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

Diagnosis: Ulcerative colitis.
Treatment: Entyvio (vedolizumab) Injections 300 (mg) Every 28 Days, Pre-service.
The insurer denied the Entyvio (vedolizumab) Injections 300 (mg) Every 28 Days, Pre-service.
The denial is overturned.

The patient is a male with ulcerative colitis. He was treated with Entyvio 300 mg(milligram) every 8 weeks, and had increased symptoms. His provider is requesting treatment with Entyvio 300 mg every 4 weeks.

Yes, the treatment with Entyvio every four weeks is medically necessary.
Medical literature supports dose intensification of biologic agents in patients who lose response to FDA (United States Food and Drug Administration)-approved dosing. Entyvio has been found to be safe and effective at doses as high as 600 mg IV (intravenous) every 4 weeks.

Per Singh et al. ''shortening infusion interval from 8 to 4 weeks led to improved effect in 3/7 (43%). This is supported by recent pharmacokinetic data demonstrating significant correlation between higher vedolizumab drug levels and clinical response in inflammatory bowel disease (IBD) patients.''

During the trial completed by Williet et al, 30 out of 47 IBD (inflammatory bowel disease) patients undergoing induction with vedolizumab who had not achieved remission by week 6 of treatment had their dose frequency increased to every 4 weeks. All of those with vedolizumab trough levels less than 10 mcg/mL (micrograms per milliliter) at week six achieved clinical remission 4 weeks after initiation of the higher dosing frequency.

As the patient has had increased symptoms despite Entyvio 300 mg every 8 weeks, the requested Entyvio 300 mg every 4 weeks is medically necessary.

As increasing to Entyvio 300 mg every 4 weeks is medically necessary, the  health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: neurosarcoidosis
Treatment: Humira
The insurer denied Humira. The health plan's determination is overturned.

The patient is a female with neurosarcoidosis with optic neuritis and seronegative rheumatoid arthritis (RA). Prior tx (treatment): Remicade (stopped due to an allergic reaction). She is currently on subcutaneous (SQ) methotrexate (MTX) 20 milligrams (mg) weekly but is having gastrointestinal (GI) intolerance. Under review is medical necessity of Humira 40 mg for this patient.

Humira 40 mg (milligrams) is medically necessary for this patient. As stated, the patient has seronegative RA and Humira is approved for rheumatoid arthritis (RA). She tried Remicade but had an allergic reaction. She is on SQ MTX 20mg weekly but is having GI upset. A trial of Humira is a medically appropriate and necessary next step in the management of her RA.
Per a letter from the attending rheumatologist, the patient has both neurosarcoidosis as well as seronegative RA. Thus, Humira is medically necessary for the treatment of her RA but is also indicated for treatment given the allergic reaction to Remicade. Per a study looking at the efficacy of adalimumab in sarcoidosis patients who developed intolerance to infliximab published in Respir Med, 'adalimumab is an effective alternative for patient's intolerant to infliximab. The switch to adalimumab achieved clinical improvement in 39% and stabilization in 33% of patients intolerant to infliximab'.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Burn Injury. 
Treatment: Skilled Nursing Facility (SNF). 

The insurer denied the Skilled Nursing Facility (SNF). 
The denial is overturned. 

The patient is a female with history of acute flash burn to her face and throat. She was admitted to ICU (intensive care unit), and she was intubated/sedated. 

Prior to admission, the patient was independent with all ADLs (activities of daily living), working as a health aide for her mother, living in a two-level house with one flight of stairs, living with her three kids and mother. 

The patient was ataxic with increased tendency to fall, required moderate Assistance with gait belt for ambulation for 30 feet and contact guard for 90 feet using rolling walker, moderate assistance for lower body dressing/bath, required support with gait belt for transfers. She was independent with grooming, feeding, bed mobility. 

The patient is moderate-high fall risk, because of ataxia, and she requires gait belt for stability. 

Yes, the Skilled Nursing Facility (SNF) is medically necessary. 

The proposed SNF (skilled nursing facility) care is medically necessary and should be covered by the health plan. 

The patient was ataxic with increased tendency to fall, required moderate Assistance with gait belt for ambulation for 30 feet and contact guard for 90 feet using rolling walker, moderate assistance for lower body dressing/bath, required support with gait belt for transfers. She was independent with grooming, feeding, bed mobility. She is moderate-high fall risk, because of ataxia and required gait belt for stability. 

The patient was participating in PT (physical therapy) and OT (occupational therapy). She is medically stable and has ongoing clinical issues. She has shown gradual and tangible improvement in rehabilitation, with high motivation and participation. 

