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

Diagnosis: Asthma

Treatment is an inpatient admission 

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

This is a patient with a history of asthma, who presented to the emergency department (ED) with a 3-day history of wheezing and shortness of breath (SOB). She was previously seen in the ED and was released on PO (oral) steroids and bronchodilators (BD). She completed her course of Prednisone and her symptoms returned. 

At presentation her vital signs were Temperature 98.4 degrees F (Fahrenheit), Respirations 20, Heart Rate 91, Blood Pressure 135/95 mm Hg (millimeters of mercury) and oxygen saturation at room air was 93%. The patient was in no distress, awake and alert. Lung exam revealed bilateral wheezing.

She was admitted to the hospital for Asthma exacerbation. Her laboratory results included WBC (white blood cell count) 14.2K (thousand), Hb (hemoglobin)13.9 and her electrolytes were within normal limits.

The chest X-ray showed no acute infiltrates, and the viral panel was negative for COVID-19 and Influenza.

The patient was continued on oral Prednisone, bronchodilators (BD), Magnesium, and intravenous (IV) Fluids. She improved after treatment and was discharged on oral steroids and bronchodilators (BD).

This patient could have been placed in observation status (up to 48 hrs.) while diagnostic testing and treatment were initiated. She remained stable after admission with no pneumonia (PNA) or pleural effusion. She was treated with oral steroids and bronchodilators (BD and inhaled Corticosteroids and Long-Acting Beta-Agonist (ICS/LABA).

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

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

Diagnosis: Type 2 supracondylar humerus fracture
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient was running while at school and fell and had pain and swelling around his elbow. He was brought to the hospital, then transferred to another hospital. He was found to have a closed Type 2 supracondylar humerus fracture. There was no reported nerve or vascular injury. He was admitted to the hospital in the evening, underwent a surgical procedure the following morning, and was discharged shortly after the surgical procedure. At issue is whether inpatient hospital admission was medically necessary.

No. An inpatient stay was not medically necessary. Type 2 supracondylar humerus fractures often require surgical treatment. However, they do not present the same risk of ischemia and nerve or vascular injury that more severely displaced Type 3 supracondylar humerus fractures do. Type 2 fractures can be splinted, and surgical treatment (typically closed reduction and percutaneous pinning, as was done in this patient) can be done as an outpatient procedure. Type 2 fractures generally do not require close monitoring of neurovascular status before and after surgery, as Type 3 fractures do. This procedure could have been done at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: GI (gastrointestinal) bleed
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a female with a medical history of asthma, hypertension, peptic ulcer disease, Helicobacter pylori infection, schizoaffective disorder, bipolar disorder, anemia, hypothyroidism, sleep apnea, obesity, and cholecystectomy. She presented to the emergency department with blood-streaked emesis for 2 days, severe constipation for months, and intermittent bright red blood per rectum. 

The inpatient level of care is not medically necessary, and the care provided could have been provided at a lower level of care. In this case, the patient presented with reported rectal bleeding and hematemesis; however, there was no sustained tachycardia or hypotension, no anemia, and no significant visible ongoing gastrointestinal bleeding. The patient had close monitoring, which was also warranted as bleeding can be severe and sudden in onset. Esophagogastroduodenoscopy and colonoscopy were performed, and did not show any active bleeding or high-risk findings. All of the measures that were undertaken, including monitoring, labs, Gastroenterology consultation, and endoscopic procedures, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, osteoarthritis, and hypertension
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) to 59.5 Hours per Week, pre-service
The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP) to 59.5 Hours per Week, pre-service
The denial is upheld.

This female patient has conditions including dementia, osteoarthritis, and hypertension.  She lives with her daughter who is her personal assistant and involved in care.  She is appealing the denial of an increase in consumer directed personal assistance program (CDPAP) to total 59.5 hours per week.  The health plan approved 31.5 hours per week.  Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, and managing medications; extensive assistance with managing finances; limited assistance with bathing, personal hygiene, dressing, walking, locomotion, and toileting; and supervision with bed mobility and eating.  Uniform Assessment Systems (UAS) evaluation compared to previous assessment shows a decline in eating and bed mobility from independent to supervision.  She has frequent bladder incontinence.

