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

Diagnosis: Emphysema.
Treatment: Prolastin-C.
The insurer denied coverage for Prolastin-C.
The denial is upheld.

This is an adult patient with history of severe emphysema, 20 pack per year smoking (quit 15 years ago), and chronic obstructive pulmonary disease. The patient has an obstructive ventilatory pattern on a pulmonary function test (PFT) with reduced diffusing capacity of lungs (DLCO) consistent with a diagnosis of emphysema. The patient was tested for alpha1-antitrypsin (AAT) deficiency. His present medications include long-acting muscarinic antagonists/Long-Acting Beta-Agonists (LAMA/LABA) and inhaled corticosteroids (ICS). The patient has phenotype for Alpha 1 Antitrypsin. The patient's AAT level was 126 milligrams per deciliter (mg/dl). The patient does not meet the criteria for AAT replacement. Current recommendations for replacement require the patient to have an AAT less than 11 micromoles per liter or less than 80 mg/dl by radial immunodiffusion or 50 mg/dl by nephelometry.

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 Prolastin-C is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory syncytial virus (RSV).
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

This patient is a young child with respiratory symptoms of cough and fast breathing presented to the hospital. The patient was noted to be in no distress (in the emergency department (ED). The physician note documented "no distress", nontoxic appearance, and the patient was trying to climb the chair). The respiratory rate was 27 and most of the time less than 30. The temperature was 102.1 degrees Fahrenheit. The oxygen saturation was 93-97% (percent). No hemodynamic instability. Perfusion was adequate. The Chest x-ray (CXR) was suggestive of being normal; the patient was treated with nebulization and steroids. The clinical status improved. The patient was discharged with scheduled nebulization and steroids and close pediatrician follow up.

There was no persistent hypoxia and in fact the oxygen saturation was 93- 97% and no need for continuous positive airway pressure (CPAP) or high flow nasal canula (HFNC). There was only minimal need for oxygen. There was no need for pressors (vasopressors) nor multiple boluses. There were no abnormal labs that persisted. No arterial blood gas (ABG) was done in the ED as the ED doctor did not deem the clinical status was serious enough to give intravenous (IV) steroids.  Respiratory syncytial virus (RSV) was positive and a CXR was negative for pneumonia. Hence the concerning diagnosis of bacterial pneumonia superimposed was ruled out. Also, there was no severe dehydration as evidenced by normal physical exam and labs. There was no concerning past medical history such as prior pediatric intensive care unit (PICU) admission/intubation/premature status/chronic lung disease of infancy. Also, there was no second line treatment such as continuous albuterol or epinephrine or terbutaline. If one were to take the Pediatric Respiratory Assessment Measure (PRAM) score to assess the pediatric asthma, it would be in the category of mild asthma. The reason for asthma exacerbation is viral illness. If one were to take the Pediatric Early Warning Score (PEWS) score, it would have been desirable also, indicating an expectant and stable course in the hospital. The patient was continuing in an expected clinical trajectory while in the hospital. Due to above reasons, a child with mild to moderate asthma exacerbation from a viral illness could have been treated in observational status.

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 admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis, Vomiting
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld 

The patient had a history of gastroesophageal reflux disease (GERD) and presented with vomiting and diarrhea. The patient had some coffee ground vomiting but was not actively bleeding. The patient was afebrile, and the vital signs were stable. There was no abdominal rebound or guarding. The white blood cell count (WBC) was 22.8. The lactate level was 3.1. An abdominal computed tomography (CT) scan suggested gastroenteritis. Intravenous (IV) hydration, proton pump inhibitor (PPI) therapy, and Zofran were given. The patient's symptoms improved. The patient was diagnosed with cannabis hyperemesis syndrome and gastroenteritis. 

Clinical indications for admission for Gastroenteritis Milliman Care Guidelines (MCG) M-170 include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting that is not responsive to antiemetics, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

Clinical indications for admission for Vomiting MCG M-370 include having a severe metabolic derangement such as ketoacidosis, hemodynamic instability, severe electrolyte abnormalities, severe pain, bacteremia, acute renal failure, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had Gastroenteritis. IV hydration, PPI therapy, and antiemetics were needed but could have been given in the emergency room with observation status. The patient responded to this treatment and the symptoms improved. The patient did not meet MCG criteria for admission for Gastroenteritis or Vomiting. 

