Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Formulary exception for Cimzia Starter Kit 200mg/ml
The insurer denied the Formulary exception for Cimzia Starter Kit 200mg/ml.
The denial is overturned. 

The patient is a woman with psoriasis who has been on Tremfya for the past few years.  She is now contemplating pregnancy and will soon start IVF (in vitro fertilization) therapy.  It was recommended that she stop Tremfya and switch to Cimzia, which does not cross the placenta and is therefore safer in pregnancy.

Yes, the health plan should cover the Formulary exception for Cimzia.
The patient is now contemplating pregnancy and will soon start IVF (in vitro fertilization) therapy.

Exposure of the fetus to biologic agents during pregnancy depends on the transport across the placenta. Immunoglobulin G (IgG) is the only major class of antibody that is transported across the human placenta. Fetal levels of IgG (Immunoglobulin G) in umbilical venous blood are low in the first two trimesters of pregnancy and do not surpass maternal levels of IgG (Immunoglobulin G) until the beginning of the third trimester when active transport of the IgG (Immunoglobulin G) molecules across the placenta increases rapidly (Chambers and Johnson). Transport of IgG (Immunoglobulin G) is facilitated by the neonatal Fc (fragment crystallizable) receptor (FcRn) on the placenta.

Of the four subclasses of IgG (Immunoglobulin G) (G1-G4), IgG1 (Immunoglobulin G 1) is the most effectively transported followed by IgG4 (Immunoglobulin G 4), IgG3 (Immunoglobulin G 3), and IgG2 (Immunoglobulin G 2), respectively (Wakefield et al.). Adalimumab and infliximab are both IgG1 (Immunoglobulin G  1) immunoglobulins.

A review of 105 articles on the use of anti-TNF (tumor necrosis factor) therapy in patients with IBD (inflammatory bowel disease) and pregnancy found that anti-TNF (tumor necrosis factor) agents were safe during pregnancy, and the authors even recommended maintained use and initiation of therapy with anti-TNF (tumor necrosis factor) agents for patients who were refractory to azathioprine, steroids, and 5-aminosalicylate (Khan et al.). Clowse looked at the effect on pregnancy of infliximab, adalimumab, and etanercept both combined and individually compared with the general population and found no significant differences in the number of live-born infants, miscarriages, elective terminations, or congenital abnormalities.

As there are no head-to-head studies comparing the use of various TNF (tumor necrosis factor) alpha inhibitors in pregnancy in patients with psoriasis, it is not possible to say whether any of them would be more effective than the others or have adverse effects that are different between the individual drugs.

In conclusion, certolizumab (Cimzia) is the drug most likely to not cross the placenta and therefore likely the safest in pregnancy as far as biologics for the treatment of psoriasis are concerned. Therefore, the health plan should cover the formulary exception for Cimzia for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection (UTI).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This patient is a female with a history of kidney stones, lumbar radiculopathy, and rotator cuff tendonitis who was referred by her primary care physician (PCP) for abnormal lab results associated with dysuria.  The patient had completed a course of Bactrim.  She was referred to the emergency department after repeat urine culture was positive.  

The patient's vital signs revealed the following: temperature 98.7, pulse 106, respiratory rate 18, blood pressure 131/81 and oxygen saturation 99%.  Exam was unremarkable.  Labs revealed the following: white blood cell (WBC) count 5.9, hemoglobin/hematocrit (H/H) 12.7/87.3, and platelets 106.  Her basic metabolic panel (BMP) was normal.  Renal ultrasound (US) showed no abnormality detected (NAD).  The patient was admitted.  Plan of care included intravenous antibiotics. Infectious Disease consult recommended peripherally inserted central catheter (PICC) for intravenous antibiotics.  The patient's vital signs were stable.  The patient was continued on intravenous (IV) antibiotics.  Vital signs were stable and the patient was afebrile. Peripherally inserted central catheter (PICC) was placed.  She was discharged.

No, the proposed inpatient admission was not medically necessary.
Inpatient admission is not consistent with generally accepted standards of medical care.

