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

Diagnosis: Idiopathic Short Stature (ISS).
Treatment: Genotropin.
The insurer denied Genotropin. 
The health plan's determination is overturned. 

This is a male patient diagnosed with idiopathic short stature (ISS). His height velocity is reported to be 2.86 cm/yr (centimeters/year). His bone age was 12y (year) 6m (months) one year ago. His Insulin-like Growth Factor 1 (IGF1) was 148.
His height now was 143 cm (-2.33 standard deviation score (SDS)). His mother's height is 167.64 cm and father's height is 175.26 cm and mid parental height is 177.95 cm (+0.15 SDS).

Genotropin is medically necessary for this patient.
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."
The patient had a pretreatment height less than or equal to -2.25 SD. The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End Stage Renal Disease.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is: Upheld.

The patient is a female who was directed to the emergency department by her nephrologist for hemodialysis after missing outpatient hemodialysis. Pertinent history included hypertension, end stage renal disease on hemodialysis, systemic lupus erythematosus, rheumatoid arthritis, and chronic pain. The patient was admitted to the hospital. The admitting physician had an impression of non-compliance with hemodialysis without symptoms, and hypertension. Treatment plan included routine hemodialysis and resumption of home oral anti-hypertensives. Cardiology consulted and had an impression of hypertension. Nephrology consulted and had an impression of hypertension with end stage renal disease. The patient underwent hemodialysis without issue and was discharged thereafter.

The health plan's determination is upheld in whole.

The requested inpatient hospital admission is not medically necessary for this patient. Based on the clinical documentation provided, evidence- based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care. Moreover, the patient did not meet clinical indications for acute inpatient level of care. The patient did not have hypertensive encephalopathy that persisted past the emergency department, cerebral infarction, intracranial hemorrhage, myocardial infarction, decompensated congestive heart failure, aortic dissection, increased creatinine with reduction of more than 50% in estimated glomerular filtration rate from baseline, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, seizure, or other significant finding secondary to hypertension. The patient also did not have severe hypertension that could not be controlled at a lower level of care status.[3]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intermittent Bradycardia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This adult male was hospitalized for intermittent bradycardia. He was referred to the emergency department by his cardiologist due to high-grade heart block with plans for pacemaker placement. His past medical history included atrial tachycardia with ablation procedure, obesity with laparoscopic band procedure and diabetes. The patient reported a one-week history of exercise intolerance and lethargy. The patient's vital signs were stable. His electrocardiogram showed sinus rhythm with second-degree atrioventricular (AV) block, rate 42, right bundle-branch block. Cardiac telemetry found intermittent bradycardia due to Mobitz type I second-degree atrioventricular (AV) block and two to one (2:1) atrioventricular block (AVB) resulting in heart rates between 38-70. The patient was seen by Electrophysiology (EP) Cardiology and a dual-chamber pacemaker was inserted on day #3. There were no procedural complications, and the patient was discharged to home later the same day. The request for coverage for inpatient hospitalization has been denied by the plan and the patient is appealing the decision.

The proposed treatment was not medically necessary.

Based on the peer reviewed medical literature and the submitted InterQual guidelines, there was not a medical need for acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the 2022 InterQual Guidelines for Acute Adult Arrhythmia, Blocks, the requirements for acute inpatient hospital stay are not met, including Mobitz type II second-degree heart block, third-degree heart block, junctional escape rhythm, acute coronary syndrome, pacemaker failure, hemodynamic instability, beta-blocker, calcium channel blocker or digoxin toxicity, need for temporary pacemaker or mechanical ventilation, need for temporary pacemaker or intravenous pressor support, heart failure, arrhythmia of immediate concern or any other medical condition, symptom or finding for which inpatient hospital stay is considered appropriate. In this particular case, there was no 
clinical decline or inadequate response to treatment which required inpatient hospital stay. The care the patient received, including insertion of a pacemaker without complications for stable bradycardia like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Erythema Multiforme.
Treatment: Humira.
The insurer denied: Humira.
The denial is upheld.

The patient is an adult male with recurrent erythema multiforme major, involving the hands, feet, lips, and oral mucosa. His first episode was 8 years ago. Since then, he has had six episodes overall. The last acute flare was 5 months ago, when he required a prednisone taper, cyclosporine, and eventually IVIG (intravenous immunoglobulin) infusions before any noticeable 
improvement occurred. His referring physician is requesting approval for Humira injections.

The health plan should not cover the requested Humira.

