Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: B-cell acute lymphoblastic leukemia (B-ALL) and isolated extramedullary relapse (IEM)
Treatment: Kymriah (tisagenlecleucel)

The insurer denied coverage for Kymriah (tisagenlecleucel).
The denial is overturned.

The patient has a history of isolated central nervous system relapse of acute lymphoblastic leukemia. The patient does not have bone marrow disease. The provider is recommending treatment with CAR-T cells (chimeric antigen receptor T), Kymriah (tisagenlecleucel). 

The scientific evidence in peer-reviewed literature support a result of improvement in health outcomes.

Per Maude, S. L., et al., (2018), "In this global study of CAR T-cell therapy, a single infusion of tisagenlecleucel provided durable remission with long-term persistence in pediatric and young adult patients with relapsed or refractory B-cell ALL [B-cell acute lymphoblastic leukemia], with transient high-grade toxic effects."

Per Gardner, R. A., et al., (2017), "These data demonstrate that manufacturing a defined-composition CD19 [Cluster of Differentiation 19] CAR T cell identifies an optimal cell dose with highly potent antitumor activity and a tolerable adverse effect profile in a cohort of patients with an otherwise poor prognosis."

Kymriah (tisagenlecleucel) has final approval from the appropriate regulatory bodies for this diagnosis.

The Food and Drug Administration (FDA) approved Kymriah (tisagenlecleucel) for certain pediatric and young adult patients with a form of acute lymphoblastic leukemia (ALL).

The patient appears to be a good candidate for Kymriah. In a recently reported trial, there was no increased toxicity in patients with central nervous system (CNS) leukemia, when compared to those who are CNS negative.

Kymriah (tisagenlecleucel) is the best available treatment for this patient at this time.

The outcome using Kymriah appears to be superior to that reported with chemotherapy and radiation therapy. Therefore, Kymriah (tisagenlecleucel) would be an appropriate next step for this patient. The adverse risks are not increased over standard treatment/services.

The use of Kymriah does not have increased adverse risks. The use of Kymriah is associated with short term toxicity, which is manageable, while regular chemotherapy and radiation therapy are associated with short- and long-term toxicities.     

Based on my review of the literature, the use of Kymriah is more likely to be beneficial in terms of long-term survival, and less long-term neurotoxicity when compare with chemotherapy/radiation. Therefore, the use of Kymriah (tisagenlecleucel) is likely to be more beneficial than any of the standard treatments/procedures for this patient at this time.                                                    

The carrier's denial of Kymriah (tisagenlecleucel) should be overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Rheumatoid Arthritis
Treatment: Rasuvo
The insurer denied coverage for Rasuvo.
The denial is upheld.

The patient is a female with a history of RA (rheumatoid arthritis), bronchitis, and diabetes. She presented to the Rheumatologist's office for an evaluation of rheumatoid arthritis. The patient is doing very well on Xeljanz, Rasuvo, and Hydroxychloroquine. The physician recommended continuing Rasuvo to treat rheumatoid arthritis. 

Rasuvo is injectable methotrexate in pre-filled syringes. The physician statement indicates that SQ (subcutaneous) methotrexate is preferable to oral when using high doses or in dealing with absorption issues is appropriate, and the use of oral methotrexate here is not supported. 

The 2nd issue is the use of SQ generic methotrexate instead of brand-name Rasuvo. Reviewed were UpToDate chapters "Initial Treatment of Rheumatoid Arthritis" and "Use of Methotrexate in treatment of Rheumatoid Arthritis". These plus a PUBMed search failed to reveal any information supporting the use of Rasuvo over generic methotrexate. Drug labelling and usage recommendations are those for methotrexate. Toxicity, benefit, and dosing are the same.  

There is no mention of prior generic methotrexate use. As such, Rasuvo is not likely to produce a more clinically beneficial outcome to the patient.

The insurer's denial of formulary exception for Rasuvo is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-Vertebral Disc Problem
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient underwent a cervical (C)3-C7 anterior cervical discectomy and fusion with a right-sided approach. Estimated blood loss was 100 cubic centimeters (cc). He tolerated the procedure well with no intraoperative complications noted. He was subsequently transferred to the floor for postoperative care. On postoperative day 1, the patient was stable. His vital signs were stable, and he was afebrile. He denied any upper extremity radiating pain, he denied headaches or shortness of breath. He has been ambulating independently without difficulty. There was no difficulty swallowing. He was tolerating oral (p.o.) intake. His pain was controlled on p.o. medication. He was voiding without issue. His Hemovac drain was discontinued. The dressing was clean dry and intact. He was neurovascularly sensory intact. He was hemodynamically stable. His cervical collar was in place. He was subsequently deemed stable for discharge home with outpatient follow-up.

