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

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This patient is an elderly male who was hospitalized for chest pain. He was brought to the hospital emergency department (ED) for evaluation of severe chest pain that awakened him around 0300 on the morning of admission and associated with vomiting two times (x2). The patient's past medical history is pertinent for hypertension (HTN), hyperlipidemia (HLP), diabetes, coronary artery disease, coronary artery bypass grafting (CABG) surgery, left ventricular ejection fraction (LVEF) 65% (percent), stroke, bilateral leg amputation, and end-stage renal disease requiring hemodialysis. 

The patient's vital signs were stable. The blood pressure (BP) was initially 87/51 and then stabilized, oxygen (O2) saturation was 94% on four liters (4L) nasal cannula, and respiratory rate was 29. The patient's troponin was 0.04. His electrocardiogram (EKG) showed sinus rhythm with Q-waves (normal left-to-right depolarization of the interventricular septum) in lead three and augmented vector foot (AVF), minimal ST (interval on EKG) elevation in lead three, and peaked T-waves (repolarization of the ventricular myocardium) in V2 -V3 (leads on an EKG). There were no arrhythmias documented. Treatment included aspirin, Lipitor, Coreg, Plavix, Remeron, pantoprazole, Renvela, and nephrology consultation. The patient declined a stress test and cardiac catheterization. By the second day, the patient was deemed stable for transfer back to his nursing home with outpatient follow-up to be arranged.

The claim was denied; this is an appeal that the requested acute inpatient hospital stay was medically necessary for this patient.

The proposed inpatient hospital admission was not medically necessary.

Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the Milliman Care Guidelines (MCG) for Chest Pain, # (number) M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome (ACS), acute myocardial infarction (AMI), chest pain that is indicative of a serious cardiac condition like pulmonary embolism (PE) or aortic dissection, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care the patient received, including rule out AMI/ACS with transient hypotension like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient hospital admission 

The insurer denied coverage for an inpatient hospital admission. 
 
The denial is upheld.

The patient is a male child with a history of Kleinfelter's disease and asthma who had been unwell for several days with cough worse at night. A fever developed 4 days prior to the admission and persisted for 4 days. The child had rhinorrhea, sneezing and occasionally coughed up some yellow sputum. The child had a chest x-ray performed and he was started on azithromycin. In addition, the child had been taking Flovent twice a day and albuterol every 6 hours. On the night prior to admission, the mother noted coughing fits and an increase breathing effort. She brought the child to the pediatrician in the morning for an evaluation. The pediatrician referred the child to the ER (emergency room) for further treatment.

In the ER, the child was noted to have a rash on the face and the chest. On physical examination, the throat was slightly inflamed and there was wheezing and bilateral rales upon examination of the lungs. A chest x-ray showed bibasilar infiltrates. Blood testing was unremarkable. The decision was made to transfer and directly admit the child to the hospital for asthma and possible pneumonia. Albuterol was continued every 2 hours and prednisone was continued for wheezing. Azithromycin was continued for possible pneumonia.

The child was treated in the ER for a diagnosis of pneumonia following a prolonged illness with fever and a cough. He had a history of asthma and despite treatment with albuterol and Flovent in the home, the cough persisted. In the ER, he was treated with DuoNeb on 3 occasions and prednisone. There was no tachypnea, no increased work of breathing, no evidence of respiratory distress and no hypoxemia noted. The child was described as being comfortable and not in respiratory distress. The child was tolerating oral feedings and he did not require placement of an IV (intravenous) line. He was not considered to be in status asthmaticus and could have been discharged with continuation of azithromycin, albuterol and prednisone with a follow up visit with the pediatrician in 48 hours.

