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

Diagnosis: History of cognitive impairment, ischemic heart disease and osteoarthritis
Treatment: Personal Care Services, 24 hours/day, 7 days/week (live-in) for a total of 91 hours/week 
The insurer denied the Personal Care Services, 24 hours/day, 7 days/week (live-in) for a total of 91 hours/week.
The denial is upheld. 

The patient is a female with a history of cognitive impairment, ischemic heart disease and osteoarthritis. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of 91 hours per week Personal Assistance Services to offer increased activities of daily living (ADLs) support.

No, the proposed treatment of 91 hours per week Personal Assistance Services is not deemed medically necessary. 

This is a female with a history of cognitive impairment, ischemic heart disease and osteoarthritis. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). However, an in-home assessment of the patient's functionality and ability to perform activities of daily living (ADLs) was completed and revealed that the currently approved plan of 77 hours per week Personal Assistance Services is sufficient to meet the patient's current needs. Despite review of the additional medical records sent, there is still no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment 91 hours per week Personal Assistance Services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorder. 
Treatment: Pharmacy/Prescription Drug (Dupixent)s. 
The insurer denied Dupixent. 
The denial is upheld in whole. 

The patient is a female with  atopic dermatitis (AD). The patient has failed topical steroids. The provider states the patient has failed methotrexate but there are no paid claims for this medication in the past five years. The provider is requesting treatment with Dupixent.

Dupixent is not medically necessary for this patient. Dupixent is Food and Drug Administration (FDA) approved for the treatment of moderate to severe atopic dermatitis in patients over the age of 6. Standard treatment options for patients with atopic dermatitis include a regimen of topical steroids as well as topical calcineurin inhibitors. After topical agents fail, standard practice is to pursue systemic therapy such as phototherapy.
According to Kolb, et al., (2019) "Sensitive areas (including the intertriginous areas of the axilla and groin, in addition to the face) may require topical nonsteroidal agents including calcineurin inhibitors such as tacrolimus and pimecrolimus. When atopic dermatitis is not controlled with topical agents, systemic agents include phototherapy (ultraviolet [UV] A, ultraviolet [UV] B, and narrow-band UVB), cyclosporine, azathioprine, mycophenolate mofetil, and methotrexate."
According to Wong et al., (2017) "Topical agents are the mainstay of treatment for mild-moderate AD and include topical corticosteroids (TCS) and topical calcineurin inhibitors (TCI). TCS are effective agents in addressing the pruritus and inflammation of AD and work by inducing inhibitory proteins that decrease inflammatory mediator activity. For patients with moderate-to-severe disease refractory to topical therapy, consideration should be given to the use of phototherapy or systemic immunomodulatory agents. Narrow-band ultraviolet B (UVB) (wavelength = 311 nanometer [nm]) is the most commonly used type of phototherapy for AD and is typically administered 2 to 3 times per week. Narrow-band UVB is a safe option that can provide relief from the signs and symptoms of AD. Cyclosporine A is a calcineurin inhibitor that controls T-cell mediated inflammation by preventing the transcription of inflammatory cytokines. Cyclosporine A has been found to be effective in the management of severe and refractory AD in adults and children. Methotrexate, azathioprine and mycophenolate mofetil are antimetabolite medications that work as a folate antagonist, purine analog and purine synthesis inhibitor, respectively. These medications have been shown to be variably effective in treatment-resistant AD."
As the patient has no documented travel and failure or intolerance to any TCI such as tacrolimus and the patient has no documented contraindication, intolerance, or failure to phototherapy or any systemic immunosuppressive medication, there would be no exception for Dupixent.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Light chain amyloidosis
Treatment Venclexta 100MG OR TABS
The insurer denied the Venclexta 100MG OR TABS
The determination is upheld.

This is a patient with light chain amyloidosis. He has received CyBorD (Cyclophosphamide + Bortezomib + Dexamethasone)+daratumab. The patient has achieved a partial response. Venetoclax has been recommended as a component of care (in combination with bortezomib and dexamethasone). Venclexta is under review for medical necessity.
Venclexta (venetoclax) is not medically necessary for this patient. He has a diagnosis of light chain amyloidosis. There have been a series of case reports and small series that have been published regarding the use of venetoclax in this clinical scenario. Randomized trials have not been completed. The routine use of this agent in this scenario is not recommended by the National Comprehensive Cancer Network (NCCN). The authors of UpToDate state that although "...venetoclax may be active, further study is needed to evaluate the efficacy and toxicity of this agent in amyloid light-chain (AL) amyloidosis..." Lacking support in national guidelines or the peer-reviewed literature, medical necessity is not established for this service.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: anterior crossbite
Treatment: Braces
The insurer denied braces. The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth 10. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 24-30 months of orthodontics to address the crowding and crossbite, but the treatment was denied due to a lack of medical necessity.

