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

Diagnosis: Missing Teeth
Treatment: D5225 Partial Upper Denture
The insurer denied the D5225 Partial Upper Denture.
The denial is overturned.

The patient is a male who presented to the office of his dental provider for evaluation and treatment of his missing teeth in the maxilla. Included for review are letters of appeal and denial, a patient narrative, radiographic images, a panoramic radiograph showing multiple missing teething the maxilla, and treatment plans. In question is the medical necessity of the planned treatment of D5225 partial upper denture.

The health plan's determination is overturned.

The health plan's denial is not based on any established science as there has never been any established minimum number of posterior teeth necessary to be absent for a patient be considered eligible for a partial denture. As the patient has the diagnosis of partial edentulism, there exists a need to replace the missing teeth with either a partial denture or dental implants, this is the only requirement for tooth replacements, missing teeth. The treatment is medically necessary as it addresses the diagnosis of partial edentulism, making the treatment of D5225 partial upper denture medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arthritis
Treatment: Increase Personal Care Assistance (PCA) from 24 hours/day, 7 days/week, live-in to 24 hours/day, 7 days/week, split shift 
The insurer denied the increase in PCA from 24 hours/day, 7 days/week, live-in to 24 hours/day, 7 days/week, split shift. 
The denial is upheld.

The patient is a female with medical history notable for psoriatic arthritis, osteoporosis, history of bilateral hip replacement, history of bilateral shoulder replacement, history of right knee replacement, gait disorder (wheelchair bound), chronic pain, urinary incontinence, and chronic hypercapnic respiratory failure. The patient currently receives 24 hour live-in personal care. The patient and her care team requested an increase to 24 hour split-shift personal care and this request was denied by the insurance company. This denial is the subject under review.

A letter of support for this appeal was provided by the treating physician's office. This appeal states that the patient has needs for medical care that have been preventing the necessary 5 hour window of uninterrupted sleep for the personal care aide, causing them to be "up all day and most of the night and are exhausted." They therefore requested that the insurance company "fulfill the patient's request in order to avoid exacerbation of his/her medical condition(s)." No specific details regarding unmet medical needs were cited.

A recent office visit note from the treating physician was available for review. This note discusses the need for home health care. Per the notes: "Patient is wheelchair dependent and requires assistance with all of her activities of daily living (ADLs) at this time. Patient notes that her home attendants rotate in 24 plus (+) hour shifts (live-in) but has been having issues with care at night as she notes that her home attendants are usually tired from helping her all day and can be difficult to get the help she needs in a timely manner as her home attendants have sometimes fallen asleep secondary to exhaustion."

The health plan's determination is upheld.

The requested health service/treatment of Personal Care Assistance from 24 hours/day, 7 days/week, live-in to 24 hours/day, 7 days/week, split-shift has not been demonstrated to be medically necessary for this patient.

The question at hand is whether or not this patient's care needs can be met by a 24-hour live-in attendant, who would require a minimum of 5 hours of uninterrupted sleep at night. If the patient has medical needs that would go unmet during this 5 hour period, they would qualify for split-shift. The patient does not have any evidence of pressure ulcer and no request from the treating physician for period turning and positioning. She has urinary incontinence, but has some control present and uses incontinence supplies. There was no statement regarding incontinence issues being the cause of her home health aide being unable to sleep. It is unclear from the documentation what health needs, if any, are preventing the aide from being able to sleep. Therefore, there is no established medical necessity for split-shift services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Gallbladder problem
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer upheld in whole the health plan's determination.

The patient is an adult female who presented to the Hospital emergency department (ED) with abdominal pain of 1-day duration. She was approximately one month post Cesarean section. At the time of presentation, the patient was without fever and vital signs identified normal vital signs. She was tender in the epigastrium. The white blood cell (WBC) count was normal at 7 thousand(K). The complete metabolic panel identified elevated liver enzymes and normal bilirubin. Ultrasound showed gallstones and wall thickening. There was no sonographic Murphy's sign.
She was admitted to the hospital and initially treated with intravenous (IV) fluid and antiemetics. Surgery consultation was obtained. She was treated with laparoscopic cholecystectomy the next day. The operative dictation records completion of the procedure without complication. The gallbladder was acutely inflamed. The patient was treated with post-surgical monitoring, IV fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. The diet was advanced, and pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting on the day after surgery.