This patient was admitted with a urinary tract infection (UTI) after failed outpatient treatment.  She was hemodynamically stable and afebrile.  She did not have altered mental status.  She did not have renal failure.  Plan of care included peripherally inserted central catheter (PICC) for outpatient intravenous antibiotics.  Parenteral antibiotics do not require inpatient admission. This patient could have been treated with parental antibiotics at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute on Chronic Systolic Congestive Heart Failure (CHF).

Treatment hospital admission.

The insurer denied coverage for hospital admission.

The denial is overturned.

This is the case of an adult male that presented to the Emergency Department (ED) complaining of chest pain radiating to his left arm. Past medical history was significant for ischemic systolic congestive heart failure (CHF) with left ventricular ejection fraction (LVEF) 25% (percent)), triple vessel coronary artery disease (CAD) with recent stent placement, implantable cardioverter defibrillator (ICD) in situ, hypertension (HTN), chronic kidney disease (CKD) and diabetes mellitus (DM). Physical examination revealed stable vital signs with blood pressure (BP) of 107/75, and pulse 98 with no significant abnormalities. Serum blood testing revealed minimal elevation of troponin (0.046 nanograms/milliliter [ng/ml]), Creatinine of 1.5 milligrams/deciliter (mg/dl) and an elevated B type natriuretic peptide (BNP) of 1500 picograms/milliliter (pg/ml). Electrocardiogram (EKG) revealed normal sinus rhythm with right bundle branch block. The patient was admitted to the hospital for observation and treatment. Intravenous (IV) furosemide was administered. Troponin remained mildly elevated. Cardiology consulted and noted the troponin elevation was not due to an acute coronary syndrome (ACS) but rather demand ischemia. After stabilization on oral diuretic therapy the patient was discharged with Cardiology follow up.

This patient presented to the hospital with acute on chronic systolic CHF. He had a known history of triple vessel CAD and elevation of serum troponin demonstrated demand ischemia. Hospital admission was medically necessary while the patient was treated with IV diuretics and while serum creatinine and electrolytes were being monitored closely. (1-2) Moreover, following treatment with IV diuretic agents, hospital observation during the transition to oral diuretics is critical for managing patients with CHF. (1) Careful monitoring of renal function and serum potassium levels are also necessary. (1) The American College of Cardiology (ACC)/ American Heart Association (AHA) guidelines recommend transition to oral diuretic therapy and other guideline directed medical therapy while still in the inpatient setting. (2) 

The health plan did not act reasonably, with sound medical judgement and in the best interest of the patient. This patient could not have been managed at a lower level of care and inpatient admission was medically necessary. 

The insurer's denial of coverage for the hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral Arterial Disease

Treatment code 37221 - surgery to open up a blocked blood vessel in the leg

The insurer denied coverage for code 37221 - surgery to open up a blocked blood vessel in the leg.

The denial is overturned.

The patient is an adult male with severe peripheral arterial disease with difficulty walking. The patient had a history of arthritis, peripheral arterial disease, and hypertension. The examination revealed the patient's right leg was cool. He had a history of an ankle-brachial index (ABI) of 0.57 on the right and 0.91 on the left. The magnetic resonance imaging (MRI) scan documented high-grade stenosis on the left distal portion of the common iliac artery on the right and stenotic views of the external iliac on the left. The diagnoses included carotid atherosclerosis (disorder) and atherosclerosis of other arteries modified. The patient was scheduled to undergo a bilateral cannulation with aortography and stenting of the common iliac and external iliac arteries respectively on the right and left sides. The patient underwent surgical intervention.

The health care plan did not act reasonably and with sound medical judgment in the patient's best interest. The procedure of right iliac artery stent and intervention to the right superficial femoral artery (SFA) and tibial arteries were all medically necessary and indicated.

The insurer's denial of coverage for code 37221 - surgery to open up a blocked blood vessel in the leg is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Covid & Pneumonia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He presented to emergency room with chest pain, and was found to have bilateral pneumonia due to COVID.

The patient was admitted to acute patient level of care for the management of pneumonia. The patient received IV (intravenous) steroids and IV (intravenous) antibiotics. The cardiology and infectious disease consults were placed.

The health plan denied coverage for the acute inpatient level of care due to it not meeting medical necessity.

