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

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied personal care services 8-12 hours per day x 7 days a week. 
The denial is overturned.

The patient is a female with past medical history of hypertension, gastroesophageal reflux disease (GERD), anxiety, and urinary incontinence who had been assigned Personal Care Assistance (PCA) services 27 hours per week. The patient had a fall with fourth lumbar vertebral fracture with five day hospitalization and transfer to Skilled Nursing Facility (SNF).
The plan sent initial adverse determination denial notice approving 31 hours/week. The plan noted the patient would provide incontinence supplies and personal care services shall not be authorized if a patient's needs can be met by equipment or supplies. In addition, the denial stated the plan does not provide and aide for companionship when tasks are not being done. The plan recommended physical therapy (PT). The patient's daughter sent a note via fax stating the patient is not able to prepare food for herself due to her conditions, is extremely afraid of falling, is not able to see from one eye, is recovering from a fall she had, and she has chronic pain from her fall with lumbar fracture.

The subject under review is the medical necessity for the personal care services 8-12 hours a day x 7 days a week.

The health plan's determination is overturned.

Yes, the requested treatment of personal care service 8-12 hours x 7 days a week is medically necessary for this patient. The patient had functional decline following her fall with lumbar fracture. She was in rehabilitation and their interdisciplinary team recommended an increase in PCA hours to at least 8 hours/day, 7 days/week. The patient has unscheduled and unpredictable care needs over a continuum of time. The patient's care needs cannot be met with medical supplies and adaptive equipment alone. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs)/Instrumental activities of daily living (IADLs). The patient is not able to ambulate or walk without the assistance of another person. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 8-12 hours/day, 7 days/week, to total 56-84 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: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Zeposia. 
The denial is upheld.

The patient is a female. She has multiple sclerosis (MS). Previous treatment included Tecfidera, Rebif, and Ocrevus. Zeposia is requested. The subject under review is whether Zeposia is medically necessary for this patient.

The health plan's determination is upheld in whole.

Zeposia is not medically necessary for this patient. Zeposia has not been compared in head-to-head trials to the other available therapies other than interferon beta1a. Therefore, definitive conclusions regarding the relative effectiveness of Zeposia as compared with the other available therapies may not be drawn from the currently available data, since head-to-head comparative studies are required to determine relative effectiveness. There is insufficient evidence to conclude that the requested drug Zeposia is safer or more effective than the health plan preferred drugs Gilenya and Mayzent. Zeposia is not medically necessary for this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary
Pharmacy/prescription drugs

Diagnosis: Urinary frequency
Treatment: Myrbetriq
The insurer denied Myrbetriq. The health plan's determination is upheld. 

The patient is a female with a diagnosis of urinary frequency, urgency, and pelvic pain. Under review is the medical necessity for Myrbetriq.

Myrbetriq is not medically necessary for this patient. The health plan has denied coverage due to lack of trial of formulary alternatives (oxybutynin, oxytrol and Toviaz). Current documentation does not support superiority of Myrbetriq over these medications or an absolute contraindication to formulary alternatives. As such, the requested medication is not medically necessary.

Myrbetriq is a beta 3 agonist which relaxes the bladder by a mechanism which is different than anticholinergic medication. Current medical literature does not support superiority of Myrbetriq over traditional anticholinergic medications such as the plan's formulary drugs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastritis.

Treatment: Hospital Admission.

The insurer denied coverage for the hospital admission.

The denial is upheld. 

This is a male patient with a history of hypertension, gastric bleeding due to peptic ulcer disease (PUD), gastritis, arthritis, and prior alcohol abuse.  The patient presented to the Emergency Room (ER) from the physician's office with complaints of a 4-day history of black stools and abdominal pain.  He denied any dizziness, lightheadedness or chest pain.  No bright red blood per rectum.  In triage, his blood pressure (BP) was 107/61 and heart rate (HR) was 66.  Gastrointestinal (GI) exam was described as non-distended, no rebound, no guarding.  There was melena on rectal exam.  Labs showed blood urea nitrogen (BUN)/creatinine of 30/1.38 and hemoglobin (Hgb) of 13.4, with Hgb 3 hours later unchanged at 13.4 and 13.0 approximately 12 hours later.  Creatinine was 1.2.  Computed tomography (CT) of abdomen was suggestive of gastritis.  No other acute findings noted.  Esophagogastroduodenoscopy (EGD) showed gastritis and gastric ulcer.  Biopsies were taken.  Proton pump inhibitors (PPI) were recommended.  