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

The insurer's denial of coverage for a two-day hospital stay is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever.
Treatment: Inpatient Hospital Stay.
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient had VACTERL [vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities] syndrome who was brought to the emergency department with a fever for one day, upper respiratory infection (URI) and fussiness for two days. and not acting like himself for two days. He has bilateral hydronephrosis, frequent urinary tract infections (UTIs) for which he was on Bactrim prophylaxis, and a tethered cord pending neurosurgery. He had one prior episode of sepsis. He had not received any childhood vaccines. His temperature (T) at home was 103 degrees Fahrenheit (F) and his parents gave him Tylenol. At triage, his T was 100.7 degrees F, heart rate (HR) 164, normal blood pressure (BP), respiratory rate (RR), and oxygen saturation. He initially appeared well on exam, but then became mottled and had signs of diminished perfusion and prolonged capillary refill time. He was given an intravenous (IV) fluid bolus and a dose of IV Ceftriaxone and Vancomycin, and it was noted that his skin color and capillary refill looked better after the fluid bolus. Per the emergency department (ED) notes, he was admitted "to floor for further observation." On arrival to the pediatric floor, he was described as resting in bed comfortably, breathing in room air. The exam was normal, capillary refill less than two seconds. His respiratory viral panel was positive for a coronavirus [not coronavirus 2019 (COVID 19)], enterovirus, and parainfluenza. His urinalysis was normal. His white blood cell count (WBC) was normal. His metabolic panel was normal. A chest x-ray (CXR) was normal. The admitting team did not think he had sepsis or meningitis. A decision was made to continue Ceftriaxone "pending culture given his history of UTIs, despite negative UA." He did well overnight and was discharged home the next day with negative blood culture at 24 hours and no growth in the urine culture. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. After receiving IV fluid in the emergency room, the patient appeared completely well. His appearance and laboratory results were reassuring, and he had three documented respiratory viruses on nasal swab and a URI as a source of his febrile illness. Although he had prior UTIs and was on UTI antibiotic prophylaxis, his urinalysis was completely normal. A negative UA has a very high negative predictive value for a UTI, even with his risk status and prior history. He did not need to be admitted to the hospital to await the results of his urine culture. He had already received parenteral Ceftriaxone once. This antibiotic concentrates in the bladder and can be given every 24 hours for a UTI. So, to whatever extent there was concern about the possibility of UTI despite a normal UA, the patient was already covered for this possibility, and could have been discharged home with close outpatient follow up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain
Treatment: CT (computed tomography) scan
The insurer denied Computed Tomography (CT) of Abdomen and Pelvis . 
The health plan's determination is overturned. 

The patient is a female with history of recurrent diverticulitis and sigmoid colon resection, and lysis of adhesions. She has had constipation. She presented with significant tenderness and pain in the left lower quadrant of the abdomen. She had ongoing abdominal pain (persistent for a month).

Computed Tomography (CT) of Abdomen and Pelvis is medically necessary for this patient.

Given that a cause for ongoing abdominal pain has not been definitively determined in the patient, and CT scan has a high sensitivity for several serious etiologies for abdominal pain that cannot be discovered by physical examination or more limited imaging examinations, and given that the patient has a history of diverticulitis and may now have persistent diverticulitis or complications of diverticulitis such as abscess, the requested CT scan is medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis

Treatment: Skyrizi 150 milligrams (mg)/ milliliter (ml) subcutaneous (SC) solution prefilled syringe (SOSY)

The insurer denied coverage for Skyrizi 150 mg/ ml SC SOSY.

The denial is overturned.

This patient, with a history of psoriasis, has failed therapy with numerous topical steroids, Tremfya, and Cosentyx. Of note, the patient has a diagnosis of erosio interdigitalis blastomycetica, a Candida infection. The requested medication is Skyrizi.  

Based on the submitted documentation, Skyrizi is medically necessary. The patient has failed topical therapy and requires systemic therapy for control and management of his psoriasis diagnosis. The patient has tried and failed numerous topical agents as well as biologics, including Tremfya and Cosentyx. Skyrizi is Food and Drug Administration (FDA) approved for treatment of psoriasis vulgaris and it is reasonable to attempt this treatment option.  

The joint American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) guidelines for psoriasis treatment with biologics states, "A randomized controlled trial (RCT) assigned 166 patients to receive risankizumab subcutaneously (a single 18-mg dose at week 0 or 90-mg or 180-mg doses at weeks 0, 4, and 16) or ustekinumab (45 or 90 mg [depending on body weight] at weeks 0, 4, and 16). At week 12, 77% of patients receiving risankizumab (the 90-mg and 180- mg groups pooled), as compared with 40% in the ustekinumab-treated group, achieved Psoriasis Area and Severity Index (PASI) 90; in contrast, 45% in the pooled groups treated with 90 mg and 180 mg of risankizumab, as compared with 18% in the ustekinumab-treated group, achieved PASI 100."  

In this case, Skyrizi is a reasonable next therapy for the treatment of the patient's disease and is medically necessary. Although Siliq is an option, the risk of suicidal ideation [Risk Evaluation and Mitigation Strategy (REMS) program registration required] makes it a later line option compared to Skyrizi, which does not have this risk in the label. Furthermore, this patient has a documented diagnosis of erosio interdigitalis blastomycetica, a cutaneous Candida infection which Interleukin (Il)-17 inhibitors such as Siliq (and Cosentyx) may potentially worsen. (7) As such, Skyrizi is approved, and the decision is overturned based on the current evidence-based medical literature.

