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

Diagnosis: Abnormal Blood Test
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female with asthma, chronic cough, and anxiety who presented to emergency room with numbness on both extremities. The patient also has history of cryptogenic organizing pneumonia and is being evaluated for biopsy. The patient was found to have hypophosphatemia and was admitted. The patient was also scheduled to have lung biopsy. The patient's electrolytes were replaced. The patient tolerated the lung biopsy but had chest tube removed. The patient was discharged home. The admission was denied due to lack of medical necessity. This denial is being appealed.

No, the proposed inpatient admission was not medically necessary.
The patient had electrolyte abnormalities as well as had thoracic surgery performed while being admitted to the hospital. The patient was hemodynamically stable. The patient received electrolyte repletion in the emergency department. The patient was tolerating diet. The patient's lung biopsy was uncomplicated and the chest tube was removed within 24 hours. The patient did not require any invasive drips. The admission was not medically necessary. The care could have been safely and effectively provided at a lower level of care.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Renal Failure
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with hypertension, diabetes, gout, chronic low back pain, morbid obesity, and obstructive sleep apnea on continuous positive airway pressure (CPAP) who was admitted with lightheadedness and near syncope.  Labs demonstrated a white blood cell count of 7.0, glucose of 154, creatinine of 2.3 (baseline creatinine 1.0) and potassium of 5.3.  The patient was afebrile; the blood pressure was 126/62 and pulse was 88.  The electrocardiogram showed sinus rhythm without acute ischemic changes.  The chest x-ray showed no acute process.  The patient's metformin and angiotensin-converting enzyme (ACE) inhibitor were held, and intravenous fluids were provided.  The potassium normalized.  The creatinine dropped to 1.7, 1.4, and 1.2 on follow-up.  The patient was discharged with metformin still on hold and the angiotensin-converting enzyme inhibitor restarted.

No, the proposed treatment was not medically necessary.
The patient's acute kidney injury was not accompanied by uremia, severe acidosis, volume overload or a significant degree of hyperkalemia.  Dialysis was not required.  Renal function improved promptly with hydration.  The creatinine of 2.3 on admission was not at least threefold higher than the baseline creatinine of 1.0.  The patient remained hemodynamically stable and afebrile.  There was no evidence of arrhythmia, acute coronary syndrome, syncope or pulmonary embolism.  In summary, inpatient hospital admission was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
As detailed above, the proposed treatment was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Saxenda

The insurer denied Saxenda. 
The health plan's determination is overturned.

The patient is a female with history of obesity, body mass index (BMI) 60-69.9 and pre-diabetes.
The coverage request is for Saxenda 3 milligrams /0.5 milliliter (mL) Pen Injector. The coverage was previously denied because the patient did not meet medical necessity criteria.

Saxenda is medically necessary for this patient. Lifestyle changes remain the first line therapy according to the American Heart Association (AHA) / American College of Cardiology (ACC) 2013 obesity guidelines which for obese and overweight individuals, recommends a comprehensive lifestyle program including lower calorie diet and increased physical activity (strong recommendation with strong level of evidence, and which benefits significantly outweigh risks). The 2015 Endocrine Society obesity guidelines recommend consideration of weight loss medication in patients with BMI>27 with comorbidity or BMI over 30, but only as adjuncts to reduction of food intake and increased physical activity, noting that drugs may amplify adherence to behavioral change and may improve physical functioning and allow increased physical activity.
This patient has participated in weight loss program for at least 3 months, but due to her very high BMI would now also benefit from an additional agent for weight loss. Saxenda is an appropriate choice. Saxenda in clinical trials after 1 year was able to produce about 8 kg (kilograms) of weight loss.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chest pain
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

This case involves a male with history of obesity who presented to the emergency department (ED) with chest pain that started the day of admission. Records show the patient awoke with chest pressure and tightness associated with nausea, swelling, body aches and subjective fevers. When ambulating to the bathroom, the patient experienced a syncopal event witnessed by his wife. In the ED, the patient was hemodynamically stable. Cardiac troponins were elevated, peak 1.3. The patient was admitted under inpatient level of care for evaluation of chest pain and rule out acute coronary syndrome (ACS). Coronary computed tomography angiography (CTA) was normal indicating that the patient's presentation was most consistent with myopericarditis. Echocardiogram showed normal cardiac function. The patient was treated with colchicine and nonsteroidal anti-inflammatory drugs (NSAIDS).