As per literature review, all patients with hemodynamic instability (shock, orthostatic hypotension) or active bleeding (manifested by hematemesis, bright red blood per nasogastric tube, or hematochezia) should be admitted to an intensive care unit for resuscitation and close observation with automated blood pressure monitoring, electrocardiogram monitoring, and pulse oximetry.  This patient was hemodynamically stable, no active bleeding with a stable Hgb.  There were no acute abdominal findings that supported the need for acute inpatient management. 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.  The patient could have been observed and when there was no active bleeding, further management could have been done as an outpatient. 

The carrier's denial of coverage for the hospital admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Sided Facial Pain And Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a past medical history significant for NSTEMI (non-ST-elevation myocardial infarction). She had been evaluated with a cardiac catheterization, which revealed no obstructive CAD (coronary artery disease) and luminal irregularities only, and was treated with medical therapy. She presented with complaints of chest pain of one week duration, as well as left facial swelling and pain.

The patient was admitted to rule out ACS (acute coronary syndrome). The patient was hemodynamically stable. The ECG (electrocardiogram) revealed normal sinus rhythm with no acute ischemic changes. Cardiac enzymes were normal. The patient was given antibiotics for facial and ear pain and erythema. She was seen in consultation by GI (gastroenterology), and PPI (proton pump inhibitor) was recommended. She was seen by cardiology in consultation. No further ischemic work-up was planned, and the patient was discharged home the next day with a plan for outpatient follow-up.

No, the Inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. The patient had prior cardiac catheterization with no evidence of epicardial coronary artery disease. No further ischemic evaluation, such as catheterization, stress test or CTA (Computed Tomographic Angiography) was planned during this admission. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left lower extremity cellulitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient with a past medical history significant for hypothyroidism, depression, and status post vein stripping who presented to the Emergency Department (ED) with complaints of left leg erythema and pain. The patient's vital signs on presentation included: Temperature 99, Blood Pressure 148/79, Pulse 80, Respiratory Rate 16, Oxygen Saturation 98% on Room Air. The patient's laboratory results included the following: white blood cell (WBC) 8.35, hemoglobin 11.7, hematocrit 36.5, creatinine 0.5, glucose 93, and lactic acid 0.6. The patient was started empirically on intravenous (IV) antibiotics (i.e., vancomycin and Zosyn) for left lower extremity cellulitis. The patient's cultures remained negative. The patient's Duplex ultrasound was negative for deep venous thrombosis (DVT). Infectious Disease was consulted. The patient's magnetic resonance imaging (MRI) was negative for osteomyelitis. The patient remained afebrile, clinically, and hemodynamically stable. The patient was discharged to continue oral antibiotics (i.e., Keflex and Levaquin) as an outpatient. 

According to documentation, the patient presented to the ED with a left lower extremity cellulitis. Otherwise, the patient was afebrile, hemodynamically stable, with unremarkable laboratory results including normal WBC and lactic acid. The patient had no evidence of a disseminated infection and no surgical intervention was required. Based on above findings, the patient did not meet criteria for acute hospital admission.  

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

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Neck Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is partial approved. 

The patient is a male with cervical syrinx and C6 (sixth cervical spine vertebra) ependymoma status post multiple cervical surgeries and syringo-pleural shunt, as well as multiple other medical problems. The patient has chronic paresthesias in all extremities.

The patient presented to the ED (emergency department) and was admitted. MRI (magnetic resonance imaging) was performed, which showed no new findings in the cervical spine. Patient had IV (intravenous) antibiotics and had his oral pain medications increased.

Yes, in part. The Inpatient admission was medically necessary, in part. 

The patient presented with severe pain that required IV (intravenous) pain medications. Therefore, the initial dates are medically necessary for acute inpatient level of care, as the patient required IV (intravenous) pain medications and had severe pain that could not be controlled in a lower level of care. In addition, the patient had workup for known cervical lesion with multiple consults to specialties. As such, these dates are medically necessary. The remainder of the dates are not medically necessary, because there were no treatments provided and no issues encountered that would warrant acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-Bone Fracture/Break
Treatment: Inpatient stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in whole the health plan determination.