The patient has continued to show decreased balance, and she is classified as a moderate-high risk for fall because of her ataxia. It is imperative that the patient goes to SNF (skilled nursing facility) to improve on her balance and decrease the risk of falls before discharge. These goals cannot be met at a lower level of care. 

Therefore, the Skilled Nursing Facility (SNF) is medically necessary, as the patient will be better served continuing with a more intensive rehabilitation program. 

It is recommended that the patient remain in SNF for up to 10 days with reassessment for continued medical necessity at that time, based on ataxia and balance.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a past medical history significant for schizophrenia, diabetes mellitus type 2, coronary artery disease hypertension and chronic obstructive pulmonary disease (COPD).
The patient is requesting ongoing home skilled nursing care. The services were denied based upon medical necessity. The subject under review is the medical necessity of the requested skilled nursing visits.

The health plan's determination is upheld.

The patient is male with a past medical history significant for schizophrenia, diabetes mellitus type 2 coronary artery disease hypertension and COPD.

The patient is requesting home skilled nursing visits secondary to disability and illness, stating that he is disabled and sick and the nurse takes his blood pressure, checks his blood sugar and assist with medications. The patient is not homebound.

According to the denial letter from the health plan, it was noted "The nurse notes indicate that you monitor your blood sugar 2 times a day and that you are independent with medications and dosages at the correct time. You have family available to assist you."

Nursing evaluation stated that the patient is alert and oriented to time, person, and place. He is able to follow multi-step commands however is somewhat forgetful and depressed.

The records provided were reviewed which included the home nursing care plan along with notes from the visits to the patient's house. It was noted from the care plans that the only medical necessary service for skilled care was for medication management. The patient had difficulty setting up his medicine. He was able to take them appropriately once they were set up. There was a note stating that there was no other individual able to set up medications for him. No other services noted would be ongoing and necessary for skilled nursing services. Typically, continuing skilled nursing services for set up of medications on an ongoing basis would not be considered medically necessary, as someone else can be taught to do this. It was noted that there was no one available or willing to do this. Unfortunately, because someone is not available does not create medical necessity. The standard of care for patients who cannot manage medications on their own but are functionally able to take the medications independently would be using a pre-package medication service.

Medical necessity for home skilled nursing services was not met.
Appeal type: Medical necessity
Decision: Overturned

The patient has no known past medical history. The patient was a former smoker who had quit smoking 1 month prior to the visit to the emergency room. In January she was brought to the emergency room because of progressively increasing shortness of breath. The patient also had increased cough and congestion. When the patient came to the emergency room she was found to be hypoxic, tachycardic and tachypneic. The patient was admitted with a diagnosis of multilobar pneumonia and was admitted to the intensive care unit and treated with bronchodilators, antibiotics which included Rocephin and Zithromax. 

The health plan's determination is overturned. The patient was admitted with progressively increasing shortness of breath. The patient was tachycardic tachypneic and hypoxic at admission. PaO2/FiO2 ratio was less than 250. Chest CT scan showed multilobe pneumonia. The patient initially required 3 L of oxygen to main SaO2 greater than 90%. The patient had severe community-acquired pneumonia that required admission to the hospital.
Appeal type: Medical necessity
Decision: Overturned

This is a patient  with a history of schizophrenia, depression, substance abuse, and hepatitis C, who presented to the hospital. He presented to the emergency department for withdrawal. He reported nausea, diarrhea, and vomiting. He also reported having tremors, anxiety, and body aches. He denied a fever, chest pain, shortness of breath, and hallucinations. He reported drinking 2 pints of vodka daily and using heroin daily. Because of concerns about suicidal ideation and hallucinations, he was discharged to the psychiatry ward. The issue for review is the medical necessity of an inpatient stay.

The health plan's determination of medical necessity is overturned. Inpatient medical care was medically necessary. The patient was at increased risk for delirium tremens and other complications of alcohol withdrawal, and his hospital stay was within the window during which patients can experience withdrawal complications. This is particularly a problem for patients with a history of long-standing substance use.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the hospital, for evaluation, at 34 0/7 weeks with vaginal bleeding. She was noted to have bleeding on the morning of presentation. She was reported to have high frequency contractions on monitoring and was admitted for suspected clinical abruption. She reported that her urine was pink tinged and that she had been continuously dripping blood since that morning. The patient had an ultrasound performed that noted polyhydramnios with an amniotic fluid index of 25 centimeters (cms). The patient reported good fetal movement. She reported no recent abdominal trauma. The health plan's determination of medical necessity is upheld. In this case, the care provided could have been provided at a lower level than inpatient. In this case, the patient had no signs or symptoms of preterm labor and only had bleeding that was quiescent on admission. She completed steroids after admission. Inpatient care is not supported in this case based upon the documentation provided.
Appeal type: Medical necessity
Decision: Overturned

The patient has chronic left knee pain and abnormal range of motion resulting in a loss of baseline physical function and inability to exercise. Symptoms initially began in 2015 while playing recreational basketball when the patient sustained medial meniscus and anterior cruciate ligament (ACL) tears which required surgical intervention. Under review is the physical therapy visits.