Braces are medically necessary for this patient.
This patient presents with an anterior crossbite on tooth 10, as well as significant 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.
If left untreated the damage that will likely occur to the patients teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, the treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is upheld.

The patient has a Class II Division 2 Subdivision left malocclusion. He has a crowded occlusion and has a 100% deep bite causing soft tissue damage on his palate as well as wear on his mandibular incisors. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion. At issue is the medical necessity of braces.

The requested treatment of braces is medically necessary for this patient. A deep bite on its own is not a reason to treat with orthodontics. However, he is already damaging the soft tissue of his palate and causing wear to the incisal edges of his teeth. This will worsen with time if left untreated and can lead to periodontal problems in the future (2) that will be more invasive to correct than the orthodontic problem he currently has. Therefore, the braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, cerebral vascular.
accident with resultant hemiplegia.
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) services; 12 hours per day - seven days per week; 12 hours per day - seven days per week (split-shift) - a total of 168 hours per week.
The insurer Increase Consumer Directed Personal Assistance Program (CDPAP) services; 12 hours per day - seven days per week; 12 hours per day - seven days per week (split-shift) - a total of 168 hours per week. 
The denial is overturned. 

The patient is a female with a history of coronary artery disease, chronic angina, and cerebral vascular accident (CVA) with resultant hemiplegia. Due to impairments related to these conditions, she requires assistance for the completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of 168 hours per week Consumer Directed Personal Assistance Program (CDPAP) services to offer increased activity of daily living (ADL) support.

Yes, the proposed treatment of 168 hours per week Consumer Directed Personal Assistance Program (CDPAP) services is deemed medically necessary. 

This is a female with a history of coronary artery disease, chronic angina, and CVA with resultant hemiplegia. Due to impairments related to these conditions, she requires assistance for the completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's physician indicates that due to worsening congestive heart failure (CHF), weakness and contractures related to her CVA, and increased bedbound status with resultant recurrent pressure ulcers, the currently approved plan of 63 hours per week is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 168 hours per week Consumer Directed Personal Assistance Program (CDPAP) services are deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male with type II diabetes on Humalog and Levemir and alcohol abuse who presented with fatigue, polyuria, and diarrhea. He had not been adhering to taking his insulin regularly due to his work schedule. Glucose was 459 milligrams per deciliter (mg/dL). His vital signs were 124/78, 102, 98.2, 16, and oxygen saturation (SP02): 97%. 

In the emergency department, glucose: 731, anion gap: 18, beta-hydroxybutyrate: 0.6, lactic acid: 3.5, pH 7.28; carbon dioxide (CO2) 22 and pH. The patient was treated with intravenous fluids and his glucose improved to 365 mg/dL. He had elevated liver enzymes and he was advised to avoid alcohol. The patient was started on Levemir and lispro. Endocrinology was consulted. 

No, the proposed inpatient admission was not medically necessary.

Patients with diabetic ketoacidosis can be safely managed in observation units unless they present with severe alteration of mental status or with critical illness such as sepsis [1], which is not documented in this case. This patient presented with hyperglycemia with known type II diabetes. He was not adherent to his medication. He presented with mild diabetic ketoacidosis with an initial pH of 7.28. His hyperglycemia quickly improved with intravenous hydration. He was hemodynamically stable. This patient did not have alteration in his mental status and the documentation does not support a diagnosis of hyperglycemic hyperosmolar syndrome. Therefore, no, the proposed inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Failure to thrive secondary to a cow's milk protein intolerance.
Treatment:  Enteral Nutramigen Toddler B4161.

The insurer denied coverage for Enteral Nutramigen Toddler B4161.  The denial is upheld.

This is a male child with a past medial history notable for transient tachypnea of the newborn, failure to thrive, mild oropharyngeal dysphagia, frequent spit-ups and cow's milk intolerance.  As per the patient's medical record, he has had the following studies done for his workup: (1) esophagogastroduodenoscopy (EGD) that showed normal study with unremarkable histopathology; (2) flexible sigmoidoscopy that showed nodular mucosa in the rectum and distal colon with unremarkable histopathology; (3) modified barium swallow that showed mild oropharyngeal dysphagia.  The patient's treating gastroenterologist prescribed Nutramigen Toddler formula 24 ounces per day (yielding 480 kilocalories /day; approximately half his daily requirements) as a supplement to his oral solids.  The patient reportedly takes 8 ounces of water and 4 ounces of juice daily, as well.  The patient's last reported weight was 9.3 kilograms (2nd percentile for age), and his height was 82 centimeters (10th percentile for age).  There is no report of failing other dairy-based formula (i.e., goat's milk) or plant-based formula (i.e., soy milk).