The patient had an uncomplicated surgery and postoperative course. He was stable to be discharged home within 1 day post procedure. Therefore, based on the provided medical records, an acute inpatient stay is not warranted or considered medically necessary in this scenario. 
Additionally, per Milliman Care Guidelines, 25th edition, (Cervical Fusion, Anterior) this claim does not meet criteria for an inpatient admission. Specifically, the floor to discharge and complete discharge planning criteria were met within one day post procedure. The patient was hemodynamically stable, there was no evidence of infection or vascular compromise, vital signs, respirations, voiding, and neurologic status were within normal limits, pain was controlled with P.O. medications and the patient was ambulatory and tolerating p.o. medications and intake. Overall, the severity of disease, intensity of services provided, and documentation did not support and justify the necessity of inpatient admission.

Per review of the medical records, the benchmark criteria for discharge were all met within one day of the procedure. The patient had an optimal recovery course. Hence, an extended stay was not necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoporosis
Treatment: Prolia

The insurer denied the Prolia.
The determination is upheld.

The patient has a past medical history significant for seronegative rheumatoid arthritis, osteoporosis, and Raynaud's phenomena. The patient has been treated for these conditions for many years.

This review is for the medical necessity of Prolia for the treatment of osteoporosis.
The requested treatment with Prolia is not medically necessary.

The progress note states that the patient was on a bisphosphonate, currently Fosamax and previously Reclast with poor results. There is no noted specific intolerance to bisphosphonates in her medical record. Pharmacy claim records show the purchase of alendronate monthly for the last year. Records prior to last year that list pharmacy claim records are not available. There is no record of previous Reclast either from pharmacy purchase or other specific claims history. There is a notation in the medical record that the patient did take Reclast .

A dual-energy x-ray absorptiometry (DEXA) scan showed a T score of -2.1 , no other pretreament or post treatment DEXA scans are available for review. There is a note that the patient was remotely treated by the previous primary care physician (or provider) (PCP) with Fosamax followed by Reclast but due to lack of improvement was advanced to Prolia.

The patient did not try a pharmacy alternative bisphosphonate. There is no evidence of intolerance based upon the medical record of the alternative or failure of alternative. The other issue is that there is limited documentation available for review. The last DEXA scan did show a T score of -2.1, but there was no previous DEXA scan noted in the medical record to compare treatment modalities in response to treatments. Without a definitive scan to compare response to treatment, it is difficult to make a decision in regards to failure of one or more medications. There does not appear to be a specific intolerance, at least from the purchase history. Whether there was a specific failure with alendronate alone is not clear without appropriate documentation/diagnostic testing. Additional information, prior DEXA scan, was requested. The additional information provided was a DEXA scan on the patient which is the same scan that was originally referenced in the provided medical records. This scan does not add any additional documentation. A DEXA scan prior to this would be necessary to make a comparison in regards to failure of treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female with past medical history of Von Willebrand disorder, hypothyroidism, anemia, chronic pain, who was admitted for complaints of headache for 3 weeks. Review of system was positive for headache and syncope. The patient was afebrile, described as alert, and no acute distress. Her blood pressure was 114/75, pulse rate of 79, respiratory rate of 17 and oxygen saturation of 96%. Physical examination on admission was unremarkable for positive findings. The patient was reported to have normal mental status with no focal neurologic deficits.

