound and CT scan suggested the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and an appendectomy. The early post-surgical course was uncomplicated and the patient was clinically stable for discharge from the hospital on the first post-surgical day.
The patient was clinically stable at the time of presentation and remained so during the course of care. While the initial WBC count was elevated, he responded promptly and appropriately to the treatment provided. 
Generally accepted medical standards indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the procedure of appendectomy may be performed with an observational level of care. In this case, the patient tolerated oral hydration, diet and medication and pain was well controlled. Presurgical assessment, laparoscopic appendectomy and post-surgical monitoring could have been provided at a lower level of care. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Sarcoidosis with skin involvement. 
Treatment: Humira 40 milligrams (mg).

The insurer denied Humira 40 milligrams (mg). The health plan's determination is upheld. 

The patient is a female who suffers from pulmonary sarcoidosis with skin involvement. The patient has been complaining of shortness of breath and cough. The patient has been on prednisone and Plaquenil. The patient gained weight while on the steroid. The provider is requesting the coverage of Humira. The subject under review is the medical necessity for Humira.

The health plan's determination is upheld in whole.

The requested health service/treatment of Humira 40 mg is not medically necessary for this patient. Sarcoidosis is a multisystem disorder of unknown cause with a highly variable course. Corticosteroids are considered the standard agent for treatment. Tumor necrosis factor-alpha (a) is thought to be crucial in the development of the typical granulomas in sarcoidosis. Many case reports and case series suggest that specific therapy targeted against this cytokine is very effective. Despite these promising results, only limited evidence is found in multicenter randomized controlled trials.

Based on Milliman care guidelines, adalimumab (Humira) may be indicated for:  1) Rheumatoid arthritis, 2) Psoriatic arthritis, 3) Ankylosing spondylitis, 4) Plaque psoriasis, 5)  Juvenile idiopathic arthritis, 6) Crohn disease, 7) Hidradenitis suppurativa, 7) Ulcerative colitis, or 8) Uveitis (noninfectious, chronic).

This patient suffers from sarcoidosis. Milliman care guidelines do not recommend the use of Humira for the treatment of sarcoidosis. The Food and Drug Administration (FDA) did not approve Humira for the treatment of sarcoidosis. The available evidence regarding the efficacy of Humira in patients with sarcoidosis is limited to either small, uncontrolled, short-term and/or retrospective studies. There are no well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long term efficacy and safety of Humira in the treatment of sarcoidosis. There is no high-quality literature showing an improvement in health outcomes with the use of Humira for this patient condition.

Humira is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied the Braces.

The determination is overturned.

The patient had an anterior crossbite on tooth number 6. He presented with a skeletal Class I malocclusion with crowding in the maxilla and mandible. He is treatment planned for 36 months of orthodontics to address the crowding and crossbite, but the treatment was denied due to a lack of medical necessity. At issue is the medical necessity of braces

The braces are medically necessary.
This patient presented with an anterior crossbite on tooth number 6, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3) If left untreated the damage that will likely occur to the patients teeth will be much more time consuming to correct than the patient's existing orthodontic problem. The braces are  medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional/Diabetes.
Treatment: Pharmacy/Prescription Drugs-Humulin N Kwikpen.
The health plan denied the requested prescription drug-Humulin N Kwikpen as not medically necessary. 
The health plan's determination is upheld.

This is a male diagnosed with type 2 diabetes mellitus (T2DM). This request is for Humulin. As reported, his diabetes was complicated by proteinuria and neuropathy. He remains on steroids and insulin injections. His current regimen: Jentadueto 2.5 mg-1000 milligrams (mg) through mouth (per orem), by mouth, or oral nutrition (po) twice daily (BID); Novolog insulin via sliding scale coverage for sugars >180; Humulin NPH 16-18 units subcutaneous (sq) . Humulin NPH is not the only NPH that comes in the pen and the patient needs a pen device.
At issue is whether the formulary drug will be as effective as the non-formulary drug.

