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

Diagnosis: Atopic Dermatitis. 
Treatment: Rinvoq. 

The insurer denied: Rinvoq. 
The denial is upheld. 

The patient is an adult female with severe atopic dermatitis and alopecia areata present for many years, treated with multiple agents including oral and topical steroids, intralesional steroids, Elidel, Dupixent and Opzelura. She is using Opzelura as spot treatment as a steroid-sparing agent. Prior to starting Dupixent, the patient's body surface area (BSA) was 20% to the scalp, trunk and extremities. She has improved some on Dupixent but is not completely resolved. The provider is requesting addition of Rinvoq to her current regimen. The health plan denied this as Rinvoq is not covered when used in combination with other biologic therapies and Opzelura. 

The proposed treatment is not medically necessary. 

The health plan denied this as Rinvoq is not covered when used in combination with other biologic therapies and Opzelura. No evidence-based literature was found regarding combination use of Dupilumab and Janus kinase (JAK) inhibitors. The literature supports superiority of Rinvoq over Dupilumab. Therefore, a trial of Rinvoq as monotherapy may be appropriate. 

The randomized controlled trial (Blauvelt et al) studied 692 patients with moderate-to-severe atopic dermatitis, with statistically significant superiority for upadacitinib compared with dupilumab. There were no new safety signals reported for either upadacitinib or dupilumab. Therefore, use of combination Dupixent plus Rinvoq is not currently supported. Use of Opzelura as spot treatment is reasonable, but again no evidence-based literature was found regarding use of this topical agent in combination with systemic Janus kinase inhibitors. Therefore, the request for combination therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, cough, increased work of breathing.
Treatment: Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission.
The denial is upheld.

This is a toddler male with asthma and eczema who was admitted for breathing difficulty. His symptoms included fever, cough, decreased activity, decreased oral intake, shortness of breath, and increased work of breathing for three days. In the emergency department, the patient's vital signs showed a heart rate of 156 and respiratory rate of 56. He had nasal flaring, cervical/intercostal retractions, decreased air movement and 
wheezing. He was given three Duonebs, intravenous magnesium, and intramuscular Decadron. 

Upon admission, the patient continued to have to have tachypnea with a respiratory rate of 38. He had decreased air movement, wheezing and rhonchi. He was started on albuterol every two hours and continuous cardiac and pulse oximetry monitoring. On the next day, the patient was spaced to every four-hour albuterol and was discharged home on Flovent and albuterol.

The proposed treatment was not medically necessary.

This patient was admitted for an asthma exacerbation. He did not require intensive cardiorespiratory monitoring, respiratory support, intravenous medications, or any other service requiring an acute inpatient level of care. Upon admission, the patient had minimal tachypnea and moderate respiratory distress. He improved quickly within the observation period of care. 

An acute inpatient hospital stay was not medically necessary for his care; the patient could have been safely cared for in observation status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is a previously healthy adult male. He presented to the ED (emergency department with upper abdominal pain. At the time of presentation, the patient was without fever and vital signs were normal. He was tender in the right upper quadrant. The WBC (white blood cell) count was normal at 7.7 K (thousand). The complete metabolic panel identified normal liver enzymes and bilirubin. Abdominal ultrasound showed gallstones within the gallbladder. He was admitted to the hospital with the diagnosis of biliary colic. The patient was evaluated with surgery consultation. The patient underwent laparoscopic cholecystectomy. The operation was performed without complication. The diet was advanced following surgery, and pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting on the next day with planned short term follow up. The health plan denial letter states that there is no documentation of unstable vital signs, signs of infection, stone or blockage with vomiting that is severe, cholangitis, need for open surgery. The health plan's denial of coverage of the inpatient admission was based on MCG (Milliman Care Guidelines) 26th editions Cholecystectomy by Laparoscopy and Gallbladder or Bile Duct Inflammation or Stone. The denial is being appealed.