This patient presented with chest pain and syncope concerning for a cardiac etiology. Given his concerning presentation and elevated cardiac troponins, inpatient evaluation was medically necessary and appropriate to complete a thorough cardiac evaluation with telemetry monitoring given the patient was at increased risk for complications including progressive heart failure, arrhythmias, and mortality due to acute myopericarditis. Hospitalization under inpatient level of care is supported by the peer reviewed medical literature and expert consensus guidelines on evaluation and management of patients presenting with chest pain due to acute myocarditis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genetic Diseases/Spinal Muscular Atrophy
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested medication, Zolgensma Injection. 
The health plan's determination is overturned.

The patient is a girl with a diagnosis of Type 3 spinal muscular atrophy (SMA) with an initial diagnosis at 1 week of age based on a newborn screen that revealed absent SMN1 (survival motor neuron) and 4 copies of SMN2. At issue is the denial of treatment with Zolgensma based on the patient's current signs and symptoms of SMA and the guidelines for treatment based on (less than or equal to) <=3copies of SMN2, vs. (versus) the patient's 4 copies that predicts a Type 3 phenotype. Initial recommendations for treatment were based on the clinical course of Type 1 or 2 SMA vs. a more variable and potentially indolent course of Type 3 SMA.
At issue is the medical necessity for the requested health service/treatment of Zolgensma Injection.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, based on the family history of an uncle that lost ambulatory skills at 15 and died at 27, and the available information on the highly variable phenotype of SMA Type 3. Clearly the best time for intervention with a therapy such as Zolgensma is prior to the onset of symptoms or significant decline in motor milestones.
The requested treatment with Zolgensma for this patient is clearly medically necessary. Her diagnosis of SMA Type 3 is not in question. The only thing in question is the trajectory of her disease process. While overly simplistic, the common sense approach to preventing disease is not to get it in the first place. Since there is nothing that this patient can do about her genetic diagnosis, the next best solution is to intervene with a truly disease-modifying therapy in the form of Zolgensma. Therefore, it is medically necessary and the sooner that she receives it the less likely she is to be impacted by the inevitable morbidity of this disease process.
The rationale for Zolgensma is incontrovertible. The only issue is the timing of this intervention and allowing this patient to benefit from its clearly demonstrated therapeutic utility for all forms of SMA sooner rather than later will spare her of potentially irreversible deficits that will impact her life and her activities of daily living.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer.
Treatment: Verzenio.
The insurer denied Verzenio.
The determination is upheld.

This is a patient with metastatic breast cancer. The patient received adjuvant tamoxifen. She has also received letrozole. Alpesinib was initiated at the diagnosis of metastatic disease but the patient could not tolerate therapy. The patient was then started on Ibrance but has progressed. Verzenio has been recommended and is under review.

The Verzenio is not medically necessary.

It is stated the patient previously received Ibrance and progressed. Verzenio has a similar mechanism of action (cyclin-dependent kinase [CK] 4/6 inhibition) and is not known to be effective in this clinical scenario. The use of sequential CK4/6 inhibitors is not recommended in the National Comprehensive Cancer Network (NCCN) Guidelines, the peer-reviewed literature, nor by the authors of UpToDate.

Lacking data demonstrating efficacy in this scenario, medical necessity for Verzenio cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fractured Tooth.

Treatment tooth-colored crown for tooth # 30.

The insurer denied coverage for tooth-colored crown for tooth # 30.

The denial is upheld.

Upon review of the documentation provided which includes copy of periapical radiographs, dental charting and treatment notes, narrative letter from the patient and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist noted fracture of the MB (mesiobuccal) and DB (distobuccal) cusps of #30 which was endodontically treated and recommended a treatment plan that included a core buildup with a guarded prognosis or extraction of the tooth. The patient was made aware that the insurer will likely not allow the full coverage crown that the patient was requesting. The insurer has denied these services stating that the documentation provided does not meet medical necessity criteria. The patient is appealing.

The objective documentation provided for review is a copy of periapical radiographs and dental treatment records. The patient herself states that she appreciated a vertical fracture of tooth #30 and the dentist treating her noted fractured MB and DB cusps of #30 which has been endodontically treated. The dentist treatment plans as per note indicated a guarded prognosis for a core buildup and included extraction as a treatment option, presumably due to the poor long-term prognosis of this tooth. Based on the note the patient insisted on interfacing with insurer for a pre-estimate as she did not want the tooth extracted. As per standard of care in dental practice and based on peer reviewed literature a tooth exhibiting a vertical fracture (of which the patient is aware) a vertical fracture of a tooth most often deems the tooth non maintainable with extraction the most viable option. The patient was made aware of this by the dentist. As the tooth exhibits a clinically documented poor long-term prognosis a crown for tooth #30 is not Indicated.

