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

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

This patient is a previously healthy female who presented to the emergency department with the complaint of abdominal pain of three-days duration. She was three weeks post-partum.  Examination revealed right lower abdominal tenderness. Vital signs were normal at the time of presentation.  The white blood cell (WBC) count was normal at 10.5 thousand.  Surgical consultation was obtained. Computed tomography (CT) scan was completed showing findings of acute appendicitis.  The patient was started on intravenous antibiotics.  The patient underwent laparoscopy with appendectomy for the condition of appendicitis.

Following surgery, the patient was treated with intravenous fluids and analgesia.  Vital signs were consistently normal in the perioperative period.  She was transitioned to oral medications and diet.  She was discharged from the hospital following a period of recovery.  

The health plan rationale for denial is that the patient underwent uncomplicated appendectomy. The denial letter states that there was no documentation of need for an inpatient level of care and the care rendered could have been provided with an observational level of care.

No, the proposed inpatient admission was not medically necessary.
Inpatient care was not medically necessary for this patient.

Acute inpatient hospitalization was not medically necessary for this patient.  The medical records support that this patient could have been reasonably and safely monitored with an observational status.

This patient presented with abdominal pain.  Her evaluation with examination, lab data, and computed tomography scan supported the diagnosis of acute appendicitis.  She underwent uncomplicated appendectomy.  She was admitted to an inpatient level of care and was discharged from the hospital later the same day. 

There is no clinical documentation to support need for inpatient admission on this day.  The patient remained hemodynamically stable throughout the perioperative period, there was no fever, or documented complication of surgery.  This patient's clinical needs could have been satisfied with an observational level of care.  This level of care would have provided for pre-surgical assessment, surgical treatment and post-surgical recovery including overnight observation (if required).  The records support that the care provided was clinically appropriate.  It is the level of care (inpatient versus outpatient / observational) that is at issue in this case.

Alternative care would include an observational designation rather than acute inpatient care.  An observation level of care would have provided for pre-surgical assessment, surgical treatment and post-surgical recovery including overnight observation (if required).
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Left Sided weakness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is modified.

This case involves a patient who presented to the emergency department with complaints of the inability to move their left side.  The patient has a past medical history that does include hypertension.  The emergency department note is not provided. However, the history and physical indicated they had complaints of left-sided weakness with blurry vision.  The patient was evaluated in the emergency department for a stroke and after discussing with neurology a decision was made to administer tissue plasminogen activator (tPA).  The patient did receive tPA with improvement in numbness and improve strength to the left side.  The patient had a blood pressure of 158/109 with a heart rate of 65, oxygen saturation was 97% (percent) on room air, and physical examination revealed they were alert and oriented, and in no apparent distress.  The documentation did indicate the patient was able to smile which was noted to be symmetrical and tongue was midline.  They continued to have weakness in left upper and lower extremity however it was improving.  A chest x-ray was also negative.  The physician detailed the patient was likely status post, acute cerebral vascular accident (CVA) with tPA administration.  The patient was admitted to critical care and recommended for continued monitoring.  The documentation indicated she continued with treatment that included medication and assessment.  The documentation detailed she did not have any further significant adverse events throughout the hospital stay.  The patient was noted to be stable for discharge with instruction to follow-up.

Given the documentation indicated, the patient presented with the possibility of having a stroke, and was given tPA, a 24-hour admission is warranted. However, beyond the initial 24 hours, if they recovered fully with no residual neuro deficits, then no further hospitalization is medically necessary.

The health plan acted reasonably in part with sound medical judgment in the best interest of the patient. Initial admission was necessary but extended stay was not. 

The insurer's denial of coverage for the inpatient admission is modified. Medical necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Treatment. 
The insurer denied denied implant (tooth 8). 
The denial is upheld.

The patient is a female who presented to the office of her dental provider, for evaluation and treatment of tooth #8 with extraction and subsequent replacement. Included for review are previous letters of appeal and denial, clinical notes, consent forms, panoramic radiograph, and a single page of dental claim forms. Previous denials have been on the basis that a letter was not received by the provider indicating that a dental implant is the only viable service and that the document sent failed to adequately indicate why a fixed or removable prosthesis cannot be placed. In question is the medical necessity of the planned treatment of implant placement for #8.