The Inpatient admission was not medically necessary.

An inpatient level of care was not medically necessary in this case. This patient is an adult male who presented to the hospital with abdominal pain. He was determined to have symptomatic cholelithiasis/biliary colic. There is no documentation of 
hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient admission. The indication for cholecystectomy was established and the patient was admitted to the hospital. He underwent surgery to remove the gallbladder on the same day. The patient responded favorably to treatment and was stable for discharge from the hospital the next day with planned follow up. Acute inpatient care was not medically necessary for this patient, as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for ED (emergency department) assessment, surgical assessment and monitoring, laparoscopic cholecystectomy as performed, provision of IV (intravenous) antibiotics and fluid, and overnight care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld.

 
The patient is an adult with a history of metastatic colon cancer. He presented to the emergency department (ED) with complaints of cough and shortness of breath (SOB) on exertion. The patient has a past medical history of liver metastasis status post resection. There is a history of deep vein thrombosis (DVT) and Covid. The patient was on oral (PO) chemotherapy which was recently completed.

Vital signs at presentation were normal except for a temperature of 100.4 degrees. Oxygen saturation was 96 % (percent) on room air. The patient was in no acute distress.  Lungs were clear, heart sounds normal, abdomen soft, no edema and alert and oriented x (times) 3. Laboratory results were within normal limits. The chest x-ray showed some hilar prominence, some increased vascular markings, and mild congestion versus bronchiolitis. The patient had a computed tomography (CT) of the chest with no pulmonary embolism, bilateral small nodular opacities- possibly infectious (as not seen in prior imaging).

The patient was initially treated with intravenous (IV) steroids, fluids, bronchodilators via nebulizer and antibiotics - Vancomycin /Zosyn/ Azithromycin. In addition, he was given pain meds and Tylenol. This patient remained in the hospital for the next 2 days. He remained afebrile and was hemodynamically stable. He was switched to PO Levaquin and was discharged home.

This patient did not need acute inpatient hospitalization. He could have been placed in observation while diagnostic testing and treatment were initiated. Observation could be for up to 48 hrs. This patient was stable for discharge after a period under observation.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Crohn's disease
Treatment: Stelara every 6 weeks
The insurer denied Stelara every 6 weeks. The health plan's determination is overturned. 

The patient is a female with Crohn's disease diagnosed. She has failed 6-mercaptopurine, Humira, Cimzia, and Entyvio; she started Stelara with improvement. A Colonoscopy showed active proctitis. Stelara level was low at 2.1 (with no anti-Stelara antibodies). 

The current medical literature supports the dose escalation of Stelara to 90 mg every 6 weeks as medically necessary in this case. In this case, the patient has had disease symptoms and a colonoscopy showing inflammation while taking Stelara every 8 weeks. The American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should have their medication dose adjusted in order to attempt to optimize therapy" (Lichtenstein, et al). Furthermore, the Stelara level was low in this case; a Stelara level of at least 4.5 is associated with effective disease control (Battat, et al). Continuation of the current Stelara dose or discontinuation of Stelara (even if an alternative is attempted immediately) may result in complications such as stricture, fistula, bowel obstruction, flare, hospitalization, need for surgery, or other complications. For these reasons, the request for Stelara 90 mg every 6 weeks is supported as medically necessary for the treatment of this patient's Crohn's disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, atrial fibrillation, end stage renal disease (hemodialysis) and multiple pressure ulcers

Treatment: Skilled nursing facility continued stay

The insurer denied coverage for Skilled nursing facility continued stay

The denial is overturned

 
This is an adult with multiple medical problems including diabetes, atrial fibrillation, end stage renal disease (hemodialysis) and multiple pressure ulcers. She presented to the skilled nursing facility (SNF) and was treated with antibiotics (7 days) for cellulitis. She also received physical and occupational therapy. Under review is the medical necessity for continued stay in a SNF.

