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

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

This case involves a man with a history of seizure disorder on Keppra, who was seen in the emergency department with hemoglobin around 4, detected on outpatient testing. His primary care physician checked a complete blood count (CBC), as part of a routine workup for dyspnea and lightheadedness over several weeks and noted the anemia. The patient denied melena, hematochezia, hematemesis, or any other source of bleeding. Vital signs on arrival included a normal temperature, heart rate of 71, and blood pressure of 160/112. The exam appears to be fairly unremarkable. Repeat labs were obtained in the hospital, including normal electrolytes and renal function, hemoglobin of 4.2, and white blood cell count of 6.7. A chest x-ray showed no focal lung consolidation. The patient was admitted for symptomatic anemia, and ordered for a blood transfusion. 

The inpatient hospital stay is not medically necessary for this patient. The patient has severe anemia; but there is no evidence of a life-threatening condition triggering the anemia, placing the patient at risk of life or limb loss.
The patient has no evidence of acute gastrointestinal bleed. There is no hematemesis, hematochezia, melena, hematuria, or evidence of internal bleeding. The renal function is normal. Cardiac enzymes are unremarkable; a chest x-ray is without significant abnormalities. The patient responded to blood transfusions within the observation timeframe.
This is a common presentation in hospital settings and is typically managed at a lower level of care. Since there is no identifiable life-threatening etiology to the anemia, a lower level of care is appropriate for this presentation. The anemia was corrected with supportive packed red blood cell transfusions, and the patient was safely released home for further outpatient workup.
Appeal type: Medical necessity
Decision: Overturned

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

This patient is a male with a medical history of hypertension, collapsed right lower lung, diverticulitis, cholecystectomy, right knee meniscectomy, and right subdural hematoma. He presented to the hospital with complaints of left sided abdominal discomfort and bright red blood per rectum for 2 hours. His vital signs were a temperature of 97.9, pulse was 95, respiration rate was 18, blood pressure (BP) was 144/96 and pulse oximetry was 95% on room air. The physical examination showed absent breath sounds over the right lower lobe (RLL) and mild epigastric tenderness.
Abnormal laboratory values included a potassium at 3.4. The electrocardiogram (EKG) showed sinus rhythm with occasional premature ventricular contraction (PVC) and right bundle branch block (RBBB). The computed tomography (CT) scan of the abdomen showed active bleed per unofficial read. A colonoscopy showed non-bleeding internal hemorrhoids with diverticulosis and an 8-millimeter (mm) polyp in the sigmoid colon. His hemoglobin dropped from 14.4 to 11.7 and remained stable. The patient was discharged home.
At issue is the medical necessity of the inpatient stay.

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

The requested health service/treatment of Inpatient Stay was medically necessary for this patient.
This patient had evidence of ongoing active bleeding. He presented to the hospital with an acute gastrointestinal (GI) bleed. There was no evidence of hemodynamic instability. There was, however, evidence of ongoing active bleeding with hemoglobin dropping from 14.4 to 11.7 as well as CT imaging showing extravasation of contrast in the descending colon. Based on current standards of care, the patient required frequent monitoring at the inpatient level of care, for continued active bleeding.
Therefore, the requested health service/treatment of Inpatient Stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee Weakness. 
Treatment: Ambulatory Surgery,  (29877x 1, 29876 x 1), Pre-service. 

The insurer denied the Ambulatory Surgery,  (29877x 1, 29876 x 1), Pre-service. 
The denial is overturned. 

The patient is a male. He injured his right knee a couple years ago. He reported ongoing pains and giving way. He was evaluated by his orthopedic surgeon. The physical examination was significant for effusion, +McMurray, tenderness and laxity. The MRI (magnetic resonance imaging) report was significant for a tear to the medial meniscus. His physician recommended surgery. 

Yes, the requested surgery is medically necessary. 

The records show the patient has a defined pain generator. He has pathology localized to the medial meniscus. He has functional loss with correlative imaging. This type of pathology (i.e., mechanical locking) can only be managed by surgery. PT (physical therapy), injection or bracing will not resolve his condition. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The standard of care for this clinical situation is surgery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Tremfya, 100 MG/ML SC, Pre-service
The insurer denied the Tremfya, 100 MG/ML SC, Pre-service
The denial is overturned

The patient is a male with severe psoriasis for several decades.  Three years ago, he entered a clinical trial with mirakizumab that nearly cleared his skin.  Prior to that, he had more than 85% body surface area affected.  The trial has now finished and he is redeveloping lesions on his hands, feet, face, and trunk, covering 15% body surface area (BSA).  He has trialed and failed multiple topical corticosteroids prior to the clinical trial.  Since the patient had done so well on an interleukin (IL)-23 medication in the clinical trial, his dermatologist would like to start him on an interleukin (IL)-23 inhibitor, Tremfya, which works through the same mechanism of action.  The patient regularly consumes alcohol.

