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

Diagnosis: Dissecting Cellulitis

Treatment: Medication Humira 40 milligrams (mg)

The insurer denied coverage for medication Humira 40 milligrams.

The denial is overturned.

The patient has a diagnosis of dissecting cellulitis of the scalp.  The patient has failed appropriate medications and is currently being treated with Humira 40 mg (milligrams) every (Q) week.  The insurance has denied Humira weekly therapy, but has approved Humira 40mg Q 2 weeks.  The request is for continuation of Humira 40 mg Q week.  

Humira 40 mg Q week is medically necessary for the treatment of the patient's condition, dissecting cellulitis of the scalp.  The patient has successfully been treated with weekly Humira without complications.  The use of Humira weekly is sometimes necessary to control the significant inflammation associated with dissecting cellulitis of the scalp.  

Based on the clinical documentation provided, Humira 40 mg weekly is medically necessary in this clinical scenario.  The decision is overturned based on the standard of care.  The use of Humira 40 mg Q week is approved under the medical supervision of the physician.  With appropriate monitoring, the dosing regimen requested is within the standard of care.  

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

The insurer's denial of coverage for the medication Humira 40 milligrams is overturned.  Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope. 
Treatment: Inpatient Stay. 

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

This is a case of a female admitted for a diagnosis of near syncope. The patient presented with an episode of near syncope the day prior to admission. Vital signs demonstrated temperature 37.8C, pulse 91, blood pressure 103/58, respiratory rate 16, and O2 saturation 100%. Physical exam showed no distress or altered mental status. Neurologic exam was normal. White blood cell count was 14.7 with potassium 3.1 and glucose 129. Calcium was 9.4 with magnesium 2.2. The patient was admitted for near syncope that was thought to be a vasovagal event. 

According to the documentation submitted, the patient did not have syncope accompanied by chest pain, shortness of breath, exertional syncope, abnormal vital signs or abnormal findings on cardiac, pulmonary or neurological examination. The patient did not have history of structural heart disease, hypotension, elevated troponin, anemia, advanced age or family history of sudden cardiac death. She was found to have prolonged QT on electrocardiogram (EKG) but at the time of admission this was not thought to be contributing to her near syncopal episode. 
Although the patient had needs best addressed in the hospital setting the monitoring, diagnostic workup and therapeutic interventions prescribed could have been safely administered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is the case of a female with a past medical history of cancer, congestive heart failure, diabetes, hypertension, thyroid disorder, ovarian cyst, and chronic kidney disease. The patient presented to the emergency room with complaint of bilateral flank pain, fever, chills, dysuria. She was admitted to the hospital and recovered with intravenous (IV) fluids, IV antibiotics, laboratory and diagnostic (radiographic) testing. The patient was noted to improve with this treatment, and she was able to be discharged. 

The insurer has denied coverage for an inpatient as not medically necessary. They noted the lack of abnormal vitals, severe vomiting, persistent altered mental status or worsening of symptoms. The insurer felt that the patient could have been placed in observation under monitoring. 

The appeal on behalf of the hospital is noted and read in detail. Per Milliman Care Guidelines (MCG) Health (25th) Urinary Tract Infection (UTI), patient fails to meet clinical indications for admission to inpatient care. (Hemodynamic instability, altered mental status - severe or persistent, immunocompromised status, ureteral obstruction (stone), emphysema, pyelonephritis, etc.)  

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient. 

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

Diagnosis: CVA (cerebrovascular accident) and left eye blindness. 
Treatment: Increase Consumer Directed Personal Assistance (CDPAS) Services To 56 Hours Per Week. 

The insurer denied the Increase Consumer Directed Personal Assistance (CDPAS) Services To 56 Hours Per Week. 

The denial is overturned. 

The patient is a male. He has past medical history of CVA (cerebrovascular accident) and left eye blindness. And increase in Consumer Directed Personal Assistance is being requested. 

The request is for Increase Consumer Directed Personal Assistance (CDPAS) Services To 56 Hours Per Week from 35 hours per week; 5 hours per day, 7 days per week. 

Yes, the Increase Consumer Directed Personal Assistance (CDPAS) Services To 56 Hours Per Week is medically necessary. 