The inpatient hospital admission was not medically necessary.
The patient presented with persistent headache despite a recent unremarkable workup without any positive clinical pathology. Upon admission, the patient did not have any focal neurologic deficits (based on review of physical examination from admission and neurology consult) or hemodynamic instability. The patient was noted to have hypotension but negative orthostatic vital signs and noted improvement in blood pressure. Although the MRI was not done, the patient had an unremarkable CT scan of the brain and electroencephalogram (EEG). Given that the patient did not have any positive clinical findings or focal deficits, it was reasonable to conduct the MRI as an outpatient. An Inpatient level of care is not justified since patient was hemodynamically stable with no focal neurologic deficits.
Complex headaches or migraines can be safely treated as outpatient or observation levels of care. The typical management for migraine headache includes Non-Steroidal Anti-inflammatory (NSAIDS) agents, Triptans, caffeine, and corticosteroids. Acute admission is usually not necessary for migraine headaches. Standard therapy also includes dopamine receptor antagonists, specifically chlorpromazine and prochlorperazine, are first-line agents, particularly if there is nausea. If further treatment is needed, the evidence base is strongest for dihydroergotamines or subcutaneous sumatriptan, followed by parenteral NSAIDs. There is data to support discharge of the patient to outpatient management. Admitting for acute migraine has many downsides, and even repeated dosing of dihydroergotamines as an inpatient is no guarantee of rapid success in ending the headache. Hospital admission is likely to prove disruptive to the patient's sleep pattern, and in a shared room setting likely to involve significant ambient noise and light that can exacerbate photophobia and phonophobia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation
Treatment: Inpatient stay
The insurer denied the inpatient stay. 

The health plan's determination is upheld. 

This woman with end-stage renal disease developed dyspnea and palpitations while undergoing her scheduled hemodialysis and was noted to be tachycardic. She reported having had worsening exertional dyspnea and orthopnea for a few days. Her medical history was remarkable for hypertension, hyperlipidemia and heart failure with a left ventricular ejection fraction of 40-45% (percent). The patient was taken to the emergency department where her blood pressure was 178/109 mmHg (millimeters of mercury) with a heart rate of 119 beats/minute. Her respiratory rate was 25/minute with a room air oxygen saturation of 100%. Her physical exam was remarkable for bibasilar rales and mild lower extremity edema. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate. Her serum troponin level was normal; her brain (or B-type) natriuretic peptide (BNP) level was markedly elevated. Chest X-ray showed a left retrocardiac density. The patient was treated with intravenous furosemide and oral carvedilol and admitted to the hospital for management of new onset atrial fibrillation and congestive heart failure.

The inpatient hospital admission was not medically necessary.
This patient was admitted to the hospital for management of acute atrial fibrillation (AF) and congestive heart failure.
Regarding the AF: The patient was hemodynamically stable and her heart rate was controlled with oral medication. She did not require continuous intravenous infusion of medication for ventricular rate control. For patients presenting with acute AF, the safety of observation  or discharge to home with close follow-up has been well demonstrated. 

Regarding the patient's congestive heart failure: She did not have high risk features such as systolic blood pressure less than 100 mmHg, elevated serum troponin levels or significant hyponatremia. While her serum creatinine level was elevated, this was a chronic issue and not a result of the patient's heart failure. She responded well to initial treatment in the emergency department and ventricular rate control. She tolerated her previously scheduled hemodialysis and was subsequently discharged. In stable heart failure patients, such as this woman, studies have shown that a lower level of care is safe and effective, with similar outcomes, including readmission, repeat emergency department visits and 30 day mortality, when compared to those treated as inpatients. Thus, in this instance, a lower level of care would have been sufficient for management of this patient's heart failure. An inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall, Shortness Of Breath.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with hypertension, COPD (chronic obstructive pulmonary disease), chronic pain, Arnold-Chiari malformation. She was admitted to the hospital after fall and shortness of breath and was found to have COPD (chronic obstructive pulmonary disease) exacerbation.

The patient was admitted and was started on oral steroids, and duonebs. Due to the fall, patient had musculoskeletal pain and was being treated with pain medications and physical therapy.  The patient was able to tolerate oral diet as well as ambulation.

The patient was ready for discharge, but was awaiting skilled nursing facility opening, which prolonged the hospital admission.

No, the Inpatient admission was not medically necessary.
The patient had COPD (chronic obstructive pulmonary disease) exacerbation and fall. The patient was admitted to acute inpatient level of care for further management. The patient was hemodynamically stable. The patient was tolerating oral diet and was ambulating. The patient was not requiring any supplemental oxygen or any invasive drips. The patient was awaiting discharge to skilled nursing facility. The Inpatient admission was not medically necessary.

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

Diagnosis: Alcohol intoxication.
Treatment: Inpatient stay.
The insurer denied the Inpatient stay.
The determination is upheld.