An inpatient level of care was not medically necessary in this case. This patient presented to the ED with abdominal pain of 1-day duration. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. Surgery was performed and the patient had an uncomplicated initial recovery period. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.
A lower level of care would have provided for ED assessment, perioperative care and monitoring, provision of IV antibiotics and fluid, surgical treatment, and overnight care. There were no peri-operative complications or other clinical issues. The patient's presenting condition, lab data and imaging and her clinical course did not justify an inpatient level of care. The care provided could have appropriately been rendered with a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Stelara 90 MG (milligrams) /ML (milliliter) Syringe
The insurer denied coverage for Stelara 90 MG /ML Syringe.
The denial is overturned.

The patient has fistulizing ileocolonic Crohn's disease. He was previously treated with Humira and then switched to Stelara. He had an initial positive clinical response to giving the Stelara every 8 weeks. More recently he has had an increase in his Crohn's symptoms. An endoscopy performed found active ileitis. The Stelara trough concentration was found to be low. His physician is now requesting to increase the Stelara dose to every 4 weeks. 

Clinical Gastroenterology and Hepatology 2021 Jan 19 (1): 104-110 has an article titled "Effectiveness of Ustekinumab Dose Escalation in Patients with Crohn's Disease." Data was studied from patients who initially received ustekinumab every 8 weeks and then had their interval shortened to every 4 weeks. The conclusion was that shortening the ustekinumab dose to every 4 weeks, in patients who did not respond to dosing every 8 weeks, improved clinical and biological Indices of disease activity. It was noted that dose interval shortening was effective and safe.

This patient has severe Crohn's disease and has failed biologic agents. There was an initial good response to Stelara, but he is now having a flare up of the disease; his physician has advised dose escalation to 90 mg every 4 weeks. The medical literature supports this dose escalation. He is no longer responding well to dosing every 8 weeks and requires the shorter interval. Giving Stelara every 4 weeks is medically necessary. 

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 Stelara 90 MG /ML Syringe services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Constipation, abdominal pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a medical history of constipation, human immunodeficiency virus, hypertension, obesity, bilateral osteoarthritis, schizophrenia, anxiety, insomnia, and methadone dependence. He presented to the emergency department with a lack of bowel movements for three days, five episodes of vomiting, lower abdominal pain, back pain, and numbness in his hands and feet. His vital signs were notable for an elevated blood pressure of 156/75 millimeters of mercury (mmHg). The physical examination was notable for a soft, protuberant abdomen without abdominal or costovertebral angle tenderness. Lab results showed a low hemoglobin of 11.9 grams per deciliter (g/dL) and hematocrit of 35.3% (percent), and unremarkable comprehensive metabolic panel. An x-ray of the abdomen showed a normal nonobstructive gas pattern, and no abnormal mass or calcification. A computed tomography scan of the abdomen and pelvis showed significant hepatic steatosis without acute findings in the abdomen or pelvis. He reported vomiting after an attempt to use GoLytely. Lab results showed a low hemoglobin of 11.3 g/dL and hematocrit of 33.2%, and elevated aspartate aminotransferase of 90 units per liter (U/L). He left against medical advice and was started on MiraLAX and senna-docusate, with a plan for Primary Care and Gastroenterology follow-up. At issue is the medical necessity for the inpatient level of care.

The inpatient level of care is not medically necessary in this case. The patient presented with constipation, lower abdominal pain, and vomiting; imaging did not show any definite bowel obstruction, volvulus, or other complications which would warrant the inpatient level of care [1-6]. No other cause for the inpatient level of care, such as bowel perforation, peritonitis, toxic megacolon, sepsis, abscess, fistula, or other complication was documented. The patient was appropriately treated with osmotic laxative therapy [5,6]. All of the measures that were undertaken, including monitoring, labs, and imaging, could have been performed without the inpatient level of care, at a lower level of care [2-5].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancreatitis.
Treatment: Inpatient Stay.
The insurer denied: Inpatient Stay.
The denial is: Upheld.

The patient is a male with medical history of pancreatitis, gastroesophageal reflux disease (GERD), hypertension, atrial fibrillation status post ablation, and alcohol abuse. He presented to the emergency department with severe epigastric pain radiating to the back, and nausea. He had been admitted recently for pancreatitis, was found to have gastritis, and started on fenofibrate; fenofibrate had been discontinued a few days prior, and he had alcohol in the prior 3 days.