The patient has history of stroke and left eye blindness. He lives alone in a one bedroom apartment. According to assessment, he has age-related forgetfulness. He has reported three falls in the past three months. He needs help with meals. He cannot make a sandwich. The patient needs helps with turning in bed and with transfers. 

Therefore, given the above, the Increase Consumer Directed Personal Assistance (CDPAS) Services To 56 Hours Per Week is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The patient has left hemiplegia and needs more help and supervision. More hours are needed for personal care services. The patient is at risk of recurrent falls.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Paralysis/Right Arm
Treatment: Durable Medical Equipment(DME)
The health plan denied the requested MyoPro motion device as experimental/investigational. 
The health plan's determination is upheld.

The patient is a male with complete paralysis of the right arm due to severe complete brachial plexus root avulsion injury following a motor vehicle accident. The brachial plexus injury was so severe that it resulted in the nerve roots being avulsed, which means that all the nerves to the right upper extremity were disconnected from the spinal cord and brain. He was left with a completely paralyzed right upper extremity with no function of any muscle groups in the right upper extremity. Treatment has included physical therapy, occupational therapy, nerve repair surgeries, and (cervical-thoracic) C4-T1 laminoplasty with right sided DREZ (dorsal root entry zone) procedure (to treat pain). The nerve repair surgeries were not successful.
At issue is whether the proposed health service or treatment of the MyoPro Motion Device is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

I uphold, in whole, the health plan's determination regarding the proposed health service or treatment.

The proposed health service or treatment of the MyoPro Motion Device is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The MyoPro is a custom fabricated myoelectric upper extremity orthosis for use in patients with partial paralysis. The patient has complete paralysis, which makes this device unlikely to be beneficial. 
The medical records indicate that there has been no recovery from the nerve repair surgeries and that the patient has complete paralysis of the right upper extremity. The brachial plexus nerve root avulsion injury means that all of the nerves to the right upper extremity have been completely disconnected from the brain and spinal cord. The nerves and muscles of the right upper extremity cannot work without a connection to the brain and spinal cord. The MyoPro Motion Device is considered experimental/investigational and there are no well-designed well conducted studies published in peer-reviewed journals to support this device, demonstrate that this device affects health outcomes, or show that this device is equally or more effective than conventional therapies. There are many standard treatments for the diagnosis of complete paralysis of the right arm due to severe complete brachial plexus root avulsion injury, including surgery, physical therapy, occupational therapy, and medications. The use of the MyoPro Motion Device is not considered medically necessary, not supported by the peer-reviewed medical literature is not considered the standard of care in United States at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Paralysis/Right Arm
Treatment: Durable Medical Equipment(DME)
The health plan denied the requested MyoPro motion device as experimental/investigational. 
The health plan's determination is overturned.

The patient is a right hand dominant murnedale who was involved in a motorcycle accident during which he sustained a right brachial plexus injury leaving him with a complete loss of motor and sensory function from this right shoulder to his hand. He subsequently underwent at least 2 separate nerve grafting/transfer surgeries which were not successful in restoring any level of function in his right upper limb. In addition to pain, he also suffered from severe neuropathic pain in the entire right upper limb after the accident believed to be related to an avulsion injury. He subsequently underwent DREZ (dorsal root entry zone) surgery, which is a procedure used to "deaden" the pain signals within the spinal cord (dorsal root ganglion) that specially cause pain in avulsion injuries. The procedure was successful in reducing a significant amount of the patient's pain. However, his right upper limb remains non-functional.
At issue is whether the proposed health service or treatment of the MyoPro Motion Device is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The health plan's determination regarding the proposed health service or treatment is overturned, in whole.

Yes. There is substantial medical evidence in the form of randomized controlled trials supporting the use of the MyoPro Motion Device as a viable means to assist an individual with voluntary movement after brachial plexus injury. The patient has failed all standard treatments for his impairment and the use of a MyoPro has the ability to significantly help him improve his current level of function. The MyoPro device also has the potential to enable the patient to become more physically active thereby helping to improve his overall health.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Paralysis/Right Arm
Treatment: Durable Medical Equipment(DME)
The health plan denied the requested MyoPro motion device as experimental/investigational. 
The health plan's determination is overturned.