This case describes a patient who sustained an injury to both feet while walking down some stairs in her home. She accidentally missed the last step in a flight of stairs and stepped forcefully down onto the landing in her home. This resulted in significant bilateral foot pain. She was evaluated initially at a local urgent care, then was referred to the emergency department for further management. Evaluation and plain x-rays confirmed left foot metatarsal fractures in the 2nd through 4th digits. The diagnosis for the right foot was a 5th metatarsal base fracture. A magnetic resonance imaging (MRI) scan of the right foot ruled out a Lisfranc ligamentous injury. The patient was brought to the operating room for open reduction and internal fixation of the left foot metatarsal fractures. The patient was then discharged home the following day. 

The requested health service/treatment of Inpatient Hospital Admission was medically necessary for this patient. The injuries included multiple metatarsal fractures on the left foot which required surgical fixation and a right foot injury which included a metatarsal base fracture and widening of the tarsometatarsal joint which was concerning for a Lisfranc injury. This patient sustained bilateral foot injures of high complexity. This patient could not weight bear on either lower extremity. The work up included a medical clearance for operative intervention on the left foot and an MRI scan of the right foot which subsequently ruled out a Lisfranc injury. The patient then underwent surgical fixation of the left foot metatarsal fractures. The patient was deemed stable for discharge after she was gait trained with physical therapy to be weight bearing as tolerated in a Cam walker boot for the right foot injury and non-weight bearing on the left foot for which surgical correction was performed. The care rendered in this case was consistent with the recommendations of the current, peer-reviewed orthopedic literature as documented by Kim and colleagues in the Journal of Foot and Ankle Surgery.
Appeal type: Formulary Exception
Decision: Overturned

Endocrine
Pharmacy/Prescription Drugs

Diagnosis: Obesity
Treatment: Saxenda
The insurer denied Saxenda. The health plan's determination is overturned. 

The patient is a man with a history of morbid obesity who is requesting coverage for Saxenda (liraglutide). It is noted in his provider's letter that the patient has a long history of obesity, which is now complicated by the metabolic syndrome. It is also noted that the patient has had trials of combinations of metformin, phentermine, and topiramate, which have been ineffective and caused "significant" side effects.

Saxenda is indicated for this patient. According to the prior authorization form, as well as the plan formulary, the patient has indeed had trials of formulary drugs including metformin, phentermine, and topiramate. It has been documented by his provider that these medications have been ineffective and/or have caused significant side effects. Other apparently formulary drugs for weight loss, including diethylpropion, benzphetamine, and phendimetrazine, would not be more effective than the requested non-formulary liraglutide and would very likely have considerably more side effects. Hypertension is a very frequent side effect of phentermine and the related sympathomimetic amines on the formulary. This would be quite worrisome for this patient who has had elevated blood pressures noted on occasion. Other important, and fairly frequent, side effects include tachycardia, palpitations, nervousness, insomnia, and dry mouth.

Therefore, a formulary exception is indicated for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 

The insurer denied braces and monthly visits.  The denial is upheld. 

The patient is a male with a diagnosis of Class I malocclusion, appropriate overjet and overbite. The upper and lower arches are both crowded. He is treatment planned for orthodontics with extraction of a mandibular incisor to correct his malocclusion. The provider is appealing on the grounds that tooth 22 is in crossbite with gingival attachment loss.

The subject under review is the medical necessity for braces and monthly visits.

The health plan's determination is upheld.

The requested treatment of braces and monthly visits is not medically necessary for this patient. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.1 This patient presents with none of those conditions.  

The patient has appropriate overbite and overjet. There is crowding but that alone does not rise to the threshold of medically necessary. The photos do not support a diagnosis of a crossbite of tooth 22 with tooth 10, and the gingival margin of 22 appears to be similar to tooth 27. There does not appear to be attachment loss. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. The diagnosis states the patient is has a skeletal Class I relationship which is the most efficient jaw relationship for mastication.2 If his teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma/Injuries/Spinal Cord Injury
Treatment: Durable Medical Equipment (DME)

Diagnosis: Trauma/Injuries/Spinal Cord Injury.
Treatment: Durable Medical Equipment (DME).
The health plan denied the requested durable medical equipment. The health plan's determination is overturned.