The health plan's determination is overturned. The requested physical therapy is medically necessary. The patient's initial post surgical outcome was sub-optimal and atypical. In this unique case, the patient required more rehabilitation in the form of one on one supervised physical therapy than what is usually encountered. It is possible that the time lapse from injury to repair may have played a role in the patient's protracted post operative course. The physical therapy notes provided for this review clearly document functional deficit and gradual improvement towards stated functional or clinical goals. In this particular case, the time required to restore optimal physical function through rehabilitation took longer than expected.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bi-malleolar ankle fracture and syndesmotic ligament disruption
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient sustained a fall down some stairs in her home resulting in a bi-malleolar ankle fracture and syndesmotic ligament disruption. She was admitted through the emergency department. She was medically cleared for surgery. She underwent an open reduction and internal fixation of the ankle fracture as well as fixation of a syndesmotic ligament disruption. There were no complications of the operation and she recovered well after surgery. She was deemed stable for discharge to home. At issue in this case is the medical necessity of the inpatient hospital admission.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The provided records document that this patient underwent an open reduction and internal fixation of a bimalleolar ankle fracture and syndesmotic ligament fixation on. The surgery was completed successfully with no documented complications. The patient had no major medical co-morbidities and had sustained a closed ankle fracture with no nerve or vessel damage associated with the injury. Her vital signs and lab values were within normal limits before and after the operation. Thus, the medical necessity of the inpatient hospital admission is not established based upon the documentation in the records.
In addition, recent articles in the peer-reviewed orthopedic by Qin and colleagues support the performance of outpatient ankle fracture surgery.
The current, peer-reviewed orthopedic literature, including articles published by Qin and colleagues in the Journal of Bone and Joint Surgery and in the Orthopedic Clinic of North America determined that outpatient ankle fracture surgery is safe and effective. In their 2016 article, these authors concluded that "In patients with closed fractures and minimal comorbidities, outpatient open reduction internal fixation (ORIF) was associated with reduced risk of select 30-day medical morbidity and no difference in surgical morbidity, reoperations, and readmissions relative to inpatient. Factors unaccounted for when creating matched cohorts may impact our results. Our findings lend reassurance to surgeons who defer admission for low-risk patients." Therefore, the medical necessity of the inpatient hospital admission in this case is not supported by the peer-reviewed literature and medical records.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: right above the knee transfemoral amputation
Treatment: Otto BockX3 prosthetic knee
The insurer denied the Otto BockX3 prosthetic knee. The health plan's determination is overturned. 

The patient is a male with a past medical history significant for a right above the knee transfemoral amputation. He was denied request for a replacement Otto BockX3 prosthetic knee. This is the subject of this review.

The requested Right Lower Extremity Prosthesis, Not Otherwise Specified (Otto Bocks X3 Knee) with Right All Lower Extremity Prosthesis, Shank Foot System with Vertical Loading Pylon and Right All Lower Extremity Prostheses, Mullti-Axial Rotation Unit ('MCP' or Equal) is medically necessary.
The patient is a male who has been a right above the knee amputee. His current prosthesis is over three years old and as documentation noted the X3 knee component is out of warranty. In addition, the suction which was already replaced 2 years ago was recently serviced and at that time it was noted that the inner socket was softening - placing the patient at high risk of hardware failure and subsequent bodily harm. He is an extremely active ambulator who works as a ski instructor and requires the microprocessor for transversing uneven terrain both at work and on his five acre home. As his employment involves and requires the ability to sustain the environmental hazard of getting wet (as does his every day activities of daily living which were noted to include maintaining his irrigation system, cleaning his pool and servicing his septic tank) his prosthetic must have the X3 knee component. The OttoBocksX3 Knee is also necessary for him to be able to maintain his highly active work and personal lifestyle in a safe and efficient manner - not with a socket that is softening and at risk of malfunction at any point which would result in significant bodily harm given that he is a downhill ski instructor.
Lastly, the patient has been using these exact components on his existing prosthesis for three plus years and, therefore, it would not be appropriate to downgrade him to a less advanced prosthetic which would prevent him from performing his job and continuing his activities of daily living. This is essentially his right leg which he uses on a daily, aggressive, basis and it is medically necessary that he obtain a replacement as requested prior to complete hardware failure that could cause significant bodily harm if occurring while he is being a ski instructor or even working on his property.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional-Diabetes/Diabetic Ketoacidosis (DKA)
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination of medical necessity.