No, the Inpatient admission was not medically necessary.
The patient had chest pain as well as an abnormal CT (computed tomography)-chest concerning for COVID-19 pneumonia. The patient was seen by infectious disease and cardiology. The patient was treated with IV (intravenous) steroids, and IV (intravenous) antibiotics. The patient's oxygen levels were above 90% on room air. The patient was not on any invasive drips. The patient did not have moderate to severe respiratory failure. The patient was not in any respiratory distress. The acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronavirus disease (COVID) 2019 pneumonia (PNA)

Treatment codes A0428 [ambulance service, basic life support, non-emergency transport (BLS)] with modifier HR [ambulance transportation from hospital to residence]; and A0425 [ground mileage, per statue mile] with modifier HR

The insurer denied coverage for codes A0428 [ambulance service, basic life support, non-emergency transport (BLS)] with modifier HR [ambulance transportation from hospital to residence]; and A0425 [ground mileage, per statue mile] with modifier HR.

The denial is overturned.

This is the case of an adult male patient with history of asthma and hypertension who was admitted to the hospital for coronavirus disease (COVID) 2019 pneumonia (PNA). The patient was hypoxic with oxygen (O2) saturations in the 80's. He required supplemental O2 by nasal cannula (NC). The patient was on O2 by NC until the day of discharge (DC). He was on 3-4 liters (L) via NC. O2 saturations ranged from 90-93% (percent). The patient was still on 3L NC. Pulse oximetry was 93%. Later that day, he was switched to room air with O2 saturations at 92% and also 92% after walking. This patient was discharged. His whole family was sick with COVID. The patient's O2 status was borderline at 92%.

Given his other underlying co-morbidities and unique situation of the COVID pandemic, it was appropriate to transfer the patient to his home safely under the watchful supervision of trained personnel rather than to leave him to his devices. The patient's O2 saturations were barely 92% and he was definitely a high-risk candidate for decompensation.

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

The insurer's denial of coverage for codes A0428 [ambulance service, basic life support, non-emergency transport (BLS)] with modifier HR [ambulance transportation from hospital to residence]; and A0425 [ground mileage, per statue mile] with modifier HR is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness and impaired balance

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient presented with dizziness.  In the emergency department (ED), she had normal vital signs and her exam revealed nystagmus as well as positive Romberg sign. Head computed tomography (CT) was normal.  Routine blood work was normal.  In the ED, she could not ambulate due to severe dizziness.  She was admitted to inpatient level of care for rule out stroke.  Chest x-ray revealed a 1.5 cm (centimeters) pulmonary nodule which on subsequent CT chest that showed findings consistent with primary lung neoplasm or possibly metastatic disease.  She continued to remain very dizzy and unable to progress with physical therapy (PT). Magnetic resonance imaging (MRI) of the Brain was negative for stroke. CT abdomen and pelvis did not reveal metastatic disease.  She was noted to have some slow improvement in her symptoms. 

Given that the patient had persistent dizziness and impaired balance in the ED that was concerning for a central cause, including possible acute stroke as well as a new neoplastic process based on suspicion of underlying new malignancy from chest x-ray, inpatient level of care was medically necessary.  

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

The insurer's denial of coverage for inpatient admission is overturned
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pericardial Effusion

Treatment acute inpatient stay

The insurer denied coverage for acute inpatient stay

The denial is overturned

This is the case of a female patient that was transferred to this hospital for drainage of a moderate pericardial effusion. The patient had a history of non-small cell lung cancer, hypertension, and chronic obstructive pulmonary disease (COPD). She received radiation therapy one year ago and finished chemotherapy one month prior to presentation. Echocardiography revealed a moderate pericardial effusion that had increased in size over the course of a month. The patient was normotensive but had been taken off of her medications for hypertension. Blood pressure (BP) was 133/80, no pertinent findings were noted on physical examination. She underwent successful pericardiocentesis where 400cc (cubic centimeter) of yellow fluid was removed. There were no periprocedural complications and the patient was discharged the following day.