This is a male, status post motorcycle accident with a right upper limb and neck injury. He was found to have right cervical root avulsion with right arm paralysis. He underwent conservative treatment including physical therapy (PT) and occupational therapy (OT) and subsequently underwent surgical nerve repair with minimal benefit. He has used the MyoPro myoelectric elbow wrist hand orthosis and is requesting authorization for such.
At issue is whether the proposed health service or treatment of the MyoPro Motion Device is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The health plan's determination regarding the proposed health service or treatment is overturned, in whole.

The MyoPro myoelectric device is more beneficial than standard treatment as it will restore some functional ability. The conservative treatments have failed to improve function and the patient continues to have deficits with activities of daily living and function. The myoelectric device has been denied as being investigational, however, there are multiple peer reviewed studies that confirm the myoelectric elbow, wrist, hand orthosis can be beneficial to patients by restoring function, independence, and a sense of well-being. For this patient, the MyoPro represents the only chance of some functional restoration.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholesterolosis of Gallbladder. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is the case of a male with history of hypothyroidism and GERD (gastroesophageal reflux disease) who presented for an elective lap cholecystectomy. There were no medical contraindications for surgery.  The patient was admitted. The patient did have outpatient registration for this procedure.  The patient was taken to the operating room and underwent an uneventful lap cholecystectomy. Postop the patient did well and tolerated a regular diet. Pain was controlled and he was discharged. 

The acute inpatient admission was not justified as this patient could have been managed as noted by the insurer in an ambulatory/observation setting as he had an uneventful lap cholecystectomy. 

This was an elective and scheduled lap cholecystectomy that should have been done in an ambulatory setting as it was scheduled through ambulatory. He had the lap cholecystectomy and was sent home - all of which could have been done in observation setting. According to the guidelines of MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care- 26th edition Gall bladder or bile duct inflammation) patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. The clinical indications for admission to inpatient care may include patients with 1 or more of the following:  Acute cholangitis as indicated by ALL of the following: Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L...
Finally, MCG General recovery care 26th edition Ambulatory surgery exception criteria) notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. Given the above the patient did not warrant inpatient status but ambulatory for this procedure as he did not warrant inpatient care. 

The admission was not justified at the inpatient admission level as the patient should have been managed in an ambulatory/observation setting. 

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

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Pulmozyme. 
The denial is overturned.

The member is a female with a genetic-testing-confirmed diagnosis of primary ciliary dyskinesia (PCD). She has had multiple respiratory infections, and her pulmonary functions, specifically forced expiratory volume at 1 second, (FEV1) are already mildly reduced. She is using the first-line airway clearance medications (hypertonic saline) and airway modalities (VEST). In light of documented respiratory system damage in spite of these therapies, a recommendation is now made for Pulmozyme (DNase).
At issue is whether the proposed health service or treatment Pulmozyme is likely to be more beneficial than any standard treatment for the patient's condition.

The health plan's determination regarding the proposed treatment is overturned in whole.

The proposed treatment Pulmozyme, is likely to be more beneficial than any standard treatment or treatments for the patient's condition.
When added to the already ongoing treatments that the patient is already receiving for her condition, Pulmozyme is likely to be more beneficial than any standard treatment. PCD is a rare genetic ciliopathy, in which mucociliary clearance is disturbed by the abnormal motion of cilia or there is a severe reduction in the generation of multiple motile cilia. Lung damage ensues due to recurrent airway infections, sometimes even resulting in respiratory failure. This is what is happening in this patient. To counteract this process, effective airway clearance is crucial. The efficacy of Pulmozyme for airway clearance in patients with PCD has been demonstrated in clinical practice, [1-3] research studies, [4] and its use is supported by relevant practice guidelines. [5]
Therefore, the proposed health treatment Pulmozyme is likely to be more beneficial than any standard treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Pulmozyme. 
The denial is upheld.

The patient is a female. Her medical history includes primary ciliary dyskinesia (PCD). She is non-adherent with current therapies, which are hypertonic saline, percussive vest, and azithromycin. This service was denied by the health plan as experimental/investigational, and this decision is being appealed.
At issue is whether the proposed health service or treatment Pulmozyme is likely to be more beneficial than any standard treatment for the patient's disease.