Yes, the proposed Tremfya is medically necessary.
The patient has severe psoriasis for which systemic therapy is indicated. He is not a candidate for phototherapy because of the location of psoriasis in the face, hands, and feet, which cannot be reached by phototherapy. In the era of biologic therapies for psoriasis, use of methotrexate, cyclosporine or acitretin is not the most appropriate first line treatment because their long term safety and efficacy are inferior to biologic therapies. Additionally, the patient has been in a clinical trial of an interleukin-23 inhibitor successfully for the past three years.  It is medically appropriate to continue treatment with a similar medication.

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, Tremfya is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headaches
Treatment: Ajovy
The insurer denied Ajovy. The health plan's determination is upheld. 

The patient is a woman with migraine headaches and daily tension headaches. In the history of presentation illness, the provider notes that the patient has "headache every day" and "a migraine a few times a month". The migraines respond to Zembrace or Rizatriptan with "excellent results". The patient is prescribed Ajovy for prevention of episodic migraine. The patient is also treated with propranolol, Zoloft, Wellbutrin, and Ability. Under review is the medical necessity of Ajovy.

Ajovy is not medically necessary for this patient. Ajovy is Food and Drug Administration (FDA) approved and literature supported for prevention of episodic and chronic migraine. The documentation fails to show that the patient has episodic migraine. Episodic migraine is characterized by those with migraine who have 0 to 14 headache days per month, while chronic migraine is characterized by 15 or more headache days per month. There is no documentation of migraine frequency to establish that the patient has episodic migraine. It is only noted that the patient has a migraine "a few times a month".
Furthermore, it is noted that the patient's migraines respond to Zembrace and Rizatriptan with excellent results. As such, another medication would not be indicated for prevention or treatment of migraine if the patient has two medications that are very effective.
Lastly, there is insufficient documentation that the patient has tried and failed 2 or more medications for prevention of episodic migraine. Zoloft, Wellbutrin, and Ability do not have sufficient data to conclude that these drugs are effective for prevention of migraine. The patient, then, has only used propranolol at a very low dose. Generally, patients try and fail more than one therapeutic class prior to a CGRP (Calcitonin gene-related peptide) inhibitor.
There are no data to show that Ajovy is effective for prevention of tension type headaches.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral knee pain; osteoarthritis
Treatment: Bilateral Knee Hymovis injections (Codes J7322LTx2, J7322RT X2)
The insurer denied the Bilateral Knee Hymovis injections (Codes J7322LTx2, J7322RT X2).
The denial is overturned.

The patient is a female with history of bilateral knee pain due to knee osteoarthritis.  She has failed steroid intra-articular injections with possible allergic reaction to the steroid, physical therapy, home exercise program, turmeric, and over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs). 

Magnetic resonance image (MRI) of both knees showed severe degenerative joint diseases bilaterally.  Subsequently, the patient had bilateral knee joint Hymovis (hyaluronic viscosupplementation) intra-articular injections with significant improvement.  Currently, there is a request for repeat injections.

Yes, the proposed Hymovis bilateral knee intra-articular injections are medically necessary because the patient has history of bilateral knee pain due to severe knee osteoarthritis and failed steroid intra-articular injections with possible allergic reaction to the steroid, physical therapy, home exercise program, turmeric, over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs).
Magnetic resonance image of both knees showed severe degenerative joint diseases bilaterally.  For the patient's age and the severity of the knee osteoarthritis, the option for bilateral total knee replacement may not be a better option when compared with the viscosupplementation treatment as the patient has failed all conservative treatment as described above.

The option for bilateral total knee replacement for this patient, given the patient's age, and the severity of the knee osteoarthritis, may not be a better option when compared with the viscosupplementation treatment as she has failed all conservative treatment as described above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures. 
Treatment: Inpatient Hospital Admission. 

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

The patient is a female who presented to the hospital for a scheduled continuous video assisted electroencephalogram (VEEG) to capture and characterize seizures. The documentation indicated she does have a past medical history of anxiety as well as bipolar, dyslexia and presumptive focal epilepsy. The submitted documentation indicated the patient began having seizures when she was younger. She woke up one morning not feeling well and had several bouts of vomiting. The documentation indicated she went to the Emergency Department (ED) and had two witnessed convulsive seizures. She was started on Keppra and Ativan and admitted to the Intensive Care Unit (ICU). She did undergo an electroencephalogram (EEG) demonstrating no epileptiform activity. She was discharged with instruction to follow-up. She then underwent a magnetic resonance imaging (MRI) scan and repeat EEG that demonstrated left frontotemporal sharp waves. The patient also underwent an ambulatory EEG a few months prior to this admission which revealed right temporal lobe seizures with generalized spread. She has trialed Lamictal as well as Keppra and Depakote. Since she has had almost daily episodes of spacing out that are triggered by lights and stress. She has episodes that typically last 2 to 3 minutes. The documentation indicated the patient tapered off Trileptal upon admission. She underwent the video EEG; however, given anxiety she wanted to be discharged. 