Based on the submitted documentation and an in-depth review of the literature, the use of adalimumab in the treatment of erythema multiforme major is experimental/investigational. There is a single case report, which was published in an open-access journal documenting 1 patient who was successfully treated with adalimumab. However, there are also reports of erythema multiforme major being triggered by the use of adalimumab. There are no clinical trials, reviews, or other sources of information where the use of adalimumab for the treatment of erythema multiforme major is either being investigated or considered an accepted off-label use. Therefore, it is considered experimental, investigational, and not the current standard of care in the medical community.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Erythema Multiforme.
Treatment: Humira.
The insurer denied: Humira.
The denial is overturned.

The patient is an adult male. He is diagnosed with recurrent erythema multiforme major. He has tried and failed prednisone, cyclosporine, valacyclovir and triamcinolone. He has been prescribed Humira. The patient is G6PD (glucose-6-phosphate dehydrogenase) deficient, and therefore is not a candidate for dapsone or Plaquenil. The request for Humira was denied coverage by the health plan. The denial is being appealed.

The health plan should cover the requested Humira.

The health plan denied the request for coverage of Humira, because for the diagnosis of erythema multiforme, the use of Humira is off label and considered experimental/investigational. However, there are no FDA (United States Food and Drug Administration)-approved treatments for erythema multiforme. The patient has tried and failed several conventional treatments.
Per Soares A et al (2021), "Adalimumab is a human recombinant immunoglobin G1 monoclonal antibody that binds Tumor Necrosis Factor alpha (TNF-alpha) and neutralizes this membrane soluble receptor so that it can no longer interact with p55 and p57, leading to the induction of apoptosis of TNF [tumor necrosis factor]-expressing cells. The release of many inflammatory markers like IL [interleukin]-6 and acute phase reactants are induced by TNF [tumor necrosis factor]-alpha bioactivity. It is speculated that TNF [tumor necrosis factor]-alpha plays a role in drug-induced EM [erythema multiforme] lesions, whereas the lesions from herpes-associated EM [erythema multiforme] is driven predominantly by a delayed hypersensitivity reaction through T-helper 1 cells and interferon. However, this mechanism is not fully elucidated and requires further study."
Baillis B et al (2017) writes "EM [erythema multiforme] can be broken down mechanistically into herpes-associated EM [erythema multiforme] (HAEM) and drug-induced EM [erythema multiforme] (DIEM). Further elucidation and studies show that HAEM [herpes associated erythema multiforme] lesions are predominantly a T-helper 1driven and interferon-driven delayed type hypersensitivity process, whereas DIEM [drug-induced erythema multiforme] is a mechanistically distinct macrophage and tumor necrosis factor (TNF)-driven process. A similar process of a cell-poor infiltrate with macrophages and strong immunoreactivity for TNF [tumor necrosis factor] is thought to contribute to the mechanistic processes of SJS [Stevens-Johnson syndrome] and TEN [Toxic Epidermal Necrolysis]. This understanding has led to the use of successful TNF ([tumor 
necrosis factor]-targeted biologics in the treatment of SJS [Stevens-Johnson syndrome] and TEN [Toxic Epidermal Necrolysis]."
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Erythema Multiforme.
Treatment: Humira.
The insurer denied: Humira.
The denial is overturned.

The patient is an adult male with erythema multiforme major to the hands, feet, scrotum and mucous membranes. He has been treated with IVIG (intravenous immunoglobin), cyclosporine, 
prednisone, Valtrex and topical steroids. The patient has required hospitalization for his condition. The provider is requesting Humira. The health plan denied coverage of the request as experimental. The denial is being appealed.

The health plan should cover the requested Humira.

EM (erythema multiforme) is considered a hypersensitivity reaction with several inciting factors including medications and infections. HSV (herpes simplex virus) and mycoplasma pneumonia comprise the most common infectious etiologies and triggers of recurrent EM (erythema multiforme). It comprises a spectrum of clinical disease ranging from limited cutaneous involvement (erythema multiforme minor) to more diffuse cutaneous and mucosal involvement (erythema multiforme major). Although once thought to be on a spectrum with EM (erythema multiforme), the widespread body surface and mucosal involvement of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are now considered by many to be distinct clinical entities.
One case report documented successful use of Humira for EM (erythema multiforme) (Baillis et al). Initial treatment of EM (erythema multiforme) minor has involved infection control including viral suppression in HAEM (herpes associated erythema multiforme) and treatment of bacterial infection in cases of mycoplasma pneumonia associated EM (erythema multiforme). In recalcitrant to treatment or robust recurrences, immunosuppressive measures have also been used. Case reports and small case series in the literature highlight the use of different agents with variable degrees of success. The rapid, complete, and sustained clearance with a TNF (tumor necrosis factor) inhibitor was somewhat surprising in the case, given the well-described interferon-driven pathway of viral-associated EM (erythema multiforme). Although the final cytokine contribution and interaction in EM (erythema multiforme) is not fully elucidated, the article postulates the interference with TNF (tumor necrosis factor) could contribute to clearance in refractory cases of both HAEM (herpes associated erythema multiforme) and DIEM (drug-induced erythema multiforme).
Therefore, given that this patient has tried and failed multiple immunosuppressive regimens and cannot use Dapsone and hydroxychloroquine due to G6PD (glucose-6-phosphate dehydrogenase) deficiency, the requested Humira is medically appropriate and should be covered by the health plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Iron deficient anemia 
Treatment: Ambulatory surgery (capsule endoscopy)
The insurer denied coverage for ambulatory surgery (capsule endoscopy).
The denial is overturned.