The health plan's determination regarding the proposed health treatment is upheld in whole.

The proposed health service or treatment Pulmozyme is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
There are two case reports of short-term use of Pulmozyme in a single individual [1,2] and a single long-term case report in two siblings [3] for a total of 4 patients. This anecdotal evidence is the only positive evidence in the medical literature with regards to the use of this treatment for this diagnosis.
In a double-blind placebo-controlled phase II study of the efficacy and safety of dornase alfa (Pulmozyme) given for 14 days in adults with bronchiectasis not caused by cystic fibrosis (CF) (including some with bronchiectasis caused by primary ciliary dyskinesia) showed no significant improvement in spirometry, quality of life, or in the ciliary transportability of secretions. A recent PCD Foundation consensus recommendation based on state-of-the-art review [7] states "DNase (dornase-alfa or Pulmozyme) can be used on an individual basis in PCD. Although there are no prospective trials of DNase in PCD, studies of DNase in adults with non-CF bronchiectasis show no clinical benefits in one study and increased frequency of respiratory exacerbations with worsened lung function in another study. Several case reports of DNase in PCD suggest possible benefit when used for both short and long-term periods. Larger, prospective clinical studies of DNase in children and young adults with PCD are required before the potential negative effects of this medication can be dismissed."
Therefore, the proposed health service or treatment Pulmozyme is not likely to be more beneficial than any standard treatment or treatments for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Pulmozyme. 
The denial is overturned.

The patient is a female with complaints of (c/o) primary ciliary dyskinesia (PCD) and eustachian dysfunction, rhinosinusitis, and impaired airway clearance who has been receiving the VEST therapy for 2 years. The patient is also on Albuterol, Flovent, and Symbicort for the obstructive pulmonary syndrome. She is on Pulmozyme for mucolytic therapy.
At issue is whether the proposed health treatment of Pulmozyme is likely to be more beneficial than any standard treatment for the patient's condition.

The health plan's determination regarding the proposed health service or treatment is overturned in whole.

The proposed health service or treatment Pulmozyme is likely to be more beneficial than any standard treatment or treatment's for the insured's life threatening or disabling condition or disease.
This is required for this patient and has already shown positive impact. Positive expiratory pressure (PEP) devices in Cystic Fibrosis (CF) care have been shown to increase functional residual and total lung capacities and would have similar applicability in PCD patients in accessing the channels of collateral ventilation and mobilizing peripheral mucus. Oscillatory PEP devices cause vibrations of the airway walls, which in CF are used to alter mucus rheology and augment mucociliary clearance, in addition to high-frequency chest wall (HFCW) oscillatory provide oscillatory frequencies similar to normal cilial beat frequency, which is thought optimal for secretion clearance.
This patient is at risk of severe pulmonary exacerbation. There is evidence from medical literature that Pulmozyme reduced hospitalization and morbidity in patients with PCD. Airway clearance devices and dornase alpha (Pulmozyme) can lead to changes in volume of 15 -60 milliliters (ml) and in flow up to 1.6 liters (L)/second (s), which generates minimal coughing to mobilize secretions. The typical dual treatment lasts 20-30 minutes and consists of short periods of compression at different frequencies, separated by coughing.
Therefore, the proposed health service or treatment Pulmozyme is likely to be more beneficial than any standard treatment for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperthyroidism, obesity
Treatment: Ozempic
The insurer denied the Ozempic.
The denial is upheld.

The patient is a female with hyperthyroidism and obesity with body mass index of 39.68. The request for Ozempic for weight loss is under review.

The prior request was denied coverage by the health plan, as the patient does not have a diagnosis of type 2 diabetes. The physician is appealing this determination, as the patient has gained 19 pounds and is obese.

No, the requested Ozempic is not medically necessary.

This request is for Ozempic for weight loss. Ozempic is not FDA (United States Food and Drug Administration)-indicated for weight loss. There are other drugs that are FDA-indicated for weight loss. There is no documented medical reason to use Ozempic in this particular patient. Ozempic has risks, including nausea and vomiting. Therefore, no, the requested Ozempic is not medically necessary.

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

The requested Ozempic is not medically necessary, as outlined above, and was appropriately denied.