Based on the review of the medical record, this patient suffers from frequent spit-ups and poor weight gain without evidence of Immunoglobulin E-mediated milk allergy.  The patient has been prescribed a partial protein hydrolysate formula to address a clinically diagnosed cow's milk protein intolerance.  According to a review of dietary recommendations for toddlers, pre-school and school-aged children from UpToDate, there are other available alternatives to Nutramigen Toddler formula for this patient.  For instance, there is fortified goat's milk or fortified sweetened soy milk.  The patient can consume comparable calories (480 kilocalorie /day) by ingesting 27 ounces of goat's milk or chocolate soy milk.  Thus, Enteral Nutramigen Toddler formula is not considered medically necessary for this patient.

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

The carrier's denial of coverage for Enteral Nutramigen Toddler B4161 should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female. She has a past medical history significant for HTN (hypertension), dyslipidemia, and CAD (coronary artery disease). She presented to Urgent Care for complaints of chest pain, radiating to her neck and jaw, associated with dyspnea on exertion, worsening over the last days. The patient was found to have an abnormal ECG (electrocardiogram) and was sent to ER(emergency room). 

The patient's BP (blood pressure) was elevated at 191/90. ECG (electrocardiogram) revealed normal sinus rhythm with septal infarction, age undetermined, and T-wave inversions in antero-septal leads.  Her troponin was negative, pro-BNP (brain natriuretic peptide) was mildly elevated. The patient was admitted for suspected unstable angina. 

The patient was started on therapy for ACS (acute coronary syndrome), including IV Heparin and antiplatelet therapy. Her regimen for BP control was adjusted. The patient was seen in consultation by cardiology and was diagnosed with unstable angina. A cardiac catheterization was performed, revealing a 100% occlusion of the proximal and mid LAD (left anterior descending). PCI (percutaneous coronary intervention) of the proximal LAD was performed with balloon angioplasty, and flow was restored to the first septal perforator. However, no stent was placed, and the mid LAD remained occluded. The patient was treated with medical therapy for CAD and was discharged home.

Yes, the Inpatient admission was medically necessary.

The patient presented with new onset chest pain, suggestive of unstable angina. The patient had multiple risk factors for CAD, as well as a known history of coronary artery disease, including a prior MI (myocardial infarction). The ECG was unrevealing for ACS, but was abnormal, with findings suggestive of prior myocardial infarction. There was a high index of suspicion for an ACS, and a cardiac catheterization was performed, revealing proximal LAD occlusion. High risk PCI was performed and was partially successful. No stent was placed, increasing the risk of acute vessel closure and there was residual occlusion distally, which the physician was unable to revascularize. Thus, this patient had increased post procedural risk of complications, given the high-risk nature of this procedure.  

Given the presentation, uncontrolled hypertension, as well as clinical suspicion for an acute coronary syndrome/unstable angina, as well as the high risk PCI, the patient would not be an appropriate candidate for an ED(emergency department) chest pain observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorders. 
Pharmacy/Prescription Drugs. 

Diagnosis: Psoriasis. 
Treatment: Tremfya. 
The insurer denied Tremfya. The health plan's determination is upheld. 

The patient is a male with psoriasis. The patient has tried and failed topical steroids and Protopic, as well as oral Methotrexate and Otezla, as well as Humira (injection site reactions) and Cosentyx. Stelara reportedly worked for him but had to be discontinued because of an insurance lapse. 

Coverage of Tremfya is under review for medical necessity. 

Tremfya is not medically necessary for this patient. The patient has no documented treatment failure with, or true medical contraindication to, either Enbrel, Humira, or Siliq. 

There is no current evidence or analysis that shows any risk of increased susceptibility, morbidity, or mortality using biologic therapies during the COVID-19 pandemic, and they may have some benefit with respect to prevent the cytokine storm associated with more severe cases of COVID-19 infection. Tumor Necrosis Factor inhibitors have not truly been failed; the injection site reactions with Humira suggest that the newer citrate-free Humira was not utilized, and Enbrel has no such incidence of injection site reactions as reported with Humira. There is also no evidence to presume that a failure of one Interleukin-17 inhibitor such as Cosentyx will lead to another inhibitor (Siliq) that will also fail to control this patient's psoriasis. 