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 Skyrizi 150 mg/ ml SC SOSY is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fracture to the humerus.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a young male who sustained a fall three days prior to presentation. He was evaluated in the ED (emergency-department) and diagnosed with a non-displaced supracondylar fracture to his humerus. He was placed in a cast. Subsequent evaluation revealed displacement. He was then sent to the ED (emergency department) again for admission and surgery.

On the next day the patient underwent a closed reduction and percutaneous pinning. He was admitted the previous day but was fed and surgery was delayed. His post-surgical course was non-complicated.

The inpatient admission was not medically necessary.

The records show a semi-emergent procedure was completed without problem. The surgery was delayed secondary to the child being fed. There was no documented reason why he could not have returned home and received the surgery the next day.

The operation was not complex and was of short duration, including 40 minutes anesthesia time. There was no blood loss, as the pins were placed percutaneously.

There were no reported problems after the surgery. The patient's vital signs were stable. There was no evidence of infection. There was no need for additional medical consultations nor diagnostic studies. There were no reported problems with pain.

The clinical record does not support the necessity for the level of service provided. There were no extenuating circumstances to substantiate the admission and length of stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plagiocephaly.
Treatment: Cranial orthotic (S1040).
The insurer denied coverage for a cranial orthotic (S1040).
The denial is overturned.

The patient presented for plagiocephaly. This was noted and recommendations for positional changes were employed, with minimal improvement in head parameters. There were no signs of torticollis. Therefore, physical therapy was not initiated. The physician recommended an orthotic for the left-sided plagiocephaly, based on worsening diameter changes.

Based on a review of the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations, the health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient. According to the policy, cranial orthotics are medically necessary when the child is three (3) to 18 months of age, has failed two months of conservative management, and has severe plagiocephaly where the skull axis has been rotated.

A cranial orthotic is considered medically necessary for this patient. The patient met all required criteria, and the usage of cranial orthotics is well-established in the literature:

According to Lam, S., et al. (2017), "Earlier age at presentation and type of treatment impact the degree of measured deformational head shape correction in positional plagiocephaly. This retrospective study suggests that treatment with a custom CO (cranial orthotic) can result in more improvement in objective measurements of head shape."

Per Kelly, K. M., et al. (2018), "These results demonstrate that the orthosis is successful in the treatment of deformational brachycephaly with an 81.4% improvement toward normal (95.0 to 89.4) in cephalic index."

In addition, Lam, S., et al (2017) states, "Patients with commercial insurance (OR (odds ratio) 1.49, 95% CI (confidence intervals) 1.10-2.02, p (probability) = 0.009), those diagnosed with both brachycephaly and plagiocephaly (OR 2.26, 95% CI 1.31-3.90, p = 0.003), those recommended for treatment with cranial orthosis (OR 4.55, 95% CI = 3.24-6.38, p < 0.001), and those living in proximity to the provider (OR 1.40, 95% CI 1.00-1.96, p = 0.047) were more likely to complete treatment."

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for a cranial orthotic (S1040) service is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation. 
Treatment: Multi-gated Acquisition Scan (MUGA). 

The insurer denied: Multi-gated Acquisition Scan (MUGA). 
The denial is upheld. 

The patient is an adult female with recent onset of atrial fibrillation. There were multiple coronary artery disease (CAD) risk factors. She was having atypical angina. She was claustrophobic. The electrocardiogram (ECG) demonstrated atrial fibrillation but was otherwise essentially normal. A myocardial perfusion imaging exercise test was borderline abnormal. A multi-gated acquisition (MUGA) scan is under review. 

The proposed treatment is not medically necessary. 

A multi-gated acquisition (MUGA) scan is generally utilized to obtain more accurate assessment of left ventricular (LV) function and which to base treatments. In the setting of this case, a patient with atypical chest pain and a borderline abnormal myocardial perfusion imaging exercise test, a multi-gated acquisition (MUGA) scan compared to for example coronary artery disease risk factor modification, further evaluation of the atypical chest pain clinically, and cardiac catheterization for medically refractory angina or development of high risk exercise test abnormality, has not been established as standard of care towards improved cardiac outcomes. Multi-gated acquisition is not standard of care for this patient at this time; other standard of care options exist at this time for this patient.  It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Primary Immunoglobulin A Nephropathy
Treatment: Tarpeyo
The insurer denied the Tarpeyo
The denial is upheld

The patient is a male with a history of immunoglobulin A (IgA) nephropathy and chronic kidney disease.  He had a creatinine clearance of 27 milliliters per minute.  The requested Tarpeyo was denied as the patient's creatinine clearance is less than 35 milliliters per minute (ml/min). The physician is appealing the determination.