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Eczema/psoriasis
Treatment: Xeljanz XR (extended-release) SGM (Specialty Guideline Management)
The insurer denied:  Xeljanz XR (extended-release) SGM (Specialty Guideline Management)
The denial is upheld

The patient is an adult female with severe, erythrodermic eczema/psoriasis overlap that flared with Dupixent injections. She started taking Xeljanz and saw significant improvement of pruritus within one week of initiation. This request is for Xeljanz tablets.

The proposed Xeljanz is not medically necessary.

Xeljanz is not Food and Drug Administration (FDA) approved for use in the treatment of psoriasis, eczema, or erythroderma. There is no documentation that any approved treatments for the psoriasis component was tried and failed or that the patient has contraindications to their use. In the absence of documented trials and failure of Food and Drug Administration (FDA)- approved treatments for the patient's psoriasis, off-label use of Xeljanz cannot be accepted as medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid arthritis, hypertension, and bilateral knee osteoarthritis

Treatment: Consumer directed personal assistance services (CDPAS), increase to 24 hours per day split shift (two 12-hour shift), 7 days per week, total of 168 hours per week.

The insurer denied coverage for CDPAS, increase to 24 hours per day split shift (two 12-hour shift), 7 days per week, total of 168 hours per week.

The denial is overturned. 

This is an elderly patient with medical problems that include rheumatoid arthritis, hypertension, and bilateral knee osteoarthritis. She lives alone. The insurer approved 41 CDPAS hours/week and the request is for 24 hours per day split shift (two 12-hour shifts), 7 days per week, total of 168 hours per week.

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as modified independent. However, she requires maximal assistance for bathing and locomotion. She requires extensive assistance for personal hygiene, dressing and toilet transfer/use. She is frequently incontinent of bladder and occasionally incontinent of bowel. She is independent with bed mobility and eating. She is an unsafe and non-functional ambulator. The patient has sustained multiple falls, was recently a short-term nursing home resident (where she also fell). She sustained a pubic ramus fracture and is wheelchair dependent. The patient's medical condition, essentially maximal assistance for instrumental activities of daily living (IADL) and functional needs are at a level or unpredictable as to require the requested CDPAS 24 hours/day, 7 days/week (split shift). Based on the records reviewed, a live-in CDPAS is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain an uninterrupted 5 hours of sleep. Given her recent history, the patient is particularly at high risk for additional falls and sustaining multiple fractures. The patient's health and safety are more appropriately provided and maintained at home with CDPAS services 24 hours/day, 7 days/week split shift.

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 societies, boards, and associations. All decisions are evidence-based.  

From a physical medicine and rehabilitation perspective, CDPAS increase to 24 hours/day split shift (two 12-hour shifts), 7 days/week, total of 168 hours per week is medically necessary.    

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 consumer directed personal assistance services (CDPAS), increase to 24 hours per day split shift (two 12-hour shift), 7 days per week, total of 168 hours per week services is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Ulcerative proctitis
Treatment: Uceris Foam
The insurer denied Uceris Foam.
The denial is overturned.

The patient is an adult female with ulcerative proctitis, treated with Entyvio. She has ongoing rectal bleeding and urgency felt to be related to distal disease. She has failed mesalamine suppository and Cortifoam, and recently was given Anusol suppository without improvement. The attending physician (MD) is requesting treatment with Uceris foam.

The health plan should cover the Uceris foam.

Uceris foam has been shown to be the most effective topical therapy for the treatment of ulcerative proctitis. It is more effective than hydrocortisone enemas. The patient has failed mesalamine suppositories, Cortifoam and Anusol suppositories. As the patient has failed mesalamine suppositories, there is no medical literature to support that mesalamine suspension will be effective, and a drug with a different mechanism of action such as Uceris foam has been shown to be more effective. Therefore, the formulary drugs have been ineffective, and are not as effective as the requested non-formulary Uceris foam, and the health plan should cover the proposed Uceris Foam.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral narrowed nasal valves.
Treatment: 30465 - Repair of nasal vestibular stenosis (spreader grafting, lateral nasal wall reconstruction).

The insurer denied coverage for 30465 - Repair of nasal vestibular stenosis (spreader grafting, lateral nasal wall reconstruction).  The denial is overturned.

This is a young adult patient, who underwent nasal surgery, which included a bilateral repair of her nasal valves.