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

No, the requested medication is NPH. It is Food and Drug Administration (FDA) approved for diabetes. There are no studies showing superiority of one NPH formulation over another. Novolin NPH and Humulin NPH are interchangeable [1-3].
The formulary alternative is Novolin N. This comes in a pen formulation as well as vials. The patient is reported to need a pen formulation. The patient can use Novolin N in a pen formulation. The formulary alternative would be effective and is not expected to have any difference in the side effect profile.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This case describes a patient with a complaint of left knee pain. She had advanced left knee osteoarthritis and failed conservative treatment of this condition. She elected to undergo left total knee replacement surgery. This surgery was completed without any documented complications. The patient recovered well and was deemed stable for discharge to home with home health and home therapy.

The requested health service/treatment of an inpatient stay was not medically necessary for this patient. The medical records document that this patient underwent elective left total knee replacement surgery. The surgery was successful with no documented complications. There was no documentation of bleeding, or infection and the patient progressed well with supervised physical therapy following the surgery. The patient did have a documented vasovagal episode while straining on the toilet. The progress notes document that she quickly regained consciousness and had no head trauma or fall. Her vital signs quickly stabilized, and she denied any chest pain, nausea, or vomiting. The next day the patient had no complaints, and her vital signs and lab values were normal. Based upon the documentation in the medical records, the inpatient admission  was not medically necessary.
The current, peer-reviewed orthopedic literature, including articles published by Mears and colleagues in the Journal of Surgical Orthopedic Advances and by Rutherford and associates in the Orthopedic Clinic of North America have endorsed short stay and outpatient knee replacement surgery as both safe and effective for select patients. Based on the documentation in this case and the recommendations of these peer-reviewed articles, the inpatient hospital stay was not medically necessary. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Caries. 

Treatment: Extractions, osteoplasty (bone repair), bone grafting, and implants (D1530, D5850, D5110). 

The insurer denied coverage for extractions, osteoplasty (bone repair), bone grafting, and implants (D1530, D5850, D5110). 

The denial is overturned. 

The patient  with underlying diagnoses of Sjogren's syndrome, Lupus and epilepsy with history of seizures, presented for dental evaluation. Extensive caries was noted affecting the remaining dentition, particularly in the mandible, attributed to the xerostomia secondary to her underlying medical conditions. Therefore, the recommended treatment from her doctor was for extractions, osteoplasty and an endosteal implant retained mandibular denture. The insurer  has denied these services as not medically necessary as the services recommended do not meet their medical necessity criteria and there is no documentation provided that indicated the patient cannot wear a conventional prosthesis. The attorney is appealing on behalf of the patient, noting in summary that functionally there are no alternatives other than the recommended treatment for this patient and this is dictated by her underlying medical conditions. 

Based on review of the documentation it appears that this patient is exhibiting significant dental decay and compromise with a failing dentition secondary to her underlying medical conditions. In this case, a standard of care in dental practice would be the aforementioned recommended treatment. 

Peer reviewed literature supports implant  retained dentures in this clinical circumstance to restore function. Further, as per the insurers policy guidebook, implants are covered services and this patient clinical circumstance fulfills their medical necessity criteria. As this is the case and these are covered services, the implant retained denture and associated services are deemed medically necessary. 

The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient. Extractions, osteoplasty (bone repair) bone grafting and implants (D1530, D58SO, D5110) are considered medically necessary for this patient. 

The insurer's denial of coverage for extractions, osteoplasty (bone repair), bone grafting, and implants (D1530, D5850, D5110) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Coronary Artery Disease (CAD), GERD (gastroesophageal reflux disease), Dizziness, Urinary Incontinence, Hearing loss, Peripheral Vascular Disease (PCD) and Diabetes Mellitus (DM). 

Treatment: Increase Personal Care Services To 24 Hours Per Day, 7 Days Per Week (live in) A Total of 91 Hours. 

The insurer denied the Increase Personal Care Services To 24 Hours Per Day, 7 Days Per Week (live in) A Total of 91 Hours. 

The denial is overturned. 

The patient is a female with a history of Coronary Artery Disease (CAD), GERD (gastroesophageal reflux disease), Dizziness, Urinary Incontinence, Hearing loss, Peripheral Vascular Disease (PCD) and Diabetes Mellitus (DM). Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of an increase in Personal Care Services to 24 Hours Per Day, 7 Days Per Week (live in) a total of 91 Hours to offer increased ADL (activities of daily living) support. 

