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

Diagnosis: Lupus nephritis
Treatment: Lupkynis
The insurer denied the Lupkynis.
The determination is upheld.

The patient has a history of chronic kidney disease (CKD) with glomerular disease due to systemic lupus erythematous (class V lupus nephritis) diagnosed with non-nephrotic proteinuria. Urine protein/creatinine ratio of 0.55. He is currently on Plaquenil and Cellcept. The provider wishes to continue to use Lupkynis (volcosporin) rather than the heath care plans suggested treatment with Benlysta. 
The health plan denied the use of Lupkynis stating that it was not medically necessary as there as other medications on the preferred formulary.
At issue is the medical necessity of the Lupkynis.

The treatment of Lupkynis is not medically necessary in this case based on the documentation provided. While Lupkynis is Food and Drug Administration (FDA) approved for the treatment of lupus nephritis there are no guidelines or randomized controlled studies that necessitate its use over other available treatments. The health plan has stated that the patient would quality for Benlysta therapy which is also FDA approved for the treatment of lupus.
Lypkynis is a calcineurin-inhibitor immunosuppressant indicated in combination with a background immunosuppressive therapy regimen for the treatment of adult patients with active lupus nephritis. The patient has been on this therapy for the past 4 months through the patent assistance program. His creatinine has ranged from 1.1 to 1.2. Benlysta is a B-lymphocyte stimulator (BLyS)-specific inhibitor indicated for the treatment of adult patients with active lupus nephritis who are receiving standard therapy.
There is no medically necessary indication why Lupkynis should be used over other available therapies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Home Health Care. 
The insurer denied increase in personal care worker hours to 168 hours per week. 
The denial is upheld.

The patient is an female with past medical history significant for diabetes, dementia, and hypertension. The subject under review is whether an increase in Personal Care Worker services to 24 hours continuous care by more than one person, for a total of 168 hours per week is medically necessary. The patient had previously been approved for 56 hours a week.

The health plan's determination is upheld.

The requested increase in personal care worker hours is not medically necessary for this patient. Services were denied by the patient's health plan stating that the hours provided, 56 hours a week were sufficient to meet the patient's medical needs along with providing specialized equipment and incontinence care. There are no unmet nighttime needs identified at this time. It is clear at least from the patient's appeal that her medical status has declined especially with both physical and cognitive function. What is not clear is the exact reason why the patient needs split shift services. It appears from the notations, especially the nighttime logs, that issues at night tend to be either wandering and/or incontinence issues. There is no notation in the medical record or other documentation which indicates that the patient requires frequent turning or other care during nocturnal hours associated with bedsores or other medical issues. The main issue that has changed is that the patient's cognitive function has declined. The patient may need additional medical services/PCA hours; however, the requested hours are not medically necessary based on the provided documentation. Additional services for "prevention of falls" for "monitoring" without services being provided are typically not covered under the terms of the plan. In order for services to be considered medically necessary, the aid must be performing a service such medically necessary activities of daily living (ADL) or Instrumental activities of daily living (IADL).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, diabetes and leukemia/lymphoma.

Treatment Consumer Directed Personal Assistance Program (CDPAP) 8 hours per day- 5 days per week- for a total of 40 hours per week.

The insurer denied coverage for CDPAP 8 hours per day- 5 days per week- for a total of 40 hours per week.

The denial is upheld.

This patient has chronic medical problems including hypertension, diabetes and leukemia/lymphoma.  She lives in a 3-bedroom apartment with her partner and grandson.  She is fully alert and oriented, without significant short- or long-term memory deficits.  The insurer approved CDPAP 3.5 hours/day, for 5 days/week for a total of 17.5 hours/week.  Under review is the request for coverage for Consumer Directed Personal Assistance Program (CDPAP) 8 hours per day- 5 days per week- for a total of 40 hours per week.

According to the Uniform Assessment System (UAS), the patient requires extensive assistance for bathing, dressing and toilet transfers.  She is independent with personal hygiene and eating.  She is continent of bowel and bladder.  There are no significant cognitive deficits.   She uses a walker to ambulate with assistance.  The patient's functional ability and cognitive status does not support the requested increase in CDPAP services.  However, her treating physician indicated the patient's functional status has more recently declined due to adverse effects of chemotherapy.  This physician recommends a repeat assessment to determine if there has been a significant change in her current functional and cognitive status.  