This patient presented with a rapidly expanding pericardial effusion. Neoplastic pericardial effusion may be the result of malignant pericarditis, inflammatory pericarditis or radiation induced pericarditis. (1) Although the patient was normotensive on physical examination, patients with a history of hypertension and pericardial effusion and impending tamponade are often normotensive due to increased sympathetic tone. (2) In a retrospective analysis of the United States (US) Nationwide Emergency Department Sample database, that included over 10,000 patients presenting with pericardial effusion, the average length of stay for patients undergoing percutaneous pericardiocentesis was 8 days. (3) They noted that patients with malignant pericardial effusion had a higher morbidity and mortality rate. 

This patient's history of non-small cell lung cancer results in a higher likelihood of malignant pericardial effusion. It was medically necessary to manage this patient at a higher level of care. In conclusion, acute inpatient admission was medically necessary following the removal of 400cc of pericardial fluid. 

The health care plan did not act with sound medical judgement and in the best interest of the patient. 

The insurer's denial of coverage for the acute inpatient stay is overturned. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ligamentum Hypertrophy. 

Treatment: Current procedural terminology (CPT code 0275T- Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements [minimally invasive lumbar decompression (MILD) procedure]. 

The insurer denied coverage for current procedural terminology (CPT) code 0275T- Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements [minimally invasive lumbar decompression (MILD) procedure]. 

The denial is overturned. 

According to the documentation submitted, this is a male patient with a history of a clotting disorder, chronic lumbar radiculopathy, lumbar spondylosis, and lumbosacral stenosis with neurogenic claudication. He presented to the Physiatrist's office for the evaluation of back pain. Magnetic resonance imaging (MRI) revealed several levels of ligamentum hypertrophy. The physician recommended the of minimally invasive lumbar decompression (MILD) procedure to treat symptoms. 

The records show the patient has symptomatic multilevel spinal stenosis. A course of conservative treatment had been provided. The next course would be a surgical decompression. Expanding the intra spinal space can provide benefit. There are several ways to perform the procedure. The "gold standard" is exposure of spinal elements and removal of posterior structures (ie. Lamina, spinous process and facets.) The decision of how much decompression is required is made by the operating surgeon. This is the open or direct approach. 

There has been development of the MILD approach where tubes are placed as a working area. Under image intensification the site of the compression is confirmed and removal of bone is performed. The ligamentum is also excised. On occasion even a discectomy can be performed. This type of procedure is recognized by the practicing medical community as effective. There is a learning curve and special instrumentation is required. There is less risk for certain types of complications (ie. Less infection and less pain.)

The facts are this is an accepted procedure to treat spinal stenosis. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome for MILD decompression. The MILD procedure has final approval from the appropriate regulatory bodies for this diagnosis. The patient is a good candidate for MILD surgery. The MILD procedure is the best available treatment for this patient at this time. The requested MILD decompression would be more beneficial than any standard procedure. The adverse risks are not increased over standard treatment/services. 

The carrier's denial of CPT code 0275T- Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements [minimally invasive lumbar decompression (MILD) procedure] should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ligamentum Hypertrophy. 

Treatment: Current procedural terminology (CPT code 0275T- Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements [minimally invasive lumbar decompression (MILD) procedure]. 

The insurer denied coverage for current procedural terminology (CPT) code 0275T- Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements [minimally invasive lumbar decompression (MILD) procedure]. 

The denial is overturned. 

This is the case of a male patient with chronic back pain and neurogenic claudication. Lumbar spine magnetic resonance imaging (MRI) scan demonstrated multi-level ligamentum hypertrophy. Under review is the medical necessity of minimally invasive lumbar decompression (MILD) surgery. Treatments including epidural steroid injections, physical therapy and analgesic medications have reportedly not proven effective for this patient. 

The requested MILD surgery is offered as a treatment option after failed conservative therapy and before traditional open fusion surgery. Medical literature regarding the requested MILD procedure demonstrates improvement in disability scores, pain ratings and functional ability. Unfortunately, much of the literature is hampered by small sample size, retrospective and not case controlled. However, in this case and given the lack of improvement with more conservative treatments, the requested MILD surgery is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. The requested MILD surgery does not need final approval from the appropriate regulatory bodies for this diagnosis. This patient is a reasonable candidate for the requested MILD surgery. Based on the lack of improvement from prior treatments, the requested MILD surgery is the best available treatment for this patient at this time. 

The carrier's denial of CPT code 0275T- Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements [minimally invasive lumbar decompression (MILD) procedure] should be overturned.