Uphold denial of coverage for a tooth-colored crown for tooth #30 as the clinical documentation reflects a poor long-term prognosis for this tooth.

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

The insurer's denial of coverage for a tooth-colored crown for tooth # 30 is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe Neutropenia

Treatment: Udenyca

The insurer denied coverage for Udenyca.

The denial is upheld.

The patient is an adult female with a history of ovarian cancer and left salpingo-oophorectomy. She received adjuvant chemotherapy with carboplatin AUC (area under the curve) 6 and Taxol and received Udenyca support for severe neutropenia.

Administration of G-CSF (granulocyte colony stimulating factor) is generally not recommended for routine treatment in patients with established fever and neutropenia. ASCO (American Society of Clinical Oncology) and ASH (American Society of Hematology) guidelines recommend routine use of Neulasta or Neupogen (filgrastim) for patients with an overall risk of fever and neutropenia of 20% (percent) or greater. The NCCN (National Comprehensive Cancer Network) guidelines state that for patients with a febrile neutropenia risk of 10% (percent) to 20%, prophylactic colony-stimulating factor use should be considered based on the treatment intent and the importance of chemotherapy dose delivery on schedule. This regimen produces severe neutropenia in 43% of cases and 7% febrile neutropenia. As guidelines do not recommend growth factors unless febrile neutropenia is greater than 20%, the prophylactic Udenyca is not recommended by guidelines.

"The use of G-CSF after the administration of chemotherapy may be in several settings:
'Primary prophylaxis,' when neutropenia is expected to occur following a course of chemotherapy, but the patient has never experienced it; 'Secondary prophylaxis,' when the patient had a neutropenic fever in a previous course of similar chemotherapy and is thus expected to do so again; 'Supportive' in the attempt to shorten the duration of severe chemotherapy-induced neutropenia in patients without fever (afebrile neutropenia)" (Caselli, D., Cesaro, S., & Arico, M.,).

The publication by Laskey (2012) states a risk of febrile neutropenia of 7%. 

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

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

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

The patient is a female with psoriasis to the scalp and eyebrows, treated with topical steroids and ketoconazole shampoo.  The provider is requesting Otezla.  The health plan denied Otezla due to requirement for use of phototherapy or systemic immunosuppressant.

Yes, the proposed treatment with Otezla is medically necessary.

Otezla (apremilast) is a phosphodiesterase inhibitor, and therefore its mechanism of action is different from injectable biologics.  Apremilast works intracellularly to modulate pro- and anti-inflammatory mediators.

The ESTEEM trial (randomized, double-blind) documented favorable response to apremilast over placebo at week 16.  Side effects were generally mild and did not result in discontinuation.  Seventy-five percent reduction in the Psoriasis Area and Severity Index (PASI) was seen in 33% (percent) of patients, and 50% reduction in the Psoriasis Area and Severity Index (PSAI50) in 60%.  Efficacy has been demonstrated in psoriatic arthritis as well, and it was first Food and Drug Administration (FDA) approved for spondyloarthropathies.

However, there are no studies to date comparing the efficacy of Otezla to other systemic medications for psoriasis.  It is an oral therapy and requires less medication monitoring (current data do not indicate a need for laboratory monitoring) and is not immunosuppressive.  Otezla is now among the growing number of systemic therapies for psoriasis.  Currently there are no evidence based medical guidelines indicating which therapy is best or delineating a stepwise approach to psoriasis.  The Guidelines of Care for the Management of Psoriasis state that each patient requires individual tailoring and a stepwise approach is not recommended.  No evidence based literature could be found to support the use of other therapies before Otezla.

Furthermore, according to the multidisciplinary review (Gresham, et al), vaccine efficacy may be reduced in patients receiving systemic immune-targeting therapies because of the impaired immune response in these patients.  There is a trend toward a decreased immune response and vaccine immunogenicity in patients on systemic immunotherapies, particularly patients receiving azathioprine, cyclosporine, methotrexate, mycophenolate mofetil, or Janus kinase (JAK) inhibitors.  Therefore, it would not be advisable to use a systemic therapy in this patient that can decrease vaccine efficacy and place this patient at higher risk of COVID-19 (Coronavirus 2019) complications when a safer alternative is available.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Immune system dysfunction. 
Treatment: Genetic Testing (81383 and 81377-59). 

