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

Diagnosis: Deafness
Treatment: Consumer Directed Personal Assistance Services (CDPAS)
The insurer denied Consumer Directed Personal Assistance Services (CDPAS). 
The health plan's determination is upheld.

This is the case of a female with deafness in both ears and additional diagnosis of dizziness. Per the medical records submitted, including a telemedicine visit, the patient requires assistance with activities of daily living (ADLs). She has no use of assistive medical procedures, has no recent hospitalizations or surgeries, no home services, and is ambulatory with continence of bladder and bowel. The patient has a Cochlear implant on the right. The New York State Comprehensive Assessment Report indicated that the patient requires limited assistance with ADLs and the request is based on mother's return to work and need for additional care beyond the school day.

Based on the records provided, there is insufficient evidence for the medical necessity of CDPAS services for this patient. Therefore, the requested CDPAS is not medically necessary. The patient has bilateral deafness. There is no additional indication of intellectual disability, behavioral complaints, or other medical conditions to compromise safety or medically necessitate assistance with activities of daily living (ADL). She receives therapies at school and requires only limited assistance and supervision for ADLs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pityriasis rubra pilaris (PRP)
Treatment: Stelara, subcutaneous, 90 milligrams.
The insurer denied Stelara, subcutaneous, 90 milligrams.
The denial is overturned

The patient is an adult male with pityriasis rubra pilaris that has failed treatment with acitretin, Skyrizi, and topical steroids. The patient has persistent disease on the palms, soles and
lower extremities, with near resolution of plaques on trunk. This is a request for Stelara injections.

Yes, the proposed treatment with Stelara, subcutaneous, 90 milligrams (mg), is medically necessary.
Pityriasis rubra pilaris (PRP) is a rare, chronic, inflammatory skin disease of unknown etiology. Systemic therapy plays an important role in the treatment of most patients with pityriasis rubra pilaris (PRP) and is typically started promptly for adults with widespread or highly symptomatic pityriasis rubra pilaris (PRP). Patients refractory to conventional therapies have been treated successfully with biologic drugs such as interleukin (IL)-17 and interleukin (IL)-23 inhibitors. Multiple studies have shown a shared pathogenic inflammatory pathway with psoriasis, despite evident clinical and histopathologic differences. There are no specific guidelines on therapy and treatment options include corticosteroids, vitamin D analogs, retinoids, methotrexate, cyclosporine, azathioprine and biologic therapies. Ustekinumab can be used as an alternative treatment method for patients with chronic, unremitting pityriasis rubra pilaris (PRP). Current opinion in the peer reviewed published medical literature is that use of ustekinumab as firstline biological therapy in pityriasis rubra pilaris (PRP) is warranted.

From UpToDate: "Injectable biologic inhibitors of the interleukin (IL)-17 or IL-23 pathway are our preferred first-line systemic therapies for adults and children with PRP. Oral retinoids and methotrexate are alternative initial therapies with a long history of use for PRP.

Data are insufficient for conclusions on the relative efficacy of oral retinoids and methotrexate compared with biologic therapy. Our preference for biologic therapy is based upon the more favorable side effect profile and the limited available data that suggest efficacy of biologic anti-IL-17 and anti-IL-23 therapies. Other clinicians advocate for the initial use of nonbiologic therapies."

In summary, the patient has a rare disease for which no treatment is Food and Drug Administration (FDA) approved. He has failed conventional therapy with acitretin. The literature supports use of ustekinumab  in pityriasis rubra pilaris (PRP). This is a high risk medication and there have been reports of malignancy developing in patients using ustekinumab. With all that in mind, ustekinumab is likely to benefit the patient in the treatment of his rare disease and such benefit to the patient outweighs the risks of the health service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  End stage renal disease status post renal transplant, diabetes, polyneuropathy, asthma, and right foot ulcer
Treatment: Increase Home Care/ Personal Care HHC (Home Health Care)-level 2 Personal Care Services from 37 to 70 Hours Per Week
The insurer denied: Increase Home Care/ Personal Care HHC-level 2 Personal Care Services from 37 to 70 Hours Per Week
The denial is overturned.