The health plan's determination is upheld in whole.

No, based on the provided documentation the requested service of implant for tooth #8 has not been established as medically necessary. Based on the current clinical notes there is a direct conflict with the radiographs provided. The current notes state that the patient has previously worn a partial denture and that she has had difficulty with wearing it and that she has experienced jaw pain due to a lack of dentition. From the panoramic radiograph and from the dental claim form, no teeth are missing, and no teeth have been extracted to allow for a partial denture to be used in order to then complain about having to use them. There has not been a period for which the patient had any teeth missing, any wearing of any denture.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Hypertension/High Blood Pressure
Treatment: Home Health Care
The health plan denied the requested increase in personal care services. 
The health plan's determination is overturned.

The patient is a  female who resides alone. She has a medical history of hypertension, hyperlipidemia, glaucoma, depression, and dementia, as well as severe urinary incontinence and fecal incontinence.
According to a note provided by the patient's primary care provider over the last several weeks, the patient's condition has been worsening. She has had increased confusion and disorientation. She has severe fatigue; she is very unsteady on her gait and has had frequent falls.
Due to her severe urinary and fecal incontinence, she is in need of frequent clothing and diaper changes. Due to her medical condition, she is unable to do this herself and requires assistance with changing and subsequently getting her back into bed. According to the physician's note as well as a letter provided by the daughter, these episodes and occurrences occur at all hours of the day. Additionally, due to her dementia and impaired inhibition, she often forgets that she has an emergency button or telephone available to request help and subsequently will often get up on her own, leading to falls. With her dementia she forgets that she has assistive devices available as well. According to the records, there is a question at least that the patient may have some bedsores.

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

Yes. The requested health service is medically necessary for this patient.
It is clear from the information provided by the patient's daughter and physician as well as review of the records, that this individual has care needs around-the-clock. With her severe urinary incontinence and fecal incontinence, she will require assistance with toileting, changing cleanliness at all hours of the day. This is further manifest and exacerbated by her underlying dementia, which according to the information provided impacts her ability to seek care, request assistance and adequately toileting to clean herself on her own. It would be unreasonable and inappropriate to expect her to manage these needs overnight on her own. Additionally, it will be inappropriate and unacceptable for her to remain in soiled clothing for the remaining unassisted 13 hours of the day.
There is already a concern for bedsores and if there is not one present already, this certainly will increase her risk for the possibility.
Also, with her dementia she has increased impulsiveness which does lend itself to trying to be independent in many of these activities. Unfortunately, with her mobility needs, this only increases her risk of fall and further injury.
Therefore, it is appropriate and medically necessary that the patient receives services 24 hours a day 7 days a week.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Metastatic Uveal Melanoma

Treatment: tocilizumab (Actemra) injections (procedure code J3262) 6 months

The insurer denied coverage for tocilizumab (Actemra) injections (procedure code J3262) 6 months.

The denial is overturned.

This patient previously had Tocilizumab Actemra injection denied for six months. This patient has a history of metastatic uveal melanoma. Per patient office visit, the patient had diagnosis of stage IV, left eye uveal melanoma which now involves the brain, liver, lung, pancreas, lymph nodes and bone. The patient was diagnosed with a uveal melanoma of the left eye years ago. Prior therapies have included enucleation, and ipilimumab with nivolumab cycles complicated by colitis and requiring infliximab, hepatic radioembolization, and selinexor. His doctor recommended a treatment plan that is a combination of therapies that includes tocilizumab Actemra. His treating doctor noted that given the patient prior toxicities to checkpoint inhibitor blockade it would be reasonable to consider proceeding with this regimen.  

European Society for medical oncology conference which demonstrated an encouraging response rate with a combination of therapies that also include Actemra. It was also noted that this combination of therapies offered the patient a significant chance of efficacy against while also on decreasing his risk of immune related adverse events. Supportive data included trial background combining ipilimumab, nivolumab, Tocilizumab phase 2 trial where a total of 41 patient have started the treatment on the trial and response rate was shown to be 58% (percent). Another supportive document of case report with selective inhibition of autoimmune exacerbation while preserving the antitumor clinical benefit using IL6 blockade in a patient with advanced melanoma and a Crohn's disease case report. At this time the patient is considered to have exhausted all standard therapies.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.