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, 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 society, board and associations.  All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, the requested coverage for Consumer Directed Personal Assistance Program (CDPAP) 8 hours per day- 5 days per week- for a total of 40 hours per week is not medically necessary for this patient.  

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

The insurer's denial of coverage for Consumer Directed Personal Assistance Program (CDPAP) 8 hours per day- 5 days per week- for a total of 40 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Radiation Therapy. 
The insurer denied outpatient proton radiation therapy. 
The denied is upheld.

This patient is a male with a right tonsil squamous cell carcinoma staged tumor (T) 3 node (N)2 metastasis (M) 0. He is entered in a clinical trial which is induction chemotherapy followed by concurrent radiation therapy and chemotherapy with lower dosing of radiation. Proton beam approach is requested to deliver the radiation therapy. The subject under review is the medical necessity for the proton beam radiation therapy in this case.

The health plan's determination is upheld in whole. 

The requested treatment of outpatient proton radiation therapy is not considered medically necessary for this patient. The recommended proton beam radiation for this patient with a stage four A (IVA) oropharynx squamous cell carcinoma is considered not medically necessary. There are lack of any significant studies published in peer reviewed journals supporting the benefits and safety of proton beam radiation as compared to conventional photon beam intensity modulated radiation therapy (IMRT). There are currently ongoing accruing clinical trials mirroring this patient's clinical scenario comparing proton beam radiation and conventional treatment of IMRT photon that need to mature and be evaluated and published in peer reviewed journals showing the benefits and safety of proton beam radiation. Until these studies are completed and published in peer reviewed journals, the requested proton beam radiation therapy for this patient and his clinical scenario are not considered the standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, osteoarthritis and history of subarachnoid hemorrhage. 
Treatment: PCA (Personal Care Aide) level 2: 12 hours/day- 7 days per week; 12 hours/day- 7 days per week- 168 hours per week. 

The insurer denied coverage for PCA level 2: 12 hours/day- 7 days per week; 12 hours/day- 7 days per week- 168 hours per week. 

The denial is overturned. 

The patient has chronic medical problems including hypertension, osteoarthritis and history of subarachnoid hemorrhage.  He lives with his partner and stepdaughter in a second-floor studio apartment without elevator access. 

According to the Uniform Assessment System (UAS) report, the patient requires maximal assistance to total dependence for activities of daily living including bathing, dressing, personal hygiene and toilet use.  He is incontinent of bowel and bladder.  Activities that include eating, bed mobility and transfers also require at least maximal assistance.  He is legally blind, bed bound and non-ambulatory.  Cognition is "moderately impaired."  His partner is elderly and unable to care for him.  His stepdaughter has work obligations.  The patient is also receiving home hospice visiting nurse services and his treating physician indicates he has less than 6 months to live.  The combination of his cognitive/vision impairments, functional incapacity and progressive decline supports the Personal Care Aide (PCA) level 2: 12 hours/day- 7 days per week; 12 hours/day- 7 days per week- 168 hours per week to allow the patient to continue living safely at home. 

The healthcare did not plan acted reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, 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 society, board and associations.  All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, the requested Personal Care Aide (PCA) level 2: 12 hours/day- 7 days per week; 12 hours/day- 7 days per week- 168 hours per week is considered medically necessary for this patient. 

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 personal care aide (PCA) level 2: 12 hours/day- 7 days per week; 12 hours/day- 7 days per week- 168 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Skin Disorder 
Treatment: Pharmacy/Prescription Drugs (Dupixent) 
The insurer denied Dupixent. 
The denial is partially overturned.

The patient is a male with severe atopic dermatitis, greater than 10% (percent) body surface area (BSA) and requiring hospitalization in the past. The patient was treated with topical steroids, topical Tacrolimus, and Eucrisa. The patient also has allergies and asthma and takes medications for these. The patient's provider is requesting Dupixent. The health plan requires at least 10% BSA and a trial and failure to Eucrisa and Tacrolimus. The request was denied as a recent patient weight was not submitted. The subject under review is the medical necessity for Dupixent.