The patient is an adult male. His conditions include end stage renal disease status post renal transplant, diabetes, polyneuropathy, asthma, and right foot ulcer. Denial of increase home care/ personal care HHC-level 2 personal care services (PCS) from 37 to 70 hours per week is being appealed. Uniform Assessment System (UAS) evaluation shows modified independent cognition and functional status: total dependence with meal preparation and housework; maximal assistance with shopping, transportation, and lower body dressing; extensive assistance with managing finances and medications, phone use, stairs, bathing, personal hygiene, upper body dressing, and toilet use; limited assistance with walking, locomotion, toilet transfer, and eating; and independent with bed mobility. The patient has infrequent bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline in managing finances, phone use, lower body dressing, walking, locomotion, and eating. The patient did not have incontinence during the prior UAS (Uniform Assessment System) evaluation. The clinical progress report from the provider notes that the patent would benefit from PCS (personal care service) 70 hours per week.

The requested Increase Home Care/ Personal Care HHC-level 2 Personal Care Services from 37 to 70 Hours Per Week is medically necessary.
Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase home care/ personal care HHC (home health care)-level 2 personal care services (PCS) from 37 to 70 hours per week is being appealed.

This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation shows the patient requires assistance with all ADLs (activities of daily living), except bed mobility. He has infrequent bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline in managing finances, phone use, lower body dressing, walking, locomotion, and eating. The records support that the patient's physical status has declined and he is dependent with all ADLs (activities of daily living). The information provided shows that this patient has significant limitations in functioning. The approved PCS (personal care service) 37 hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase PCS (personal care service) to 70 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Breast Cancer.
Treatment:  Zarxio (filgrastim).

The insurer denied Zarxio (filgrastim).  The denial is upheld.

The patient in this case is an adult female with breast cancer. She is being treated with neoadjuvant chemotherapy consisting of carboplatin and paclitaxel given weekly.  This is being given in combination with pembrolizumab.  Zarxio has been prescribed as primary prophylaxis against febrile neutropenia.

The proposed treatment is not medically necessary.

Weekly carboplatin and paclitaxel is associated with a low risk of febrile neutropenia. The National Comprehensive Cancer Network (NCCN) guidelines do not endorse use of myeloid growth factors for primary prophylaxis against febrile neutropenia in patients being treated with regimens associated with low risk of developing febrile neutropenia. This use of myeloid growth factors is also not endorsed by the American Society on Clinical Oncologists (ASCO) guidelines.  Given lack of consensus guideline endorsement and lack of evidence showing that this use of myeloid growth factors can improve health outcomes, it is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Testicular Torsion.
Treatment:  Inpatient Hospital Admission.

The health plan denied Inpatient Hospital Admission. The denial is upheld.

The patient is a male with autism who presented with left testis torsion and confirmed no flow on a Doppler scrotal ultrasound. He was taken to the operating room and underwent a right orchiopexy and left simple orchiectomy after de-torsion failed to restore blood flow. He recovered uneventfully. There was no fever or problems with pain management.

The subject under review is the medical necessity for the inpatient hospital admission. 

The health plan's determination is upheld.

An inpatient hospital admission was not medically necessary.

The patient's condition was handled in an expedited manner, and there was no increased acuity related to the underlying medical or anesthetic or sepsis conditions. Intravenous (IV) fluids were used briefly and IV preop antibiotics are not a higher acuity necessitating an inpatient stay.

Torsion surgery, whether bilateral orchiopexy or unilateral orchiectomy with contralateral orchiopexy done in the United States are almost exclusively outpatient observation cases, with stays less than 23 hours 59 minutes from the time the recovery room (Phase 1) starts, as here. As with this case, no criteria are met to necessitate inpatient status. An inpatient stay was not medically necessary, and the patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis of the Knee. 
Treatment: Diclofenac Sodium 2% EX Solution. 

The insurer denied: Diclofenac Sodium 2% EX Solution. 
The denial is upheld. 

The patient is an adult female with knee osteoarthritis (OA) and inflammatory arthritis.  Per attached progress note, she has been treated with Tylenol and NSAIDs (non-steroidal anti-inflammatory drugs) with minimal improvement.  She also had steroid injections to her knees.  At that time she was taking Sulindac 200 milligrams (mg) daily, alternating with diclofenac 75 milligrams (mg) daily, and workup for inflammatory arthritis was initiated.  Prednisone 5 milligrams (mg) daily was prescribed. No additional more recent progress notes are provided.  Diclofenac Sodium 2% EX Solution was denied for this patient because there was no documentation at the time that she had successfully used oral diclofenac, or that she successfully used Diclofenac Sodium 2% EX Solution in the past.  Appeal is for Diclofenac Sodium 2% EX Solution for the treatment of knee OA (osteoarthritis). 