No, the proposed treatment with Tarpeyo is not medically necessary.
The requested Tarpeyo is not medically necessary as it would not be considered safe, effective or a generally accepted national standard of medical practice. The requested Tarpeyo would be provided primarily for convenience of the patient or the practitioner and is not the least intensive and/or most appropriate among alternative diagnostic and treatment options.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Randomized controlled studies have shown the requested medication to be effective as therapy but there is no documentation of superiority to steroids. Fellstrombet al noted that targeted-release formulation (TRF)-budesonide 16 milligrams per day (mg/day), added to optimized renin-angiotensin system (RAS) blockade, reduced proteinuria in patients with immunoglobulin A (IgA) nephropathy.  

Based on the available data, the requested Tarpeyo capsules have not been proven to be safe and effective in the setting of a creatinine clearance less than 35 milliliters per minute (ml/min). Based on the available data, the requested is not recommended. The patient's creatinine clearance was 27 milliliters per minute.

Based on the available data, in the current clinical scenario Tarpeyo is not medically necessary as its use is would not be considered standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crohn's Disease.
Treatment:  Remicade 100 mg vial - 720mg infused every 6 weeks for 1 year, 72 units per dose for a total of 648 units.
The insurer denied: Remicade 100 mg vial - 720mg infused every 6 weeks for 1 year, 72 units per dose for a total of 648 units.  
The denial is overturned.

The patient is a female who has severe ileocolonic Crohn's disease with extra intestinal manifestations. She was started on Remicade at standard dose. Her dose was escalated to 10 milligrams per kilogram (mg/kg) every 6 weeks. Her Crohn's disease in remission on Remicade. Therefore, the attending provider would like to continue Remicade versus one of the infliximab biosimilars.

The health plan's determination is overturned.

The requested health service/treatment of Remicade 100 milligrams (mg) vial - 720mg infused every 6 weeks for 1 year, 72 units per dose for a total of 648 units is medically necessary for this patient. The health plan did not take into Food and Drug Administration (FDA) guidance on biosimilars which indicate that these medications should be used for new starts on therapy and not auto-substituted for the originator or another biosimilar. Additionally, none of the FDA approved infliximab biosimilars were commercially available at the time this patient was started on Remicade. 

With regard to the escalated dose of Remicade to treat this patient's Crohn's disease:

There are adequate scientific studies in acceptable peer-reviewed medical literature that support dose escalation in biological agents used to treat irritable bowel disease (IBD). Dose escalation is done either by increasing the dose of the medication or shortening the interval between doses or sometimes a combination of both. There are only a finite number of biological agents used to treat inflammatory bowel disease, and the standard of care is to optimize dose of the biological agent before switching to another agent.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autosomal dominant polycystic kidney disease (ADPKD)
Treatment: Jynarque
The insurer denied: Jynarque
The denial is: Upheld

The patient is a female with chronic kidney disease (CKD) stage 4 secondary to autosomal dominant polycystic kidney disease (ADPKD), diabetes mellitus (DM), hypertension (HTN), hypothyroidism, and hyperlipidemia. The provider has requested the use of Jynarque to slow the progression of his polycystic kidney disease. A computed tomography (CT) scan of the abdomen of pelvis showed a right (R) kidney measuring 12.6 x 4.4 x 7.9 centimeters (cm) and a left kidney measuring 6.5 x 5.8 x 12.2 cm. Renal volume was not quantified. The medication was denied by the plan for not meeting medical necessity criteria.

The health plan's determination is upheld.

The requested medication is not medically necessary for this patient. Jynarque is a selective vasopressin (V2)-receptor antagonist indicated to slow kidney function decline in adults at risk of rapidly progressing autosomal dominant polycystic kidney disease (ADPKD). This is determined by the Mayo Clinic total kidney volume (height-adjusted) calculator and ADPKD prognostic tool using kidney dimensions. A patient height was not provided so her exact class cannot be determined, however given her documented kidney volumes she would most likely be fall into the Mayo Clinic Class 1A which predicts a low risk of progression. High risk of progression is predicted only for Class 1C, 1D and 1E. Therefore, Jynarque would be unlikely to be of benefit to this patient and it is not medically necessary in this case.