No, the proposed treatment is not medically necessary.
Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  

This patient is appealing denial of increase in consumer directed personal assistance program (CDPAP) to a total of 59.5 hours per week.  The health plan approved 31.5 hours per week. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs) except bed mobility and eating.  Uniform Assessment Systems (UAS) evaluation compared to previous assessment shows a decline in eating and bed mobility from independent to supervision.  The patient is able to direct her own needs.  She lives with her daughter who is her personal assistant and involved in care.  The information provided shows no significant decline in the patient's level of functioning from previous assessment to most recent assessment.  Consumer directed personal assistance program (CDPAP) is not indicated when there are no tasks being performed.  The information provided does not support an increase from consumer directed personal assistance program (CDPAP) 31.5 hours per week to 59.5 hours per week.  Based on the stability in the patient's level of functioning, the proposed increase consumer directed personal assistance program (CDPAP) to 59.5 hours per week is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Menorrhagia in adolescence and anemia.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient presented to the hospital with complaints of dizziness, headaches, and syncope. She had a history of heavy menses. She had recently completed progesterone prescribed by her pediatrician. She also had a history of asthma and obesity. In the emergency room, her vital signs were normal. On physical exam, she was pale, and her hemoglobin was 6.8. She was admitted as an inpatient and was transfused 2 units of packed red blood cells. She also received tranexamic acid and intravenous Premarin. Her hemoglobin rose to 10.0. She was discharged with decreased bleeding to follow up as an outpatient. At issue is the medical necessity of the impatient hospital admission.

The requested health service/treatment of inpatient stay is not medically necessary for this patient.

The patient had menorrhagia in adolescence and anemia. She required a blood transfusion and medication to reduce her menstrual bleeding. All of her interventions could have been performed at a lower level of care. She could have received the transfusions and medications without the necessity of inpatient monitoring. She had no changes in her vital signs to show cardiovascular collapse or concern. She had no comorbidities such as hepatic, renal, or severe pulmonary disease. Her asthma was mild and non-contributory. Multiple electrocardiograms (EKGs) were normal showing no cardiac concerns or collapse. Her bleeding also significantly decreased with medication and she felt better after her blood transfusions. Therefore, she did not need inpatient monitoring and could have been treated at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Right Knee Pain
Treatment: Pain Management (genicular nerve injection)
The insurer denied the Pain Management (genicular nerve injection).
The denial is overturned.

The patient is a female with chronic severe right knee pain secondary to severe patella chondromalacia and medial meniscus degeneration seen on right knee MRI (magnetic resonance imaging). She has not responded to rest/activity modification, home exercise program, physical therapy, medication management (NSAIDs [nonsteroidal anti-inflammatory drugs] and Tylenol), and knee injections (corticosteroid injection and viscosupplemental injections). Her treating provider scheduled a right genicular nerve block and then ablation.

The health plan should cover the genicular nerve block.

The patient has severe degenerative changes. As such, corticosteroids may lead to progressive degenerative changes, so genicular nerve blocks and subsequently genicular nerve ablations are the only indicated non-surgical intervention left. There is adequate current medical literature showing the effectiveness and safety of genicular nerve ablations.

The requested genicular nerve block is more beneficial than any standard treatment for the insured's condition or disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Right Knee Pain
Treatment: Pain Management (genicular nerve injection)
The insurer denied the Pain Management (genicular nerve injection).
The denial is overturned.

The patient is a female with history of chronic right knee pain due to severe right knee osteoarthritis that has been ongoing for approximately more than 12 months, with the pain affecting her functionality, especially ambulation.

The patient has tried and failed physical therapy, home exercise program directed by physician, Tylenol, NSAIDs (non-steroidal anti-inflammatory drugs), injections, etc ("and the rest"), all over approximately 12 months.

The request is for right knee genicular nerve block (GNB).

MRI (magnetic resonance imaging) of the patient's right knee showed severe osteoarthritis with patellar chondromalacia with meniscus degeneration.

The health plan should cover the GNB.

The requested GNB is medically appropriate and should be covered by the health plan, based on the current general standard of care as outlined below.

1) It is required to treat the diagnosis of knee pain; 2) It is provided in accordance with generally accepted standards of medical practice; 3) It is the most clinically appropriate level of service that can be provided in this instance in terms of type, frequency, extent, site and duration; 4) It is not primarily for the convenience of the patient, Physician or other healthcare Provider; 5) It is rendered in the least intensive setting that is appropriate for the delivery of the procedure.

In this instance, the requested GNB is therefore medically appropriate, as the patient has severe knee osteoarthritis. She has failed conservative measures and she is not a candidate for knee surgery.

In a prospective randomized study, Guler, et al stated, "GNB [genicular nerve block] is beneficial in reducing pain and increasing functional and physical capacity, with greater retention of effects on the physical capacity seen at 12 weeks."

In a randomized clinical trial, Elsaman, et al concluded, "GNB [genicular nerve block] has been approved for the treatment of pain in knee osteoarthritis. GNB [genicular nerve block] in this study was able to control active knee arthritis and this effect persisted longer thane intra-articular steroid injection."