The proposed Diclofenac Sodium 2% EX Solution for the treatment of knee OA (osteoarthritis) is not medically necessary for this patient. 

This patient with knee OA (osteoarthritis) and evolving inflammatory arthritis was treated with Tylenol and NSAIDs (non-steroidal anti-inflammatory drugs) with minimal improvement.  She also had steroid injections to her knees.  At that time she was taking Sulindac 200 milligrams (mg) daily, alternating with diclofenac 75 milligrams (mg) daily, and workup for inflammatory arthritis was initiated.  There are no additional progress notes documenting current ongoing treatment of OA (osteoarthritis) or inflammatory arthritis, and response to therapy.  Topical diclofenac 1% gel is readily available as an over the counter preparation, and there is no documentation that this patient has tried or failed over the counter diclofenac 1% gel, warranting a trial of prescription Diclofenac Sodium 2% EX Solution.   Therefore, the proposed Diclofenac Sodium 2% EX Solution for the treatment of knee OA (osteoarthritis) before a trial of over the counter 1% diclofenac gel is not clinically appropriate or in accordance with standard of care, nor the most effective therapy, and thus not medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hypgonadism
Treatment: Natesto 

The insurer denied the Natesto. 
The determination is overturned.

The patient has hypogonadism. A request for Natesto is under review. The patient has tried testosterone cypionate and Androgel 1.6% (percent). The patient and his wife are trying to conceive. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug Natesto, or would have adverse effects.

This request is for Natesto for the treatment of male hypogonadism. This patient and his wife are trying to conceive. Natesto has been shown to not impact sperm count [1]. This has not been shown with the formulary alternatives generic Androgel 1.62%, testosterone solution, and Androderm, all of which would be expected to decrease his sperm count and increase his risk of infertility. Without Natesto, this patient will be at increased risk of the complications of untreated hypogonadism, including osteoporosis. The formulary alternatives are not medically appropriate in this clinical situation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld.

The patient is a female who has a past medical history of hypertension and anxiety. She presented to the emergency department (ED) with complaint of palpitations and some chest discomfort for about an hour.  At presentation to the ED, vital signs were Temperature 99 Fahrenheit, Heart Rate 105, Respiratory Rate 20, Blood Pressure 133/79 mm Hg, oxygen (O2) saturations 97% (percent) on room air.  The patient was alert and oriented, in no acute distress. She was noted to be tachycardic. Cardiovascular first heart sound (S1) and second heart sound (S2) were normal, and the lungs were clear. The patient had a non-focal neurology exam.  Labs included white blood cell count (WBC) of 13.1 and hemoglobin 12.3 Electrolytes were within normal limits. D-dimer 0.6 and Troponins X (times) 2 were negative. Electrocardiogram (EKG) showed sinus rhythm with no acute ST (interval on EKG) -T (interval on EKG) changes. Chest x-rays revealed no acute infiltrates or effusions. Computed tomography angiography (CTA) of chest revealed a left lower lobe filling defect which was suspicious for pulmonary embolism (PE).  The patient was started on Lovenox 80 milligrams (mg) every 12 hours and was admitted to the hospital for PE. The patient was evaluated by Pulmonary who recommended to continue anticoagulation and to switch to oral direct acting oral anticoagulants (DOAC) if echocardiogram (ECHO) was normal.

An ECHO was done which revealed normal left ventricular function and no evidence of right heart strain. Deep vein thrombosis (DVT) study was negative. The patient was deemed to have a low-risk PE. She did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. The patient was afebrile and hemodynamically stable. She was not hypoxic. Oxygen saturations were 97-100 % on room air. The patient did not have any evidence of right heart strain on EKG or ECHO. No elevation of cardiac enzymes was noted.

The patient could have been placed in observation for a period of time (which could be for up to 48 hours) and once determined to be stable with low-risk PE, subsequently discharged home on oral DOAC. She was afebrile and hemodynamically stable throughout her hospital stay with no evidence of hypoxia.