The patient was observed from rhinoscopy and endoscopy to have bilateral narrowed nasal valves. The peer reviewed literature notes the efficacy of various surgical corrections for narrowed nasal valves. It also observes that there are no uniform diagnostic criteria other than observation.
 
The patient has been objectively observed since she was a teenager to have bilateral narrowed nasal valves. This is a deformity most probably congenital, which manifested as she matured.

The patient nasal valve impairment fulfills the insurer's criteria; it is a functional impairment as a direct result of a birth defect.

The patient had documented nasal valve deformity, which was corrected with the accepted procedure.

The repair of nasal vestibular stenosis (spreader grafting, lateral nasal wall reconstruction) was considered medically necessary for the patient. This is substantiated by the peer reviewed literature.

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 30465 - Repair of nasal vestibular stenosis (spreader grafting, lateral nasal wall reconstruction) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infection of left hand.
Treatment: Inpatient hospital admission.
The insurer denied: Inpatient hospital admission.
The denial is upheld.

The patient presented with complaints of infection of left hand. The patient reported that he developed blister formation on the morning of previous day and was seen at urgent care and given Keflex. The patient reports taking Keflex, however he noted increased streaking up his hand. The patient reported minimal pain, and he denied fever or chills. The patient denied nausea or vomiting. The patient denied any injury to the hand; however he stated that he lifts weight and often gets calluses over the palmar aspect of the hand. The patient's vital signs in the ER (emergency room) were stable.  Left hand x-ray was normal.
The patient was given IV (intravenous) antibiotics and admitted to inpatient hospital stay. The patient improved with this treatment. The patient remained afebrile and did not develop any complications. Hand surgery consult was requested, but the patient reported that he was already feeling better and wanted to go home. The patient was discharged on oral antibiotics.

The inpatient hospital admission was not medically necessary.

The patient improved with the IV (intravenous) antibiotics. Hand surgery consult was requested, but the patient reported that he was already feeling better and wanted to go home. The patient was discharged on oral antibiotics.

For the duration of the hospital admission, the patient was afebrile and had stable vital signs. The patient did not have new symptoms or intractable pain that would require continued management in an inpatient setting. The patient was tolerating oral intake and was clinically stable. During the duration, the patient's diagnosis had been established clinically and based on the results of the investigations. The patient was hemodynamically stable and afebrile. The care that was rendered during this time was of low intensity, routine nursing and physician monitoring. Examination findings were not concerning, and the patient's medical problems did not pose an immediate high risk of deterioration. With a low severity of illness and low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, ongoing inpatient care was not medically necessary for the above dates. In view of these findings and generally in accordance with Milliman Care Guidelines (MCG), the ongoing inpatient level of care for the above duration was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female that presented with epigastric pain radiating to the LLQ (left lower quadrant). She was hemodynamically stable, with abdominal tenderness on exam. She had a normal WBC (white blood cells) count and CT (computed tomography) revealed uncomplicated diverticulitis. She was made NPO (nothing by mouth) and placed on IV (intravenous) antibiotics and IV (intravenous) morphine. She was advanced to a clear liquid diet. She was given Tylenol for pain. On day #2 she was advanced to a full liquid diet and discharged on oral antibiotics. 

The inpatient stay is not medically necessary.

The patient presented with abdominal pain and was diagnosed with uncomplicated sigmoid diverticulitis. On the day following admission, she had a normal WBC (white blood cells) count, tolerated a clear liquid diet and was improving. Observation status would have been medically appropriate, she was medically stable for discharge on a liquid diet and antibiotics.
As she was hemodynamically stable, had no peritoneal signs, no GI (gastrointestinal) bleeding, obstruction, perforation, abscess or need for surgical intervention, bacteremia, severe pain or need for prolonged NPO (nothing by mouth), acute impatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriatic arthritis
Treatment: Rinvoq
The insurer denied coverage for Rinvoq.
The denial is upheld.
 
The patient has a diagnosis of psoriasis and psoriatic arthritis. The patient has failed therapy with intralesional and topical clobetasol. The request is for Rinvoq tablets.  

Based on the submitted documentation, the use of Rinvoq tablets is not medically necessary for the patient's psoriasis and psoriatic arthritis over alternative therapies. The documentation indicates that the psoriasis and psoriatic arthritis has only been treated with intralesional and topical steroid therapy. Multiple therapeutic options are available which are Food and Drug Administration (FDA) approved for both psoriasis and psoriatic arthritis, including physician office-based injections and oral medications. The documentation provided does not preclude the use of multiple available therapies which could be tried as a first line therapy, including office based Stelara injections or Otezla. There is no documentation regarding tried and failed systemic therapies provided in the documentation. 