There is a phase II trial data that support the requested medication for metastatic melanoma. Tocilizumab (Actemra) injections (procedure code J3262) for six months does not have final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for tocilizumab (Actemra) injections (procedure code J3262) for six months based on the phase II trial.   

At this point and in this setting, the use of tocilizumab (Actemra) injections is appropriate.

Given the efficacy and safety in the clinical setting the use of this regimen in this patient is likely to be more beneficial that any standard health services.                                                
 
The carrier's denial of tocilizumab (Actemra) injections (procedure code J3262) for six months should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Metastatic Uveal Melanoma

Treatment: tocilizumab (Actemra) injections (procedure code J3262) 6 months

The insurer denied coverage for tocilizumab (Actemra) injections (procedure code J3262) 6 months.

The denial is upheld.

The patient presents with metastatic uveal melanoma. He was treated in the past with ipilimumab plus nivolumab (ipi+nivo), clinical trials, Radioembolization (Y90) radioembolization, and xpovio. The treating provider has now proposed therapy with ipi+nivo with tocilizumab based on a phase II presentation from European Society for Medical Oncology (ESMO).

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. 

There is currently insufficient support to the use of tocilizumab with ipi+nivo as therapy for metastatic melanoma in a patient who has previously received ipi+nvio. A phase II single arm non comparator trial is not considered acceptable evidence of efficacy. Only the first stage data involving a group of 18 patients is available. (Mehmi et al)

Food and Drug Administration (FDA), "INDICATIONS AND USAGE 
1.1 Rheumatoid Arthritis (RA)
1.2 Giant Cell Arteritis (GCA)
1.3 Polyarticular Juvenile Idiopathic Arthritis (PJIA)
1.4 Systemic Juvenile Idiopathic Arthritis (SJIA)
1.5 Cytokine Release Syndrome (CRS)"      

Tocilizumab (Actemra) injections (procedure code J3262) for six months does not have final approval from the appropriate regulatory bodies for this diagnosis. This is not an approved use of tocilizumab.     

The patient is not a good candidate for tocilizumab (Actemra) injections (procedure code J3262) for six months.     

Tocilizumab (Actemra) injections (procedure code J3262) for six months is not the best available treatment for this patient at this time.

It is important to note that patients with ocular melanoma were excluded from the study the treating provider cites as a basis for this therapy.     

Adverse risks are unknown as this was not compared to any standard therapy. It is unknown how adverse events compare to standard therapy.  This service is not likely to be more beneficial than any other standard therapies.   

The requested use of tocilizumab is not supported at this time to be used with ipi+nivo to treat ocular melanoma. This remains an area of active investigation and is not currently considered standard of care. A phase II study of 41 patients is not considered acceptable evidence of efficacy. In addition, patients with uveal melanoma were excluded from this study. There is insufficient evidence to support the use of tocilizumab to treat this patient's indication.                                                    

The carrier's denial of tocilizumab (Actemra) injections (procedure code J3262) for six months should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Metastatic Uveal Melanoma

Treatment: tocilizumab (Actemra) injections (procedure code J3262) 6 months

The insurer denied coverage for tocilizumab (Actemra) injections (procedure code J3262) 6 months.

The denial is upheld.

The patient has metastatic uveal melanoma. Prior therapies included enucleation and Ipilimumab/Nivolumab cycles complicated by colitis and requiring Infliximab, hepatic radioembolization, and Selinexor. Now referred for therapy from a recently presented clinical trial using ipilimumab, nivolumab and tocilizumab for melanoma.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

Tocilizumab is a monoclonal antibody that works by blocking the receptor of the interleukin-6 (IL-6) protein in the body. IL-6 is a protein thought to help cancer cells grow and survive against the body's defense mechanisms. Tocilizumab blocks the receptor of the IL-6 protein, which prevents the IL-6 protein from functioning. Immunotherapy with monoclonal antibodies, such as ipilimumab and nivolumab, may help the body's immune system attack cancer and may interfere with the ability of tumor cells to grow and spread. There is only a small phase II trial that suggests some efficacy. 