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

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

Diagnosis: Jaundice

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

This is a male infant delivered via normal spontaneous vaginal delivery. Apgar scores were 9 and 9 at one and 5 minutes, respectively. The infant was admitted following delivery and roomed in with his mother who breast fed him with lactation support. Significant findings on examination included an abnormally shaped left ear (microtia) with an auricular skin tag. Appropriately, renal and bladder ultrasounds were done (due to association of ear and renal deformations). The right kidney demonstrated diffuse echogenicity that was likely a transient neonatal phenomenon but did require follow-up scanning in 2 weeks. During the infant's course, he became visibly jaundiced and had serial bilirubin determinations done. The total serum bilirubin was 13.2 mg (milligrams) /dL (deciliter). On the day of discharge the bilirubin level had decreased to 9.7 mg/dL and phototherapy was appropriately discontinued and the infant, having otherwise done well, was discharged with his mother. 

The MCG (Milliman Care Guidelines) P-265, Neonatal Jaundice guideline acknowledges that admission is appropriate when "Total serum bilirubin (TSB) exceeding risk threshold for infant's age, gestational age, and clinical risk factors". Unfortunately, the bilirubin levels provided are only at 24-hour intervals. Nevertheless, in the context that serum bilirubin (untreated) may not peak until 96-120 hours in a preterm infant, the level of 13.2 mg/dl at 60 hours, met the MCG guideline. 

The hospital cited P-337 RRG, Newborn Care, Routine. Therein, "Admission is indicated for 1 or more of the following: "Initial evaluation and care of newborn". This criterion was clearly met. Importantly, since this is a prematurely born infant, the more exact MCG guideline to utilize would be P-358, Prematurity (Greater Than 1000 Grams and Greater Than 28 Weeks' Gestation) wherein: Admission is indicated for 1 or more of the following: Premature delivery. This MCG guideline was also met. 

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 the full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Liver Disease
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient in this case is an adult female who presented to the emergency department with symptoms of severe abdominal pain, nausea and vomiting. She had been having pain for at least two weeks and also had noted blood in her urine and stool around that time.  Magnetic resonance image (MRI) had been done before presentation to the emergency department and revealed abnormal lesions in the colon and liver.  She had gone to another emergency department the day before with abdominal pain and computed tomography (CT) was done and revealed wall thickening of the descending colon along with multiple masses in the liver.  She was sent home but presented again due to worsening pain. 
At the time of initial evaluation, the patient had abdominal tenderness. She had normal vital signs and her exam was otherwise unremarkable.  She was felt to most likely have metastatic colon cancer.  She was admitted to the hospital for expedited work up and also was treated with morphine for her pain.  On the next day her pain was improved.  Computed tomography was ordered. Gastroenterology was consulted for possible colonoscopy.  This was done and revealed a partially obstructing tumor in the sigmoid colon.  This was biopsied.  She was discharged to home after being seen by oncology.

The proposed treatment, inpatient hospital admission, was not medically necessary.
This patient had findings most consistent with metastatic colon cancer.  She presented with pain but had no active infection or hemodynamic instability.  She also had no active bleeding or severe anemia. She was admitted to allow for an expedited evaluation so that she could be diagnosed and treated appropriately.  There was no need for acute care inpatient admission in this case.  She could have been treated with pain medications and undergone evaluation to establish a diagnosis on an outpatient basis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Palpitations.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a history of palpitations in the past but who is otherwise healthy and athletic. He presented to the hospital with complaints of 2 hours of palpitations, lethargy, and vomiting. He was clinically well in the emergency department (ED) but was found to have an elevated troponin level of 1.9 nanograms/milliliter (ng/ml) (normal less than (<) 0.04 ng/ml). He was admitted to be watched on telemetry. His echocardiogram was normal. His troponins were trended and peaked at 5.5 ng/ml and then trended to 2.4 ng/ml. He was discharged two days later with a cardiac event monitor and follow up with cardiology.
At issue is the medical necessity of an inpatient admission.

Based on the findings of a significantly elevated troponin, this was a medically necessary admission. This patient very likely had myocarditis based on the history and troponin levels. Inpatient admission was appropriate until the troponin levels decreased and there was no evidence of arrhythmia. The cardiology consultation does not specify myocarditis but does mention a "potential infectious etiology" . The inpatient stay was medically necessary.