The patient has a past medical history (PMH) of hypertension (HTN), alcohol abuse, and gastritis and was admitted with complaints of (c/o) tremors, nausea, and a headache. His vital signs were unremarkable. The physical exam was notable for tremors and he was resting comfortably. Lab work was notable for pancytopenia, alcohol 522. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with alcohol withdrawal without delirium and treated with intravenous fluids (IVF), telemetry, benzodiazepines (BZDs), and multivitamin (MVI). The Clinical Institute Withdrawal Assessment (CIWA) was 7. The patient was discharged against medical advice (AMA). At issue is medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the ED with complaints of (c/o) tremors, nausea, and a headache. The patient did not have an acute co-morbid illness requiring inpatient treatment, high risk for delirium tremens, history of withdrawal seizures, long-term intake of large amounts of alcohol, serious active psychiatric condition (e.g., suicidal ideation), or severe alcohol withdrawal symptoms. This patient was found to have mild alcohol withdrawal, treated with CIWA, BZDs, IVF, and telemetry. These interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Cervical Dilation
Treatment: Inpatient emergency admission
The insurer denied coverage for inpatient emergency admission.
The denial is overturned.

The patient is a female G3 (gravida 3) P0020 (para zero full term delivery, zero premature delivery, two abortions, and zero living child) with history of 2 prior spontaneous abortions. She was referred for admission from the prenatal unit because of a short cervix. She was 17.5 weeks gestation. The patient was admitted. Due to concern for amniotic fluid infection, an amniocentesis was performed. A cerclage was placed. The patient was discharged later that day.

This patient presented with severe cervical dilation. There were some concerns about chorioamnionitis necessitating an amniocentesis and awaiting the results. A cerclage could not have been placed earlier because of concern about chorioamnionitis and the need to rule out the presence of an infection prior to proceeding.

Once the results came back with no evidence of amniotic fluid infection, the patient underwent her cerclage and was discharged later that day as per standard of care, as cervical cerclages are ambulatory procedures (see references). The patient could not be managed at the observation level of care, nor could she be followed as an outpatient due to the severity of the cervical dilation.

Based on all of the above, inpatient admission was medically necessary.

The health care 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 emergency admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Post-surgical infection

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

This is the case of a female with a history of morbid obesity, obstructive sleep apnea (OSA), rheumatoid arthritis, diabetes type 2, congestive heart failure (CHF), valvular disease and hypertension. The patient was evaluated following a left total knee replacement three weeks prior. Postoperatively, the patient had developed shortness of breath, bruising, and persistent wound drainage requiring a Praveena vacuum-assisted closure (VAC) dressing. She was felt to be at risk for deep infection and surgery was recommended. The patient presented for admission and surgical management. She was seen by Cardiology, Neurovascular, and Infection Disease and received intravenous (IV) antibiotics and physical therapy. She was discharged home with homecare and infusion services.

The medical record demonstrates the patient has a complex and serious condition. She has associated comorbidities. Her initial surgical procedure was complicated by hemarthrosis (secondary to anticoagulation medication). She had documented drainage and problems with her wound. She required an extensive revision procedure of clot evacuation and liner revision. There was a report of necrosis to wound. A drain was also placed. These factors greatly influence the acuity of care required. There would be concern for continued drainage and progressive necrosis to wound. It would be important to monitor her drainage as bleeding would be likely. She would be at great risk for infection.

Thus, although she was afebrile, hemodynamically stable, the patient was high-risk for prosthetic joint infection due to her recent knee replacement procedure, as well as her co-morbid conditions. Multiple cultures were positive for Enterococcus faecalis bacteria. Based on above findings, hospital admission was medically necessary for surgical intervention and administration of IV antibiotics. Her level of care could not be provided at a lower level.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The inpatient hospital admission is considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missing teeth
Treatment: Implant Placement: Tooth 12, 18,19, 20, 28, 29, 3, 30,31, 8 and 9.

The insurer denied the Implant Placement: Tooth 12, 18,19, 20, 28, 29, 3, 30,31, 8 and 9.
The denial is upheld.

The patient, a female, is requesting multiple implants in both the upper and lower arches. 

The denial was due to no documentation describing why dentures would not be a treatment choice.

No, the proposed treatment is not medically necessary.
There is no documentation describing why dentures could not be a treatment option for this patient. Without a reason describing why dentures cannot/would not work, there is no medical necessity for the implants.  Conventional dentures, either full or partial, are the standard of care for this case. Implants would only be recommended if there was inadequate retention of the denture(s).

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Dentures should be a treatment option for this patient until a medical reason is presented showing why they would not be a good choice.