The patient is a male who was involved in a mountain biking accident which resulted in (cervical) C5-6 cord compression/edema/hemorrhage and anterior C4-6 and posterior (cervical-thoracic) C5-T1 epidural hematoma as well as ligamentous injury and anterior subluxation of C5 on C6. He underwent C3-T1 PSIF ( lumbar posterior spinal instrumented fusion), C5 and C7 laminectomies, open reduction of C5-6 and repair of a cerebrospinal fluid (CSF) leak. He completed acute inpatient rehabilitation. 

This reviewer overturns, in whole, the health plan's determination of medical necessity.

Yes, the requested RT300-FES (Functional Electrical Stimulating) ergometer is medically necessary.  The physical therapist noted that patient had completed 11 FES ergometry sessions and was able to tolerate 50 minutes of treatment without fatigue. This ability to obtain coordinated muscle contractions demonstrates the patient's ability to reduce muscle atrophy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries-Laceration
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient presented to the emergency department (ED) following an altercation in which he was stabbed in the left upper abdomen and left hand. The patient was tachycardic (heart rate 116/min) at the time of presentation. His ED evaluation with physical exam, computed tomography (CT) scan and lab data identified abdominal tenderness, a 2- centimeter (cm) laceration of the left hand, an elevated serum lactate and a 1.4-cm metallic density in the left mid-abdomen. The colon adjacent to the foreign body appeared thickened, suspicious for bowel injury. He was admitted to the hospital for hemodynamic monitoring, intravenous (IV) fluid, pain management and serial abdominal examinations. The trauma note states that the treatment plan was to include CT scan with rectal contrast and 24-hour observation. Prior to completion of this treatment plan, the patient left the hospital against medical advice(AMA).

The medical record does not support that inpatient level of care was medically necessary for this patient. The records support that this patient presented to the ED having been stabbed in the abdomen and left hand. The trauma note states that the treatment plan was to include CT scan with rectal contrast and 24-hour observation. However, the patient left the hospital AMA prior to completion of the treatment plan. The care and treatment provided could have reasonably and safely been provided at a lower level of care as proposed in the trauma note.
This patient's clinical needs (follow up imaging with contrast enhanced CT and serial abdominal exams) could have been satisfied with a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic arthritis. 
Treatment: The prescription Orencia (abatacept) for the treatment of Psoriatic Arthritis. 

The insurer denied coverage for the prescription Orencia (abatacept) for the treatment of Psoriatic Arthritis. 

The denial is overturned. 

This is a female patient who was diagnosed with psoriatic arthritis (PsA).  The patient has also been diagnosed with underlying systemic lupus erythematosus (SLE).  The patient is under the care of a rheumatologist.  The patient has used multiple medications to treat her condition, such as methotrexate, hydroxychloroquine, apremilast and secukinumab.  The patient also has a history of side-effects from Otezla, as she was experiencing diarrhea and nausea.  The patient was also on Cosentyx, which she had a good response to for psoriatic skin rashes, but it did not improve her joint pain.  The patient's treating providers determined it was not appropriate to try anti-tumor necrosis factors (anti-TNF) inhibitor medications due to her positive anti-nuclear antibody history and systemic lupus erythematosus (SLE) diagnosis, as it can induce a flare.  The patient is still experiencing joint pain, and the patient's rheumatologist has recommended Orencia infusion. 

As per review of UpToDate literature on "Tumor necrosis factor-alpha inhibitors: Induction of antibodies, autoantibodies, and autoimmune diseases," Orencia is considered medically necessary for this patient. Anti-tumor necrosis factor (TNF) therapies are well-known inducers of autoantibodies and, much less frequently, drug-induced lupus.  Frequency of induction of lupus or, as would be the case here, induction of flares of pre-existing lupus may run as low as 1%, but there is no reason to take this risk.  The extent and persistence of a flare would not be predictable.  The labeling for Humira includes warnings about stopping Humira for lupus-like reactions.  Orencia is a Food and Drug Administration (FDA)-approved alternative for psoriatic arthritis (PsA) not known for autoantibody induction or lupus. 

While anti-TNF therapies would ordinarily be reasonable alternatives, this is not the case for this patient with underlying systemic lupus erythematosus (SLE) diagnosis. In this case, there is an alternative medication, Orencia that is not associated with a risk for flaring SLE. Thus, Orencia is considered medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the prescription Orencia (abatacept) for the treatment of Psoriatic Arthritis should be overturned.  The medical necessity is substantiated.