Yes, the Increase Personal Care Services To 24 Hours Per Day, 7 Days Per Week (live in) A Total of 91 Hours is medically necessary. 

The patient is a female with a history of Coronary Artery Disease, GERD (gastroesophageal reflux disease), Dizziness, Urinary Incontinence, Hearing loss, Peripheral Vascular Disease and Diabetes Mellitus. Due to impairments related to these conditions, she requires assistance for completion of the majority of his activities of daily living (ADLs). 

Although an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and came to the conclusion that the currently approved plan of 84 hours/week Personal Assistance Services is sufficient to meet the patient's current needs, the patient and her daughter relate that this schedule leaves her home alone, completely unassisted for multiple hours per day. This is problematic, as she has been experiencing worsening fluctuations in her cognition, memory, gait with recent falls, and chronic gait ataxia. 

Hence, provision of 91 hours/week Personal Assistance Services can reasonably be expected to be beneficial for the patient, and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 91 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Skyrizi, Pre-service
The insurer denied the Skyrizi, Pre-service.
The denial is overturned. 

The patient is a male with severe plaque psoriasis. He presents with itchy, erythematous plaques with silvery scales on the bilateral extensor elbows, knees, posterior auricular area, scalp, bilateral axillae, and groin. He has 12% body surface area (BSA) affected. He has tried and failed numerous medications, including betamethasone, fluticasone, triamcinolone, fluocinonide, mometasone, Otezla, and intralesional Kenalog injections.

Yes, the treatment with Skyrizi is medically necessary.

The patient has severe psoriasis for which systemic therapy is indicated. In the era of biologic therapies for psoriasis, the use of methotrexate or cyclosporine is not the most appropriate first-line treatment because their long-term safety and efficacy are inferior to biologic therapies. Because of involvement of sensitive areas, phototherapy is not appropriate.

Skyrizi (also known by its generic name risankizumab-rzaa) was approved by the United States Food and Drug Administration (FDA) for the treatment of moderate-to-severe plaque psoriasis in adults. Skyrizi works within weeks. Three out of four patients saw 90% clearer skin within four months (16 weeks). In clinical trials, Skyrizi helped people achieve both clearer skin and psoriasis symptom relief. A majority achieved 100% clear skin at one year. At four months (16 weeks), on average, people reported a significant improvement in the pain, itching, burning, and redness of psoriasis.

Biologics show superior results to conventional systemic therapies (70% improvement versus 40% improvement) for the treatment of patients with moderate to severe psoriasis, as measured by decrease in simple-measure for assessing psoriasis activity (S-MAPA) (physician global assessment [PGA] multiplied by body surface area) at week 24. These results were observed despite the fact that patients on biologics had a greater baseline severity and had a greater number of previous treatments.

Based on the above data, Skyrizi is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Carcinoma with liver metastasis.
Treatment: Inpatient admission.

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

The patient had colon carcinoma with liver metastases. He had required a colostomy. He presented with nausea and elevated liver enzymes. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. A Computed Axial Tomography (CAT) scan showed biliary dilatation and metastatic liver disease. An endoscopic retrograde cholangiopancreatography (ERCP) with stent placement was performed. He was switched to oral antibiotics to complete a 10-day course.

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone (M-555) include having acute cholangitis if it is associated with systemic signs of inflammation, such as fever or leukocytosis. The patient did not have systemic signs of inflammation. Admission is also indicated for a bile duct obstruction if it is associated with hemodynamic instability, severe vomiting, severe dehydration, or bacteremia. The patient did not have these conditions.

Clinical indications for admission for Vomiting (M-370) include gastrointestinal obstruction, hemodynamic instability, severe electrolyte abnormalities, acute renal failure, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had advanced carcinoma with liver metastasis. He had bile duct dilatation and required an ERCP with stent placement. However, this procedure could have been done on an outpatient basis. He did not meet Milliman Care Guidelines (MCG) criteria for admission for either Bile duct inflammation or Stone or vomiting. The healthcare plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.