The patient was an appropriate candidate for the SNF subacute rehabilitation level of care. She had functional impairments amenable to (subacute) rehabilitation therapy. The physical and occupational therapy notes document continued improvement over the next several weeks. The patient improved from dependent to supervision level for activities such as toilet transfer and wheelchair mobility. Chair to bed transfers improved to the supervision level. She was also able to ambulate short distances (20-30 feet). This is particularly impressive given her multiple comorbid conditions and concurrent treatment for COVID pneumonia. In addition, her active comorbid medical conditions and associated treatments also supported her continued stay in a skilled nursing facility.

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 coverage for continued care in a skilled nursing facility (SNF) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Acute appendicitis
Treatment: Inpatient Admission
The health plan denied the requested inpatient admission as not medically necessary. The health plan's determination is upheld.

The patient is a female with a past medical history (PMH) of hypothyroidism on Synthroid who presented with right lower quadrant (RLQ) pain as a transfer from another facility and was admitted with a diagnosis of acute appendicitis. Her heart rate was 104 beats per minute (bpm) and her white blood cell count (WBC) was elevated at 15.1. A computed tomography (CT) scan showed an appendix of 7.5 millimeters (mm) with fat stranding. Rocephin and Flagyl were administered. She underwent a laparoscopic appendectomy and was found to have an edematous appendix without purulence. 
At issue is the medical necessity for the requested health service/treatment of an inpatient admission.

I uphold, in whole, the health plan's determination of medical necessity.

The treatment of an inpatient admission was not medically necessary for this patient. The patient could have been cared for in the emergency room, taken to the operating room and then discharged from the post-anesthesia care unit (PACU).
Several studies have demonstrated safety in same day discharge in uncomplicated appendicitis patients after laparoscopic appendectomy. [1-3] There is no increase in complications with this approach and even has been studied in the community hospital setting. [1] Another study found that in same day discharge for uncomplicated appendicitis patients, there is no increase in readmission, unplanned visits to the emergency room, or complications. [2] This is also associated with a lower cost of care. [2] Finally, there is high parental satisfaction with same day discharge. [3]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Appendicitis.
Treatment: Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female who presented to the emergency department (ED) with a history of abdominal pain and dizziness of 1 day in duration. Her comorbid health conditions included morbid obesity. Her evaluation included a physical examination, laboratory studies, and a computed tomography (CT) scan. Her temperature was 100.9 Fahrenheit at the time of presentation. The heart rate was elevated at 117 beats per minute. She was tender in the right lower quadrant. Her laboratory studies showed an elevated white blood cell count (WBC) count of 21. The CT scan yielded the diagnosis of early acute appendicitis. Treatment was initiated with intravenous (IV) fluid, a nothing by mouth (NPO) status, and antibiotics. A surgical consultation was obtained.

The records indicate that the patient was admitted to the hospital with an inpatient level of care. She underwent a laparoscopic appendectomy. The procedure was completed without complication. The day after surgery, the patient was afebrile with normal vital signs. She was tolerating a regular diet and her pain was well controlled. The day after surgery she was considered to be stable for discharge from the hospital.

The health plan rationale for the denial referenced the Milliman Care Guidelines (MCG) Appendectomy without abscess (page 11/293). This letter states that there was no hemodynamic, pulmonary, neurological, or metabolic reason for acute level of care. 

Yes, the records support that the health plan acted reasonably with sound medical judgment with its determination in this case.

No, the acute inpatient admission was not medically necessary for this patient. This patient presented with abdominal pain. Her evaluation with examination, laboratory studies, and a CT scan confirmed the diagnosis of appendicitis. The treatment plan included NPO status, IV fluids, and IV antibiotics and the appendectomy that was performed. She tolerated the surgical procedure without adverse incident. Her vital signs were consistently normal throughout the period of monitoring. She was tolerating a regular diet on the day after surgery.