The patient had an abnormal EEG twice in prior workups. There is no need for an inpatient video EEG in this clinical scenario given the above. Therefore, the requested inpatient admission was not medically necessary and the prior determination is upheld. 

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

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

Diagnosis: Brain Cancer (glioblastoma)
Treatment: Electric Tumor Treatment Field (E0766) (Pre-Service)
The insurer denied the Electric Tumor Treatment Field (E0766) (Pre-Service)
The denial is overturned. 

The patient is a male with glioblastoma. He was diagnosed after presenting to the ED (emergency department) with gait and balance issues. The patient underwent surgical resection, which confirmed GBM (glioblastoma multiforme). The patient has undergone radiation and chemotherapy, and he is being recommended Optune device.

Yes, the Electric Tumor Treatment Field (E0766) is medically necessary.
The patient has a very aggressive tumor known as GBM (glioblastoma multiforme). This has a very high progression rate and mortality associated with it. The patient has undergone appropriate medical/surgical management, including resection and concurrent chemoradiation. Optune TTF (tumor treatment fields) has been shown to be beneficial in these patients with a severe and debilitating disease, and therefore is appropriate and medically necessary for this patient. The outcomes of patients treated with TMZ (temozolomide) and Optune have been shown to be better than those with TMZ (temozolomide) alone and results in improved progression free survival. Optune TTF (tumor treatment fields) is considered standard of care for patients like this one and should be approved for use.

The literature also supports it use (1):
"In 2 large randomized, controlled phase 3 trials, the addition of TTF (tumor treatment fields) was associated with increased overall survival when combined with adjuvant temozolomide (TMZ) chemotherapy in patients with newly diagnosed GBM (ndGBM) and comparable overall survival compared with standard chemotherapy in patients with recurrent GBM (rGBM). "

The patient has an aggressive tumor with limited options for treatment. The literature has shown conclusively that Optune TTF (tumor treatment fields) and TMZ (temozolomide) have improved outcomes compared with chemoradiation alone. This is within the standard of care and medically necessary for this patient and it should be approved.

While the MRI (magnetic resonance image) does show some questionable growth of the tumor, it is likely more commonly related to pseudoprogression after radiation. The patient is currently asymptomatic from this and would not warrant additional surgical resection. The best option for this patient, as well as the standard of care, is for Optune to be included as part of his treatment regimen. For this reason, Optune is medically necessary.

The use of Optune TTF (tumor treatment fields) has been shown to be medically necessary and appropriate and has provided improvements in outcome compared with best medical management alone. It is within the standard of care and is appropriate and medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied coverage of ancillary charges for Estrace cream. 
The denial is upheld.

The patient is a female with atrophic vaginitis. She experienced vaginal dryness without treatment since several years ago. She was treated for several vaginal infections including bacterial vaginosis (BV) and yeast. Physical exam was normal two months ago. At that time Replens was recommended as she felt Estrace cream caused her headaches in the past and she discontinued its use in the past. Olive oil also alleviated her symptoms. In a letter she indicated she has tried generic estrogen cream in the past however it did not control her symptoms and documentation of this is not found in her office visits. She feels now that Estrace vaginal cream is the only medication that alleviates her symptoms. Coverage of the ancillary charge for Estrace cream was denied.

The health plan's determination is upheld in whole. 

The requested coverage of ancillary charges for Estrace cream is not medically necessary for this patient. The coverage of ancillary charges for Estrace cream is not medically necessary. The patient has not attempted alternative methods covered under her plan in the past. In a letter from the patient, it states she has tried generic cream in the past however documentation of this is not found in her medical documentation. In addition, the medical documentation indicated that Estrace and not a generic has caused headaches in the past. If this was in error, and it was in fact, a generic cream that caused headaches this would not be considered a life-threatening and serious reaction. It would be considered a typical side effect of the alternative. There is no office documentation of the patient taking a generic estrogen cream and her progress on this cream including side effects. Therefore, the coverage for ancillary charges for Estrace cream is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis Vulgaris
Treatment: Cosentyx pen (2 pens) 150 milligrams per milliliter, 300 milligrams via subcutaneous injection every month for one year
The insurer denied the Cosentyx pen (2 pens) 150 milligrams per milliliter, 300 milligrams via subcutaneous injection every month for one year
The denial is upheld.