The health plan's determination is overturned in part. The requested drug is medically necessary; however, the health plan is correct in that a current patient weight is required in order to properly administer the medication. The treatment with Dupixent is medically necessary for this patient. The patient has tried and failed Eucrisa and Tacrolimus, however the dosing for Dupixent cannot be determined without a patient weight. The medication is medically necessary, but a current weight will be required in order to calculate the medication dosage.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Left Knee Pain
Treatment: Nerve Stimulator (SPRINT PNS System)
The insurer denied the Nerve Stimulator (SPRINT PNS System).
The denial is upheld.

The patient is a female with a history of chronic left knee pain. She is status post-surgery surgery x (times) 3. She has had various injections. She has tried various medications. Her physical exam reveals knee pain on palpation and flexion related spine pain. A peripheral nerve stimulator (PNS) has been recommended. Coverage for this was denied by the insurance for not being medically necessary. Imaging was not available.

No, the requested nerve stimulator is not medically necessary.

The requested procedure is not a commonly accepted treatment for this condition, and has not been shown to be effective in the treatment of chronic knee pain, as shown by high quality randomized control trials (RCT). There is a randomized controlled trial in the setting of chronic pain following amputation, but not this condition. These pathologies are quite different. Other case reports, and observational studies show some benefits in other pain conditions. Other more proven, conventional treatments have been shown to be superior in the literature, such as spinal cord stimulation, genicular radiofrequency ablation, and physical therapy, and knee replacement. Given the lack of data to support an invasive procedure for this type of condition, the requested PNS is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Cerebrovascular Accident

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This case involves a patient who presented to the hospital with a history of diabetes, irritable bowel syndrome, rheumatoid arthritis, hyperlipidemia, fibromyalgia, and a left torturous carotid artery.  The patient presented to the hospital with complaints of left facial paresthesia.  Magnetic resonance imaging of the brain revealed a small acute infarct.  The patient was admitted with an acute cerebrovascular accident.  Plavix was continued and the statin dosage was increased.  The patient was deemed not a candidate for tissue plasminogen activator.  Neurological checks were completed every 2 hours.  The patient's condition improved after treatment.  She was deemed stable for discharge.

Per the cited references, admission for transient ischemic attack is indicated for hemodynamic instability, recurrence of focal neurological signs, findings on brain imaging that require inpatient care such as with a mass, altered mental status, or when an urgent inpatient procedure is needed.  Inpatient care is recommended for ischemic stroke in patients with dysphagia that warrants evaluation, when there is significant arm or leg weakness, for those who require inpatient physical and occupational therapy treatment or evaluation, and when clinical stability is unclear such as with recurrent or worsening findings.  In this case, the patient presented to the hospital with complaints of left facial paresthesia.  She was found to have a focal tiny acute infarct within the posterior left frontal lobe and tiny linear acute infarct within the posterior medial right frontal lobe.  The patient required neurological checks every 2 hours.  She had recurrence of focal neurological signs and neurological findings with significant arm or leg weakness and clinical instability.  

Based on Milliman Care Guidelines (MCG), the medical necessity of inpatient treatment has been met.  The patient reported worsening paresthesia over the left face with pauses in her speech.  The patient could not be safely discharged home and required further management.  Given the worsening symptoms, the patient's clinical stability was unclear.  This meets MCG recommendations for admission.  Thus, the denial of coverage for inpatient admission was not appropriate and is overturned.

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 inpatient admission is overturned.  Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis; artery occlusion
Treatment; Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man who presented with worsening bilateral lower extremity pain with ambulation. He has Type 2 Diabetes. He has a history of Prostate carcinoma, status/post (s/p) prostatectomy, and is a cigarette smoker.
The patient was admitted to the hospital for an arteriogram with possible intervention. The procedure was performed with anesthesia assistance. The femoral arteries were accessed with ultrasound guidance and the arteriogram revealed total occlusion of the left common iliac artery with distal iliac reconstitution. The right common iliac artery had moderate stenosis. Bilateral common iliac artery simultaneous angioplasty and stenting with advancement of the aorta, was performed. No residual stenosis was noted at completion of the procedure. The procedure took approximately two hours and was uncomplicated.