Vital signs were notable for elevated blood pressure 159/96 mmHg (millimeters of mercury). Physical examination was notable for epigastric tenderness without rebound or guarding. Labs showed unremarkable complete blood count, elevated aspartate aminotransferase of 158 units per liter (U/L), elevated alanine aminotransferase of 120 U/L, elevated bilirubin of 1.4 milligrams per deciliter (mg/dL), elevated lactate of 3.03 millimoles per liter (mmol/L), and elevated lipase of 113 U/L (upper limit of normal 78 U/L). Chest x-ray showed no acute pulmonary pathology. Computed tomography scan of the abdomen and pelvis showed fat stranding adjacent to the pancreatic head, diverticulosis, and diffuse hepatic steatosis. He was treated with intravenous fluids, morphine, hydromorphone, and ondansetron. He was made nothing by mouth (NPO) status.

Two days later he felt better, with no pain; he was tolerating a low-fat diet. Labs showed normalized lipase. Gastroenterology consultation noted recent alcohol use, prior cholecystectomy, and recent admission for acute pancreatitis secondary to hypertriglyceridemia; the assessment was acute pancreatitis likely secondary to alcohol use and elevated transaminases, and the recommendation was to continue aggressive intravenous fluids, monitor for fluid overload, advance diet as tolerated, follow transaminases and international normalized ratio, and follow up as outpatient. He was discharged on pantoprazole, with a plan for Primary Care and Gastroenterology follow-up. At issue is medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay is not supported as medically necessary by the provided information. The patient presented with symptoms and imaging consistent with acute pancreatitis [1]. He was appropriately treated, with intravenous fluid administration, and subsequent improvement in pain, and gradual advancement of diet [1-5]. However, there was no hemodynamic instability or other complications such as pseudocyst, pancreatic necrosis, thrombosis, ascending cholangitis, abscess, active gastrointestinal bleeding, peritonitis, or sepsis, which would require a higher level of care [4-8]. He did not have persistent signs or symptoms of acute alcohol withdrawal [9,10]. The interventions performed, including labs, imaging, intravenous fluids, and monitoring, could have been performed without the inpatient level of care, at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Neck pain, back pain, muscular weakness.
Treatment:  Inpatient admission.

The insurer denied the inpatient hospital stay.  The health plan's determination is upheld.

The patient is a male with a history of diabetes, coronary artery disease (CAD) with stent, bipolar disorder, anxiety, Parkinson's disease, arthritis, gastroesophageal reflux disease (GERD) and fibromyalgia. He also has a history of hypertension, neuropathy, sleep apnea, stroke, bilateral upper and lower extremity weakness, peripheral artery disease, fatty liver, and irritable bowel syndrome. He presented to the emergency room with several complaints including progressive bilateral upper and lower extremity weakness, dysesthesia of the lower extremities and watery diarrhea. He had a viral syndrome, with cough and fever, that resolved one week ago. On this presentation, his vital signs were normal, and he was in no apparent distress. His physical exam was notable only for weakness of all four extremities. Labs were remarkable for a white blood cell count (WBC) of 12,900, a slightly elevated erythrocyte sedimentation rate (ESR) and a mildly elevated c-reactive protein (CRP). There were no acute intracranial abnormalities identified on a computed tomography (CT) scan of the head, the magnetic resonance imaging (MRI) of the brain, cervical spine, thoracic spine or lumbar spine. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation.

Upon admission, the patient was treated with his usual home oral medications. The next day, the neurologist evaluated the patient and noted "He does have a functional motor exam and no objective sensory findings." A several day hospitalization ensued. The remainder of the stay was clinically uneventful, and the patient was discharged.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission.

It was noted in his past medical history that he had bilateral upper and lower extremity weakness, yet this past history was not reconciled in the context of this most recent presentation, making it objectively unclear as to whether his weakness was acute.

The services provided were oral medications, consultations, monitoring, imaging, lab studies. These services were not at the acute inpatient level of intensity. Therefore, based on the standard of care the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer
Treatment: 42 hours per week of consumer directed personal assistance services
The insurer denied 42 hours per week of consumer directed personal assistance services.
The health plan's determination is overturned. 