The member is a man with psoriasis of the scalp and forehead, and psoriatic arthritis for whom Cosentyx 300 milligrams via subcutaneous injection every month for one year is requested. He has tried and failed treatment with triamcinolone, hydrocortisone, Taclonex, Enbrel and Otezla.

No, the proposed Cosentyx is not medically necessary.
The patient has psoriasis affecting the scalp and face, and psoriatic arthritis. He is a candidate for systemic therapy. He has failed Enbrel and Otezla. The formulary offers multiple systemic therapies that are appropriate for the treatment of psoriasis and psoriatic arthritis, with a different mechanism of action than Enbrel and Otezla, such as Taltz, Stelara and Skyrizi. Taltz is an IL17 (interluekin 17) inhibitor, as is the requested Cosentyx. Cosentyx has a greater number of possible adverse events. Side effects of Cosentyx that are different from Taltz include diarrhea, oral herpes, hives, tonsillitis, oral thrush, impetigo, inflammatory bowel disease, ear infection, eye infection or inflammation (conjunctivitis), increased liver transaminases, and low white blood cell count (neutropenia). These drugs have not been directly compared in clinical studies. However, one review of studies of plaque psoriasis found that Taltz was more effective than Cosentyx at reducing symptoms of psoriasis. In the meta-analysis of studies with active comparators, PASI 90 [90% (percent) reduction in Psoriatic Arthritis Severity Index score] response rates were 127% [95% confidence interval (CI), 100% (95% CI [confidence interval] and 112% (95% CI [confidence interval]) higher and PASI 100 [100% reduction in Psoriatic Arthritis Severity Index score] response rates were 117% (95% CI [confidence interval]), 127% (95% CI [confidence interval]) and 131% (95% CI [confidence interval]) higher for ixekizumab compared with secukinumab using BU, SG total and SG separate methods (Bucher (BU) method and two modified versions of the Signorovitch method). Ixekizumab had higher PASI (Psoriatic Arthritis Severity Index) 90 and PASI (Psoriatic Arthritis Severity Index) 100 responses at week 12 compared with secukinumab using adjusted indirect comparisons. Therefore, Cosentyx is not medically necessary, as there are formulary options that are equally medically appropriate.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congenital heart disease, autism, feeding problems, food aversion.
Treatment: Speech therapy visits.

The health plan denied the requested additional speech therapy visits as not medically necessary. 
The health plan's determination is overturned.

This patient is a male. He has a history of congenital heart disease, autism, feeding problems and food aversion. He is dependent on oral formula and is unable to eat age-appropriate foods. He was previously started on feeding and speech therapy, however, the therapy was interrupted by a cardiac surgery. Due to his dietary habits, he is at risk of obesity.
The requested service is the continuation of feeding therapy.

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

Yes, the requested service of 20 additional speech therapy visits is medically necessary.
This patient has a complex condition and has feeding problems, food aversion and inappropriate diet for age. The current standard of care is to provide intensive feeding therapy to overcome the feeding dysfunction. The patient has already started the treatment but was forced to stop due to a surgical procedure. Therefore, continuation of the extensive feeding program is recommended in this case.
The requested feeding program provides a superior level of collaboration and evidence-based approach. The therapy is provided by a multidisciplinary team that includes speech therapy, occupational therapy, psychology, and nutrition service. The requested feeding program is proven to be safe and effective in improving the patient's condition.

According to Clark, Racheal R., et al: "Admission to intensive programs can be beneficial for these high-risk populations. These benefits include the capacity to rapidly wean children from feeding tubes, access to medical and dietary professionals throughout, and a highly-controlled environment to make behavior change. Intensive programs also typically involve multiple feeding sessions per day and a treatment team approach in which multiple providers (e.g., psychology, speech, occupational therapy, nutrition) deliver services concurrently. This high frequency of feeding sessions can result in rapid improvement in behavior (e.g., volume, variety, mealtime problem behavior) and offer greater monitoring of the child across multiple providers".
Therefore, the requested service is consistent with the generally accepted practice and proven to be beneficial. There is no less costly or safer alternative for this patient. The requested service is not intended for the convenience of the patient or his provider.
The patient has severe feeding problems and is not consuming age-appropriate diet. He is already obese due to his unhealthy eating habits. The feeding therapy is expected to improve his condition and prevent future morbidity related to his feeding dysfunction. Therefore, enrollment in the intensive feeding program is medically necessary.