The patient has a history of type 1 diabetes mellitus on insulin pump, and autism. 
The patient presented to the hospital with nausea, abdominal pain, vomiting, and hyperglycemia. He was alert and oriented on exam. Laboratory values included glucose of 680, potential hydrogen (pH) of 7.29, bicarbonate 15, lactic acid 3.5, anion gap 20, 80 ketones on urinalysis. The patient was admitted with diabetic ketoacidosis(DKA). He received intravenous (IV) fluids and was started on insulin drip. The patient was also found to have a bundle branch block, QT prolongation and troponin of 61 and was evaluated by cardiology, however his family requested outpatient workup instead. The patient's DKA resolved, and he was transitioned back to insulin pump. He was discharged home.

The hospital stay is medically necessary.
Clinically, this patient meets criteria for diabetic ketoacidosis. He presented with severe symptomatic hyperglycemia, elevated anion gap, decreased bicarbonate, elevated ketones in the urine and decreased blood ph. Clinical diagnosis of DKA requires an inpatient admission for insulin drip or frequent insulin injections and adjustments, frequent glucose monitoring, and frequent electrolyte monitoring that could not be accomplished at a lower level of care (e.g. observational care, or emergency department).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal Bleeding
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a medical history of diabetes mellitus type 2, peripheral artery disease status post stent placement on aspirin and Plavix, human immunodeficiency virus, depression, hypertension, hyperlipidemia, and Roux-en-Y gastric bypass surgery. He presented to the emergency department  with two days of gastrointestinal bleeding (hematochezia the day before and melena that morning), epigastric pain, lightheadedness, dyspnea, and faintness. He had been without his proton pump inhibitor for two weeks. Vital signs were notable for tachycardia with a pulse rate of 108/minute. The physical examination was notable for a soft, nontender, nondistended abdomen and rectal exam showing brown stool with a maroon tint. Lab results showed a low hemoglobin of 9.1 grams per deciliter (g/dL) and hematocrit of 27.5%; repeat labs showed a lower hemoglobin of 8.1 g/dL and hematocrit of 25.6%. A computed tomography scan of the abdomen and pelvis showed gaseous distention of the colon. He was treated with intravenous normal saline and pantoprazole. He was made nil per os (NPO). He was noted to have melena overnight, but no bowel movements that day. Lab results showed a low hemoglobin of 7.9 g/dL hematocrit 24.0%, and low sodium of 136. An esophagogastroduodenoscopy showed gastrojejunal anastomosis with edema, erythema, friable mucosa, and nonbleeding gastric anastomotic ulcers with clean base; one visible staple was removed. Lab results showed a low hemoglobin of 8.5 g/dL and hematocrit of 26.1%. He was discharged with a plan for primary care follow-up. At issue is the medical necessity for an inpatient level of care.
The acute inpatient level of care was not medically necessary. 
The patient presented with anemia and melena. However, there was no sustained tachycardia or hypotension, and hemoglobin remained stable after initial equilibration. He had close monitoring, which was warranted as bleeding can be severe and sudden in onset [1-3]. Proton pump inhibitor therapy was appropriately initiated [1-4]. Gastroenterology performed an endoscopy, which was appropriate, and a gastrojejunal ulcer was seen but no active bleeding was found [5,6]. All of the measures that were undertaken, including monitoring, proton pump inhibitor therapy, Gastroenterology consultation, and endoscopy, could have been performed without acute inpatient level of care, at a lower level of care [1-5]. An inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease.

Treatment: Stelara to treat Crohn's disease.

The insurer denied coverage for Stelara to treat Crohn's disease.

The denial is overturned. 

This is a female patient who has Crohn's Disease. She had been treated with Stelara every 8 weeks. A colonoscopy showed active colitis. Her doctor advised decreasing the Stelara interval to every 4 weeks. The physician has provided an article that was submitted to the Congress of the European Crohn's and Colitis Organization in March 2019 titled "Optimization helps patients with Crohn's recapture Stelara response." The study looked at patients with active Crohn's disease on Stelara every 8 weeks. The dose was escalated to every 4 weeks and 57% of patients had a successful clinical response.

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." The conclusion was that shortening the ustekinumab 90 milligrams (mg) dose to 4 weeks in patients with Crohn's disease, who did not respond to doses every 8 weeks, improved clinical and biological indices of disease activity. Patients who love response to the standard dose of ustekinumab might benefit from dose interval shortening which was effectiveness and safe.

The medical literature supports the use of Stelara at 4 week intervals. It is a medically necessary treatment. The healthcare plan did not act reasonably or in the best interest of the patient.

The insurer's denial of coverage for Stelara to treat Crohn's disease is overturned. Medical necessity is substantiated.