The submitted clinical documentation does not support the need for inpatient admission for this patient. An alternate level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care. There was no documentation of hemodynamic instability, complications of his condition, severe pain, or unstable comorbidities. The patient tolerated oral hydration, diet and medication as of the day after surgery. The patient's pain was well controlled and she responded appropriately to the surgical therapy without complication. An alternate level of care designation would have provided for surgical assessment, provision of antibiotics, operative treatment and overnight monitoring as provided.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia

Treatment: Praluent 75 milligram/milliliter (mg/ml) subcutaneous (SC) solution auto-injector (SOAJ).

The insurer denied coverage for Praluent 75 milligram/milliliter (mg/ml) subcutaneous (SC) solution auto-injector (SOAJ).

The denial is overturned.

 
This is an adult patient with hypercholesterolemia and transient ischemic attack (TIA). She failed to tolerate multiple statin therapies due to muscle pain.  According to medical records provided rosuvastatin 40mg was not tolerated and a previous trial of atorvastatin resulted in similar symptoms. On maximally tolerated rosuvastatin and vascepa cholesterol remained elevated above the recommended target goals. Past medical history is relevant for atherosclerotic vascular disease.  

This patient has a history of myositis on multiple statin agents and has an elevated low-density lipoproteins (LDL) cholesterol level on maximally tolerated statin therapy (Crestor 20mg). She cannot tolerate atorvastatin 80mg as this formulary drug is likely to cause an adverse reaction. The patient has a history of TIA and evidence of atherosclerotic cardiovascular disease (ASCVD). Addition of a non-statin agent such Evolocumab in this setting has been associated with significant event rate reduction regardless of serum LDL level. Current American Heart Association and American College of Cardiology guidelines recommend addition of monoclonal antibody PCSK-9 (proprotein convertase subtilisin/kexin type 9) inhibitor therapy to maximally tolerated statin therapy in patients at high risk for future ASCVD events.  According to the European Society of Cardiology guidelines this patient with documented ASCVD is considered to have "very high risk" of cardiovascular events. Such patients have a class I indication for treatment with non-statin therapy such as evolocumab when LDL-C (low-density lipoprotein cholesterol) levels are greater than 70. In conclusion, the proposed treatment is medically necessary and is more effective than the insurer suggested medications as the patient has developed diffuse muscle pain on multiple statin therapy and has an elevated LDL cholesterol despite maximally tolerated statin therapy (rosuvastatin 20mg).

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 Praluent 75 milligram/milliliter (mg/ml) subcutaneous (SC) solution auto-injector (SOAJ) services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:  Personal Care Assistance Services: 24 Hours per Day, 7 Days per Week - Split Shift (Monday through Sunday), Total of 168 Hours per Week.
The insurer denied Personal Care Assistance Services: 24 Hours per Day, 7 Days per Week - Split Shift (Monday through Sunday), Total of 168 Hours per Week. 
The health plan's determination is overturned.

The patient is a female with past medical history of Alzheimer's dementia, anxiety, depression, hypertension, osteoarthritis, insomnia, gastroesophageal reflux disease (GERD), urinary incontinence, bowel incontinence, vitamin B12 deficiency, hyperlipidemia, and chronic back pain who had been assigned PCA (personal care assistant) services.

Personal Care Assistance (PCA) Services: 24 Hours per Day, 7 Days per Week - Split Shift (Monday through Sunday), Total of 168 Hours per Week are medically necessary for this patient.

There is documentation of worsening physical and cognitive functioning by the patient's PCP (primary care provider), family, and health care advocate. The patient required at least limited assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet the patient's unpredictable and unscheduled care needs. There is documentation of overnight assistance needs with activities of daily living (ADL) such that a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. The plan assumed the patient had informal support outside of the currently assigned PCA services which was not the case. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADL/ Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 Hours per Day, 7 Days per Week - Split Shift (Monday through Sunday), Total of 168 Hours per Week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.