The requested GNB is not experimental/investigational, as this is a national standard practice for the treatment of severe chronic knee pain in a patient who has failed extensive conservative measures and who is not a surgical candidate. It has been demonstrated, through existing peer-reviewed, evidence-based, scientific literature to be safe and effective for treating knee pain. It is therefore medically appropriate and should be covered.

The GNB will be more beneficial than any standard treatment for the insured's condition or disease.

The patient has severe knee osteoarthritis, and she has failed all conservative measures, as stated above, and she is not a candidate for total knee arthroplasty for her young age.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Right Knee Pain
Treatment: Pain Management (genicular nerve injection)
The insurer denied the Pain Management (genicular nerve injection).
The denial is upheld.

The patient is a female with a painful right knee. The duration was approximately over a year and worsened with activity. She had tried PT (physical therapy), trigger point injections, and medications.

The patient's physical examination was significant for swelling, active range of motion: 5-120, crepitus, and tenderness.

The patient's MRI (magnetic resonance imaging) report was significant for chondromalacia, small effusion, and degenerative changes to meniscus.

The patient's physician has recommended a genicular nerve block.

The health plan should not cover the genicular nerve injection.

Recent literature, including ODG (Official Disability Guidelines), do not support this treatment in the management of osteoarthritis.

See below:
ODG (Official Disability Guidelines)
Genicular Nerve Block for Knee and Leg Conditions
Body system: Knee and Leg Treatment type: Diagnostic Testing, Injections Related Topics:
See Nerve Block for Knee and Leg Conditions and Neurotomy for Knee and Leg Conditions.
Not Recommended (generally)
Not recommended for diagnostic evaluation or treatment of osteoarthritis of the knee.

Evidence Summary
Genicular nerve block and radiofrequency neurolysis have been studied as alternative treatments for patients with osteoarthritis who fail conservative therapy and are not candidates for, or are not interested in, total knee arthroplasty. (1) A retrospective study of 176 patients with chronic knee pain secondary to osteoarthritis who underwent genicular nerve block found that 31.8% (percent) of patients failed to achieve greater than or equal to 50% pain relief from the procedure; those who failed the nerve block were significantly more likely to have psychological comorbidities, smoking history, and diabetes. The authors stated that the utility of genicular nerve block is still under investigation, and additional research is needed to identify patients who may be more likely to respond to this procedure. (2) A review article identified several small uncontrolled trials of radiofrequency ablation of the genicular nerve (often preceded by genicular nerve block to identify candidates for the procedure) that demonstrated significant pain relief; however, the small sample sizes limited the ability to generalize results to larger populations, and there was a lack of evidence to support superiority over other therapies. (3) A literature review concluded that the utility of prognostic blocks prior to radiofrequency ablation is unclear. (4)

The genicular nerve injection is not more beneficial than any standard treatment for the insured's condition or disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Motorcycle accident with multi-trauma
Treatment: Skilled Nursing Facility
The insurer denied the Skilled Nursing Facility.
The determination is overturned.

This is a patient with a history of rheumatic heart disease (RHD), hypertension (HTN) and hyperlipidemia who is status/post (s/p) motorcycle accident with multi-trauma. He fractured the left tibial shaft and pylon, left clavicle, and left scapula and ribs. He underwent external fixation of his tibia, incision and drainage (I&D) with partial fixation of the tibia, and definitive tibia fixation. The clavicle was repaired. He has applied for Skilled Nursing Facility (SNF) rehabilitation which was denied by the health plan. At issue is the medical necessity of the SNF.

The requested service is medically necessary/appropriate for this patient. The patient remains non-weight bearing, left upper and lower limb. He is tolerating physical therapy to work on sit to stand transfers on the right lower extremity (RLE) with a hemiwalker, chair transfers, car transfers, wheelchair (WC) mobility, strength and endurance exercises. The goals for SNF rehab are to increase function, independence and safety. This otherwise healthy patient sustained traumatic fractures and has been participating in therapy daily after surgical fixation. His progress is limited only by the non-weightbearing status of his left arm and leg. He is to work on strength and endurance exercises as well as functional mobility to include all transfers via a hemiwalker. He will have goals for, and will tolerate, 1-2 hours of therapy daily. Therefore, the requested service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Stelara dosed 90mg (milligrams) every 4 weeks. 

The insurer denied the Stelara dosed 90mg every 4 weeks. 
The denial is overturned. 