Accordingly, treatment with Humira (citrate-free), Enbrel, and Siliq are all viable options for this patient, and would be consistent with the current medical literature.
Appeal type: Medical necessity
Decision: Overturned in Part

Orthopedic/Musculoskeletal. 
Skilled Nursing Facility. 

Diagnosis: Total Hip Arthroplasty. 
Treatment: Skilled Nursing Facility Stay. 
The insurer denied the continued Skilled Nursing Facility Stay. The health plan's determination is overturned in part. Five additional days are medically necessary. 

The patient is a female who underwent total hip arthroplasty and was admitted to a skilled nursing facility. 

Five additional days are medically necessary at the skilled cursing facility. 

The patient required moderate assistance (MODA) for bed mobility, MINA (minimum assist) for transfers and was ambulating 75' FWW (front-wheeled walker) contact guard assist (CGA). No stair training and occurred. The patient had progressed to MINA bed mobility, CGA transfers and was ambulating 100' FWW stand by assist (SBA). Stair training had not occurred. The patient was not ready for discharge at this point. Documentation noted the patient lived alone and had 2 steps to enter home and stair training had not been completed. Furthermore, she was continuing to make progress but was not yet at a safe level for discharge as she still required MINA for bed mobility and CGA for transfers. In addition, she was still requiring CGA for toileting and lower body dressing. 

The patient was SBA for bed mobility, SBA transfers, ambulating 150' FWW SBA, lower body dressing SBA and toileting SBA. The only concerning rehab factor was that she had completed 6 steps with MINA but as the documentation noted she only had 2 steps to enter her home. In addition, despite documentation stating she had 10 steps to her bedroom there was no mention that a bathroom was not on the first floor and it is acceptable to make a makeshift bedroom. 

Therefore, after day 5 the patient would have been safe to discharge to a lower level of care. It is noted that the patient was seen for leg edema and nasal congestion and Lasix 20mg three times per day (TID) x 3 days was ordered, but this does not support medical necessity as the patient had previously been treated for this same lower edema with the same order of Lasix 20mg x 3 days. In addition, while the patient complained of congestion, treatment was with over the counter medication of Flonase and Afrin. 

Therefore, from day 5 forward the patient was safe for discharge to a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Seizures.
Treatment:  Inpatient hospital admission.

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

This is a male pediatric patient with a history of prematurity, neonatal seizures, remote right frontal hemorrhage, and benign myoclonus of infancy.  The patient was seen for a scheduled admission for a video-electroencephalogram (EEG) for new daily episodes concerning for seizures.  The episodes were described as a quick jerk of the face and neck associated with tonic extension of upper extremities.  The documentation indicated that the patient began using phenobarbital after an EEG showed focality in the first week of life.  The patient underwent additional EEG tests, which showed diffuse cerebral dysfunction, abnormality of the right cerebral hemisphere with focal potentially epileptogenic abnormality.  The patient was placed on Keppra, but the patient's mother reported that the medication did not help much.  Thus, Topamax and clonazepam were prescribed.  The patient continued to have additional seizure episodes, but the patient's physical exam revealed that he was an active child in no distress.  He was awake, alert, and cooperative.  The patient was able to point to different body parts when asked.  The patient's speech did include naming colors, as well as numbers and a few words.  The patient's movements were symmetrical in all 4 extremities.  The patient was admitted to the epilepsy monitoring unit for continuous video EEG monitoring.  Multiple events in question were captured with notable correlation.

According to Milliman Care Guidelines (MCG) clinical guidelines of seizure in pediatrics, a pediatric patient may be admitted to inpatient services for seizures when there is evidence of hemodynamic instability, a complex febrile seizure, status epilepticus, or repetitive seizures are evident that are not controlled with emergent treatment.  Furthermore, MCG guidelines for general admission indicate that an inpatient admission may be noted when there are cardiac arrhythmias of immediate concern, altered mental status that is severe or persistent, or there is a metabolic disorder or new focal neurologic deficits.  However, in this case, these medical indications for inpatient admission were not found in the medical record.  This patient with a history of neonatal seizures and frontal hemorrhage presented with seizure-like activity but was otherwise stable on physical examination.  Documentation does not detail a failure of lower levels of care or any of the above indications.  No treatments were initiated as a result of the admission.  Therefore, it appears that the patient was clinically stable enough to receive services at a lower level.  Inpatient admission was not medically necessary for this patient.

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.