The patient is a female with past medical history of gastric cancer, deep vein thrombosis (DVT), PE (pulmonary embolism), dumping syndrome, depression, asthma, cachexia, anxiety, gastroesophageal reflux disease (GERD), and osteopenia who underwent a telehealth universal assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, shopping, and transportation while maximum assistance with task of stair use. With task of bathing, the patient was assessed at extensive assistance while limited assistance with tasks of managing medication, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. The patient was assessed at independent with tasks of phone use, personal hygiene, and eating. 

42 hours per week of consumer directed personal assistance services (CDPAS) are medically necessary for this patient.

There is documentation from the patient's primary care physician (PCP) of medical necessity of increased CDPAS services. The patient requires limited assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs when the patient did not have informal help. There is also documentation that the patient's husband works during the day and is unable to provide informal help during the hours that CDPAS services are requested. The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL) as she is only independent with tasks of phone use, personal hygiene, and eating. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services to total 42 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic idiopathic urticaria
Treatment: Xolair (omalizumab)
The insurer denied: Xolair (omalizumab)
The denial is overturned.

This patient is an adult female with a diagnosis of chronic idiopathic urticaria (CIU). The prior denial reason was that there were no pharmacy claims seen for Allegra or second-generation antihistamines at four times the normal dose. While Allegra is over the counter, the health plan felt it is unlikely that the patient was obtaining the quantity noted to have been used without a prescription.  Therefore, Xolair was denied stating the patient could try dose advancement of second-generation antihistamines (Cetirizine up to 40 milligrams daily, Levocetirizine up to 20 milligrams daily, Loratadine up to 40 milligrams daily, or Fexofenadine up to 720 milligrams daily) for at least four consecutive weeks.

The proposed Xolair is medically necessary.
Xolair is Food and Drug Administration (FDA) approved for the treatment of chronic idiopathic urticaria in adults and adolescents 12 years of age and older who remain symptomatic despite H1 antihistamine treatment. This is based on clinical trials showing efficacy of Xolair in treating chronic idiopathic urticaria in patients who remain symptomatic despite H1 antihistamine treatment. 

The patient had taken Allegra 360 milligrams twice a day (BID) but continued to have hives several days per week. This is the maximum dose of a second generation H1-antihistamine, and this dosing is available over-the-counter. The patient has a diagnosis of chronic idiopathic urticaria and remains symptomatic despite H1 antihistamine treatment. The patient meets the Food and Drug Administration approved indication for the use of Xolair. A four week trial of a maximum dose of a second generation H1-antihistamine is not required per the medical literature prior to using Xolair for chronic idiopathic urticaria (CIU).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative colitis
Treatment: Humira (CF) Pen 40 mg/0.4 mL weekly
The insurer denied Humira (CF) Pen 40 mg/0.4 mL weekly.
The health plan's determination is upheld. 

The patient is a male with Ulcerative Colitis (pancolitis). He failed mesalamine. He was previously in remission on infliximab. Testing showed low infliximab level (< 0.4) and the presence of anti-infliximab antibodies (885). He was changed to Humira. He had improvement in symptoms. Testing showed low Humira level and the presence of anti-Humira antibodies.

Humira 40 milligrams (mg) weekly is not supported as medically necessary. This patient has Ulcerative Colitis with a low Humira level on the current Humira dose of 40 mg every other week. In the high-quality ULTRA 2 trial used for Food and Drug Administration (FDA) approval, it was part of the protocol to increase the Humira dose if response was not adequate on Humira 40 mg every 2 weeks. The trial advanced non-responders at week 8 to weekly therapy as well as week-8 responders - both groups contained a fraction that responded to dosing frequency increase. In the ULTRA 3 trial, weekly Humira was started for inadequate response, or for flare. The American Gastroenterological Association guidelines for management of Ulcerative Colitis state that when there is loss of response to anti-TNF (tumor necrosis factor) medication with a subtherapeutic drug level, the recommendation is to increase drug dose. All of this literature recommends dose intensification for loss of response; guidelines for drug monitoring do not recommend increasing dose to address low drug level in the absence of symptoms. In this case, while a low drug level is documented, loss of response to Humira is not documented. Therefore, the provided information does not support use of Humira 40 mg weekly.