The patient is a male who has severe Crohn's colitis. He has previously tried and failed steroids, an immunomodulator (6-Mercaptopurine) and an anti-tumor necrosis factor (TNF) agent (infliximab). He was started on Stelara and did well initially on Stelara at standard dosing every 8 weeks but recently lost response. He had evidence of active inflammation on colonoscopy and had elevated inflammatory markers. Hence the attending gastroenterologist is requesting the use of Stelara at the escalated dose of 90 milligrams (mg) subcutaneously (SC) every 4 weeks to treat this patient's severe Crohn's disease. The medical necessity of this is the subject under review. 

The health plan's determination is overturned. 

The treatment of Stelara 90mg every 4 weeks is medically necessary for this patient. Dose escalation in patients with inflammatory bowel disease (IBD) who are on a biological agent and not responding to standard dose of the medication, is considered the standard of care. 

Since this patient was not responding to standard dosing of Stelara, it is reasonable to increase the dose of Stelara to 90mg every 4 weeks. Dose escalation in biologic therapy used in inflammatory bowel disease can be done either based on clinical symptoms or laboratory markers or endoscopic or radiological features with or without therapeutic drug monitoring. 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. Therefore, it is medically necessary to use Stelara 90mg SC every 4 weeks to treat this patient's severe Crohn's disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Stelara
The insurer denied the Stelara.
The determination is upheld.

The patient has psoriasis. The body surface area affected is 10%. She has failed mometasone, and triamcinolone. The medication under review is Stelara.

The requested health treatment of Stelara is not medically necessary for this patient. According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines such as Cosentyx and Enbrel are effective treatments for the management of psoriasis (1, 2).
Within the peer-reviewed literature, Garnock-Jones writes, "Subcutaneous secukinumab is an effective and generally well tolerated first-line treatment for moderate to severe plaque psoriasis" (3). Moreover, Kivelevitch writes, "Anti-tumor necrosis factor (TNF) agents are currently considered as first line biological therapies for the treatment of moderate to severe psoriasis and psoriatic arthritis" (4). The preferred agents are appropriate agents for the treatment of the patient's psoriasis. The formulary medications should be tried and failed prior to initiating Stelara.
It is noted that the patient has tried and failed topical steroids However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Stelara prior to the formulary alternatives such as Cosentyx and Enbrel. There is no proof or documentation provided that the patient has tried two preferred drugs and had an adverse effect or proof that two formulary tried drugs did not work for the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Acne
Treatment: 0.3% Adapalene-2.5% Benzoyl Peroxide Gel (Epiduo Forte Gel)
The health plan denied the prescription as not meeting its formulary criteria. 
The health plan's determination is upheld in whole. 

The patient is an adolescent male with facial acne. As of a clinic visit submitted for review, the patient was only using over the counter (OTC) facial washes and without improvement. At that visit, Epiduo Forte Gel and oral Doxycycline were prescribed. The correspondence reports that the patient has tried and failed topical adapalene, tretinoin, sulfa/sulfur wash, and clindamycin, but no further elaboration of the patient's treatment history has been documented.

The non-formulary drug of 0.3% (percent) Adapalene-2.5% Benzoyl Peroxide Gel (Epiduo Forte Gel) is under review.

The patient has insufficient to no documented treatment failure with, or true medical contraindication to, either formulary-preferred topical antibiotics (benzoyl peroxide, clindamycin, clindamycin-benzoyl peroxide, erythromycin, erythromycin-benzoyl peroxide, and sulfacetamide lotion), or topical retinoids (adapalene, tazarotene, tretinoin, or tretinoin microsphere) used as standard first- and second-line treatments for acne vulgaris. The requested 0.3% Adapalene-2.5% Benzoyl Peroxide Gel (Epiduo Forte Gel) is not proven to be superior to all other formulary alternatives as per comparative, controlled studies.

Current medical literature supports the preferred topical acne medications as much as the requested 0.3% Adapalene-2.5% Benzoyl Peroxide Gel (Epiduo Forte Gel) for this patient's clinical scenario. 0.3% Adapalene-2.5% Benzoyl Peroxide Gel (Epiduo Forte Gel) is being requested out of convenience and/or preference, and not true medical necessity. 0.3% Adapalene-2.5% Benzoyl Peroxide Gel (Epiduo Forte Gel) is not any more effective and is not associated with any significantly different incidence of adverse effects, compared to the aforementioned formulary alternatives.

Therefore, the preferred topical acne medications are consistent with current standards of good medical practice based on modern dermatology literature, and the requested non-formulary 0.3% Adapalene-2.5% Benzoyl Peroxide Gel (Epiduo Forte Gel) is not considered more effective than the formulary drugs.