In a recently published guideline by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) group they stated "non-steroidal anti-inflammatories (NSAIDs) and intra-articular and oral glucocorticoids are conditionally recommended for relieving symptoms of peripheral arthritis as per the 2015 recommendations  as no new relevant data were identified. For treatment-naive patients, there remains a low level of evidence to support the use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) for the treatment of peripheral arthritis. However, in view of supportive observational data and universal accessibility, the use of csDMARDs (methotrexate, sulfasalazine or leflunomide) is strongly recommended. In many circumstances, csDMARDs can be used as first-line therapy, with regular assessment of clinical response (every 12-24 weeks) and early escalation of therapy (between 12 and 24 weeks) advised as necessary. It is important to acknowledge that new, high-quality data support the superiority of Tumor necrosis factors (TNF) inhibitors over csDMARDs as first-line therapy, particularly in patients with early disease."

Based on the documentation submitted, the use of Rinvoq would not be supported over other reasonable alternatives.  

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 Rinvoq is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis (AD).
Treatment: Dupixent.
The insurer denied: Dupixent.
The denial is: Upheld.

The patient is a female with atopic dermatitis (AD). She has tried and failed clobetasol ointment and betamethasone. She has also failed Duobrii and calcipotriene. The subject under review is the medical necessity for Dupixent.

The health plan's determination is upheld.

The treatment with Dupixent is not medically necessary for this patient prior to a trial with the preferred plan treatment modality phototherapy. Phototherapy has been well-documented as an efficacious, safe treatment for atopic dermatitis (eczema), as in this patient (1-3).
Meduri et al. writes in "Phototherapy in the management of atopic dermatitis: a systematic review" that "narrowband ultraviolet B (UVB), should be used for the management of chronic AD" (1). Sidbury et al. writes "narrow band (NB)-UVB is generally the most commonly recommended light treatment by providers when considering its low risk profile, relative efficacy, availability, and provider comfort level" (2).
There is no documentation provided that the patient has tried and failed, has a contraindication to, or intolerance to this preferred treatment modality. Phototherapy should be tried and failed prior to treatment with Dupixent. Therefore, Dupixent is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Leptomeningeal Disease. 
Treatment: Proton Beam Therapy (PBT), pre-service: 77525 Proton treatment delivery; complex, A9552: Fluorodeoxyglucose f-18 FDG, diagnostic, per study-dose, up to 45 millicuries, 77523 Proton treatment delivery; intermediate, 77520 Proton treatment delivery; simple, without compensation. 

The insurer denied: Proton Beam Therapy (PBT), pre-service: 77525 Proton treatment delivery; complex, A9552: Fluorodeoxyglucose f-18 FDG, diagnostic, per study-dose, up to 45 millicuries, 77523 Proton treatment delivery; intermediate, 77520 Proton treatment delivery; simple, without compensation. 

The denial is upheld. 

The patient is an adult female with history of mantle cell lymphoma status post multiple courses of chemotherapy, immunotherapy, palliative radiotherapy, and status post autologous stem cell transplant who presented with leptomeningeal disease referred for craniospinal irradiation (CSI) with proton beam radiotherapy. The prior denial reason was proton beam radiotherapy was considered not medically appropriate. 
The reason for appeal is to re-consider approving the use of proton beam radiotherapy for this case. 

The health plan should not cover the proposed treatment. 

Efficacy and safety of proton beam therapy for this case are not clear. Data on proton beam therapy is very limited for this case. Treatment with intensity modulated radiation therapy (IMRT) may be a safer option. Although there are published reports on the technical superiority of proton therapy over conventional therapy with three-dimensional (3D) conformal treatment or intensity modulated radiation therapy (IMRT), this advantage has not been proven to result in clinical advantage such as efficacy, significant decreased toxicities, and better quality of life for 
the patient. 

Proton radiotherapy for this case is investigational since the data are limited, mostly from a few institutions such as Loma Linda and MD Anderson. Moreover, the follow-up time for the available studies is short with no clear evidence that this type of therapy is clinically superior to conventional treatment in terms of survival or lower long-term toxicities. Data and reports on proton radiotherapy for thoracic tumors are premature and longer follow-up times and results are needed before one can conclude that this therapy is superior to conventional treatment.