The patient has a history of irritable bowel syndrome (IBS), Nonalcoholic steatohepatitis (NASH), gastritis, and colonic polyps. The patient had an endoscopy and colonoscopy. The patient has been on a proton pump inhibitor (PPI) for gastritis and gastroesophageal reflux disease (GERD). The patient's IBS was treated with rifaximin, and the diarrhea improved. The helicobacter pylori (H. Pylori) infection was treated. The symptoms have all improved, but the patient remains with iron deficient anemia. The physician writes that neither the endoscopy nor colonoscopy have revealed the source of the patient's anemia. The provider is now recommending a capsule endoscopy. A telehealth visit states that the patient has low iron saturations and has been on oral iron treatment. 

The American Society of Gastrointestinal Endoscopy (ASGE) has published guidelines based on the American Gastroenterological Association (AGA) Guideline on gastrointestinal (GI) Evaluation of Iron Deficiency Anemia (Gastroenterology 2020 August 15). The guideline states that video capsule endoscopy should be considered in patients with negative bidirectional endoscopy who do not respond to iron or have ongoing symptoms. 

This patient remains with iron deficient anemia in spite of having had both an upper GI endoscopy and colonoscopy and being on iron supplementation. Since there is no clear source for the iron deficient anemia, doing a capsule endoscopy is appropriate in order to determine the cause of the anemia. The capsule study meets the ASGE and AGA guideline for the workup of iron deficiency anemia. The health care plan did not act in the best interest of the patient. The capsule endoscopy is medically necessary. The denial is overturned.

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 ambulatory surgery (capsule endoscopy) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pemphigus Vulgaris. 
Treatment: Ocrevus 30MG (milligrams)/10ML (milliliters) IV (intravenous) Solution. 

The insurer denied: Ocrevus 30MG (milligrams)/10ML (milliliters) IV (intravenous) Solution. 
The denial is overturned. 

The patient is an adult female with moderate pemphigus vulgaris. She has failed treatment with methylprednisolone, azathioprine, and IVIG (intravenous immunoglobulin) and is allergic to rituximab. She had an infusion of ocrelizumab, which led to improvement and two-year near remission. This is a request to approve Ocrevus (ocrelizumab) infusions. 

The requested Ocrevus is medically necessary. 

Pemphigus vulgaris is an autoimmune blistering disease that may result in significant morbidity and death. Traditional first-line treatment for pemphigus consists of systemic immunosuppression with systemic glucocorticoids with or without adjuvant immunosuppressive medications. Patients who do 
not respond to traditional first-line therapies may benefit from additional interventions. Treatment regimens that include rituximab, intravenous immune globulin (IVIG), immunoadsorption, plasmapheresis, and cyclophosphamide may lead to clinical improvement in these patients. The traditional initial approach to the treatment of pemphigus vulgaris and pemphigus foliaceus consists of systemic glucocorticoid therapy, which is often given in conjunction with an adjuvant nonsteroidal immunosuppressant, such as azathioprine or mycophenolate mofetil. The term refractory pemphigus is generally used to refer to pemphigus that fails to respond sufficiently to optimal administration of these agents. The major therapeutic options for refractory disease include interventions that directly target the antibody-mediated pathogenesis of pemphigus (rituximab, intravenous immune globulin [IVIG], immunoadsorption, and plasmapheresis) and cyclophosphamide, a drug that may be used as an alternative adjuvant immunosuppressant. Concern for the high burden of rituximab, IVIG (intravenous immunoglobulin), immunoadsorption, and plasmapheresis and the unfavorable adverse effect profile of cyclophosphamide (e.g., sterility, cytopenia, hemorrhagic cystitis) contribute to the preferred use of these agents for refractory pemphigus, rather than for new-onset disease. Due to a lack of high-quality comparative trials, data are insufficient for definitive conclusions on the relative efficacies of therapies for refractory pemphigus. Factors such as patient tolerance for specific treatments and treatment availability influence treatment selection. 