The inpatient hospital admission was not medically necessary. Endovascular treatment of aortoiliac occlusive arterial disease, in an elderly man, with Diabetes and active cigarette smoking, is not always without risk. In dealing with total occlusion of the iliac artery, it is necessary to advance a guide wire through the blockage or to recanalize the vessel by going extra arterial and then reentering the artery. Therefore, the risk of postoperative bleeding is higher when treatment is for a total occlusion. Given this information and his history of cigarette smoking and diabetes, the reasonable and prudent decision is to keep the patient overnight (observation). 
The procedure, Arteriogram with angioplasty and stenting of the aortoiliac bifurcation was appropriately performed. Keeping the patient overnight following the procedure was appropriate given his total iliac occlusion and history of diabetes and cigarette smoking. However, this could have been done at a lower level of care. An inpatient level of care was not medically necessary. Postoperatively, there were no complications and the patient progressed with ambulation, ability to urinate and pain control.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis
Treatment: Inpatient admission

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

The patient is a male that was exposed to an older sibling with a cold virus. The infant developed nasal congestion days prior to the hospital admission. On the night prior to the admission when the mother was feeding the baby, he had significant nasal congestion and had difficulty feeding. The child gasped for air during the feeding and the mother noted that the child's face appeared bluish for a second, so she stopped feeding and brought him to the emergency room (ER) for an evaluation.

In the ER, he was afebrile with a heart rate of 162, a respiratory rate of 36 and a pulse oximeter reading of 99% (percent). He was described as irritable with nasal congestion and mild respiratory distress. On physical examination, there was some redness noted in the throat, nasal congestion and audible rales upon examination of the chest. He was begun on treatment with IV (intravenous) fluids, nebulizer treatments with normal saline and saline nasal spray followed by suctioning of the nose. Blood testing, a venous blood gas and a nasal respiratory viral panel were negative. A chest x-ray was found to have peribronchial thickening. The child was noted to have a normal suck, but he appeared to get tired easily during feeding. He was having normal urine production and mom noted having to change 5 diapers which was a normal quantity. He was treated with 2 nebulizer treatments with normal saline in the ER and the decision was made to admit him to the hospital for ongoing treatment with normal saline and nasal suctioning with a diagnosis of bronchiolitis.

The patient was treated appropriately for a respiratory illness with nasal congestion and some difficulty feeding. He was not found to have evidence of dehydration and no hypoxemia was noted on repeated pulse oximeter measurements. He was having some difficulty feeding because of the nasal congestion but he had a normal suck and normal quantity of wet diapers. There were no physician notes in the medical record of a repeat examination following treatment in the ER to document failure to improve with the treatment administered. The decision to admit to the hospital for ongoing treatment with IV fluids, saline nasal sprays and possible nebulizer treatments with normal saline was not consistent with the standard of care for a young patient with nasal congestion and a viral illness. The mother could have been instructed how to administer normal saline nose drops and how to suction the nose with a nasal aspirator prior to feedings with a follow up visit with the pediatrician in 24 to 48 hours if the symptoms were not improving. 

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

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

Diagnosis: Paradoxical vocal cord dysfunction and laryngeal edema

Treatment service code 81291, MTHFR (methylenetetrahydrofolate reductase) genetic testing

The insurer denied coverage for service code 81291, MTHFR genetic testing

The denial is upheld

This is a case of an adult male with diagnosis of paradoxical vocal cord dysfunction and laryngeal edema due to gastroesophageal reflux disease and with history of laryngeal trauma.  Work up included blood testing for MTHFR genetic mutation.  Based on peer reviewed literature and recommendations by American Academy of Otolaryngology Head and Neck surgery, there is no role in use of MTHFR gene in diagnosis and treatment of paradoxical vocal cord dysfunction and laryngeal edema.  Medical Necessity is not established.

The health care plan act reasonably and with sound medical judgment.  Routine testing of MTHFR gene is not recommended in work up and treatment of throat symptoms such as dysphagia and/or dysphonia.  There are some data that show a link between MTHFR gene and sudden hearing loss and esophageal cancer. [1,2] There are no data showing link between this gene and throat symptoms.

The insurer's denial of coverage for service code 81291, methylenetetrahydrofolate reductase (MTHFR) genetic testing is upheld. Medical Necessity is not substantiated.