Tocilizumab (Actemra) injections (procedure code J3262) for six months do not have final approval from the appropriate regulatory bodies for this diagnosis. The use of Tocilizumab for this patient's indication is not Food and Drug Administration (FDA) approved or recommended by any applicable guideline.     

This patient is not a good candidate for tocilizumab (Actemra) injections for uveal melanoma nor is this the best available treatment for this patient at this time because it is not proven.  The adverse risks are increased over standard treatment/services.   The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.                                                    
     
The carrier's denial of tocilizumab (Actemra) injections (procedure code J3262) months should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient Stay. 
The denial is upheld in whole.

The patient is a female without significant past medical history, who presented to the emergency department (ED) with abdominal pain and fever of the past 6 days. She had fever on and off for 3 days and had a maximum temperature of 101 Fahrenheit (F) at home. She had a pressure like pain in her umbilical and epigastric region. She tried Pepto-Bismol and Tylenol for her pain, but that did not help with her pain. 
She was slightly tachycardic with a heart rate (HR) of 111 and temperature of 101F in the ED. The rest of her vital signs were stable. Her labs showed mild hyponatremia with a sodium of 133. Her aspartate aminotransferase (AST) was 68 and alanine aminotransferase (ALT) was 133. A right upper quadrant (RUQ) ultrasound (US) showed a 1.3 centimeter (cm) right hepatic lobe cyst.
She was given intravenous (IV) hydration and pain medications. She was admitted to the medicine service. She underwent a computed tomography (CT) scan of the abdomen and pelvis that showed small intramural myoma, liver cyst and sub-centimeter low-density lesion within the liver that were too small to characterize. The patient was feeling well, and she decided to leave against medical advice (AMA). She had an appointment with her primary care doctor and stated that she will follow up with her doctor.
At issue is the medical necessity of the Inpatient Stay.

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

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient had fever but no hemodynamic instability. Most of her work up was unrevealing. She had outpatient follow up scheduled with her primary care in a couple of days. Due to close follow up and due to hemodynamic stability and lack of any significant finding on the work up, the patient was safe to be monitored in the outpatient setting and did not require an inpatient level of care. She presented with fever and abdominal pain. She had a liver cyst and mild transaminitis. The patient was presumed to have sepsis but her quick Sepsis Related Organ Failure Assessment (SOFA) score was zero and she did not meet the criteria for severe sepsis (end organ damage, hemodynamic instability, acidosis, etc.). [1,2]  She had abdominal pain that was worked up. The CT scan did not show anything concerning requiring urgent evaluation and/or intervention.
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyponatremia.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a history of hyperlipidemia and recent left shoulder surgery who presented to the hospital with weakness and severe nausea. She had taken Zofran and Gaviscon without relief. She stated she felt very dehydrated and very sick. She also complained of abdominal pain. Vitals signs showed that she was afebrile with a blood pressure of 111/64, a pulse of 86, a respiratory rate of 16 and a room air pulse oximetry of 98%. Her physical exam was unremarkable. Lab results were significant for a serum sodium of 122. A urine sodium was less than 20 millimoles per liter (mmol/L) and a random urine osmolality was 64. She was admitted for further management. She was given 2 liters (L) of normal saline and Zofran. Her sodium improved to 128. X-rays showed gas throughout the small and large bowel consistent with an ileus. Nephrology was consulted for her hyponatremia which they felt was due to dehydration and poor solute intake. Her sodium increased to 139. She felt better and was stable for discharge. She was discharged home. At issue is the medical necessity of an inpatient stay.

The inpatient admission was medically necessary in this case. The patient presented with hypovolemic hyponatremia in the setting of severe nausea and reduced oral intake. Her serum sodium level was 122 on presentation. Low serum sodium levels should not be corrected too quickly due to the risk of osmotic demyelination syndrome which can lead to severe chronic neurologic deficits. Profound hyponatremia (sodium [Na] values less than 125), such as present in this case, should have serum Na corrected at a rate less than 8mmol/L over the first 24 hours and can take several days or longer to reach normal levels if corrected appropriately. Her serum Na level was corrected too quickly as her level was already up to 139 the following day; this level should have been brought back down in a controlled inpatient setting to reduce the risk of osmotic demyelination. An inpatient hospital stay is necessary to manage such severe serum sodium levels.