The patient has refractory pemphigus that has failed multiple therapies, including IVIG (intravenous immunoglobulin). She is allergic to rituximab. Therefore, ocrelizumab, is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness, Low Heart Rate, Nausea and Vomiting. 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult male with a past medical history of heroin dependence on methadone and tobacco dependence. He presented to the emergency department for evaluation of vomiting, diarrhea, and dizziness. On arrival to the ED (emergency department), the patient was afebrile, heart rate was 41 bpm (beats per minute), blood pressure was 167/82, SPO2 (pulse oximetry) was 98% on room air. On exam, he was noted to be bradycardic, but the rest of the physical examination was unremarkable. Initial labs were notable for a troponin of 74 (153), magnesium of 1.7, sodium of 141, potassium of 3.8, BUN (blood urea nitrogen) of 18, creatinine of 0.81, WBC (white blood cell) count of 6.7, hemoglobin of 13.6, AST (aspartate aminotransferase) of 121, ALT (alanine aminotransferase) of 15. His UDS (urine drug screen) was positive for cannabinoids and opiates. Twelve-lead EKG (electrocardiogram) showed sinus bradycardia without significant ST (segment) changes. Chest x-ray showed 
no acute cardiopulmonary abnormalities. The patient was hydrated with IV (intravenous) fluids, was given Zofran and was admitted to the inpatient unit for further care. He received supportive care and was placed on bowel rest with improvement of his abdominal symptoms. In the setting of bradycardia, his methadone was held for 1 day and then restarted at 50 mg (milligrams) twice daily. He was ultimately discharged with 
outpatient follow-up. 

The Inpatient Hospital Admission was not medically necessary. 

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. He did not have any significant electrolyte abnormalities and no seizure-like activity related to potential withdrawal syndrome. Although he was bradycardic, there was no evidence of advanced conduction disease, no significant symptoms as a result of this (such as syncope) and no hemodynamic instability related to it. He had elevation of his cardiac enzymes (i.e., troponin) but there was no other signs or symptoms of ischemia to be suggestive of acute coronary syndrome. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care. 

Observation level of care would have been appropriate in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Legal blindness, anxiety, depression, PTSD (post-traumatic stress disorder), diabetes, and sleep disorder
Treatment: Increase in Personal Care Aide (PCA) to a total of 40 hours/week, consumer direct, 1 client
The insurer denied the increase in PCA to a total of 40 hours/week, consumer direct, 1 client.
The denial is upheld.

The patient is an adult male. His conditions include legal blindness, anxiety, depression, PTSD (post-traumatic stress disorder), diabetes, and sleep disorder. Denial of increase in personal care aide (PCA) to a total of 40 hours/week is being appealed. The health plan approved 22.75 hours/week. The patient notes that he is legally blind, needs assistance with meals due to diabetes, and he is unable to care for himself due to depression and anxiety. Uniform Assessment System (UAS) evaluation completed 6 months ago shows independent cognition and functional status: maximal assistance with meal preparation and housework; extensive assistance with managing finances and medications, phone use, stairs, shopping, transportation, and lower body dressing; limited assistance with bathing, personal hygiene, upper body dressing, walking, locomotion, toileting, and bed mobility; and independent with eating. The patient is continent of bowel and bladder.

The requested increase in PCA to a total of 40 hours/week is not medically necessary. 

Personal Assistance Services (PAS) provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs), health maintenance activities, and routine support services. Denial of an increase in PCA to a total of 40 hours/week is being appealed. The health plan approved 22.75 hours/week. The health plan denied the additional hours due to lack of updated medical records and documents supporting worsening of his condition and need for additional hours.

This patient has multiple conditions, including legal blindness and diabetes. The patient notes that he needs assistance with meals due to diabetes and he is unable to care for himself due to depression and anxiety. His doctor provided a statement for additional hours but did not provide information supporting this recommendation. UAS evaluation completed 6 months ago shows the patient needs assistance with all ADLs except eating. He does not have incontinence. The currently approved PCA of 22.75 hours/week is sufficient to meet the patient's needs for assistance with meals and ADLs. PAS are not indicated when no tasks are being performed or to manage medical conditions, such as anxiety and depression. The requested increase in PAS to 40 hours/week is not medically necessary.