The insurer denied the Genetic Testing (81383 and 81377-59). 
The denial is overturned. 

The patient is a male child with history of ADHD (attention deficit hyperactivity disorder), verbal dyspraxia, and developmental language disorder. He has been undergoing extensive work-up to determine the nature of his immune system dysfunction. According to a letter from the parents, he has history of vomiting, bloating, irritability, abdominal distention, and diarrhea with foul-smelling stools. This symptomatology has prompted a work-up for celiac disease. 

Yes, the testing is medically necessary. 

Celiac disease is an autoimmune disorder of the intestines triggered by gluten ingestion in genetically predisposed patients. Children may present with failure to thrive, abdominal distention, and chronic foul-smelling diarrhea. Prevalence is about one in 100 to one in 400. Diagnosis involves anti-transglutaminase and anti-endomysium antibody testing, and frequently HLA (human leukocyte antigen) testing. Previously, patients have had to undergo duodenal biopsy (presence of villous atrophy would be diagnostic), but with serological testing revealing high levels of anti-transglutaminase and anti-endomysium antibodies and absence of HLA (human leukocyte antigen) DQ2 or DQ8 alleles for negative predictive value, biopsy is now no longer considered standard of care. The gluten-free diet is the only effective treatment for celiac disease, involving avoidance of wheat, barley, and rye products. Clinical remission may occur rather quickly, but healing may take years. Long-term sequelae include osteoporosis, other autoimmune disorders, decreased fertility, and cancers. 

This child's clinical history is significant for signs and symptoms that could be consistent with celiac disease. While the family is concerned because of previous reports of potential association between ADHD (attention deficit hyperactivity disorder) and celiac disease, the current literature does not support this contention. However, the child's symptoms are consistent with autoimmune enteropathy. Testing for celiac disease is medically necessary and appropriate including testing for HLA (human leukocyte antigen) DQ2 and DQ8 (gene alleles) for the negative predictive value as part of the standard of care. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebral infarction
Treatment: Nursing Home Service
The insurer denied the Nursing Home Service
The denial is upheld

The patient is a male with hyperlipidemia, deep venous thrombosis (DVT), seizure, insomnia, hypertension, bipolar, and cerebral infarction.  The request is for Nursing Home Services.  The patient walks with intermittent supervision, needs intermittent supervision with eating, and requires intermittent supervision with activities of daily living.

No, the proposed treatment was not medically necessary.
As per the records, the patient is a male with hyperlipidemia, deep venous thrombosis, seizure, insomnia, hypertension, bipolar, and cerebral infarction.  The patient walks with intermittent supervision, needs intermittent supervision with eating, and requires intermittent supervision with activities of daily living.  There are no needs for continued skilled nursing facility.  The services can be provided in the community setting if needed.

The patient does not require supervision with mobility, or transfer, or toileting; the patient does not require any supervision with eating or feeding himself; the patient does not require any specialized services or physical recreational therapy.  The services were requested because the patient was deemed without capacity by psych to make medical/financial decisions and is not able to take care of his own activities of daily living at times and family cannot provide care for this patient.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Based on the records, the patient did not need any continued skilled nursing facility care and can be safely and effectively treated in the community setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Post-surgical pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female with a history of asthma, anemia, fibroid uterus with menorrhagia.  She underwent an elective hysteroscopic myomectomy, dilatation and curretage, and Novasure endometrial ablation.  The procedure was uncomplicated and total anesthesia was about one hour.  The patient was transferred to recovery. 

The patient's vitals were stable.  She had appropriate pain control and she was tolerating diet.  By later that day, her pain had worsened to a seven out of ten and was not controlled with medication.  Her vitals remained stable.  She was voiding and had minimal bleeding.  A consult with the pain team was performed and she was admitted overnight for pain control.  By the next day her pain had improved, she had normal blood work and she was discharged to home.

No, the proposed inpatient admission was not medically necessary.
An outpatient observation bed is an alternate level of healthcare comprising of short stay encounters for patients who require close nursing observation or medical management.  It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient.  

The patient in question was taken to the operating room and underwent an uncomplicated procedure.  After surgery she was not ready for discharge on the same day due to her uncontrolled pain.  She required observation and nursing care to assist with her medical management of pain.   This could have been done in an observation status.  By post operative day #1, the patient was ready for discharge, requiring less than a 24 hour stay.  Therefore, the patient did not require an acute inpatient stay, as the same care could have been provided at a lower level of care, observation.

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