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

Diagnosis: Low Back Pain

Treatment: Epidural steroid injections (64483, 64484) for low back pain

The insurer denied coverage for epidural steroid injections (64483, 64484) for low back pain.

The denial is upheld.

This case involves a male who was seen complaining of low back pain. The documentation indicated he complained of worsening pain over the last few months with radiation into the bilateral lower extremities. He had participated in months of physical therapy and utilized over-the-counter medications without relief. The physician referenced prior imaging indicated given he has not responded to conservative treatment including therapy medications. It was recommended he undergo epidural steroid injection. The documentation indicated he underwent a bilateral L (Lumbar) 4-L5 and a 5-S (sacral)1 TFESI (transforaminal lumbar epidural steroid injection). An MRI (magnetic resonance imaging) reveals a small left paracentral disc herniation with annular fissure at the L5-S1 level with no neural compression or stenosis. At L4-5 level there was right-sided disc space narrowing with disc desiccation and degenerative bone marrow. There was a right paracentral and right intraforaminal disc desiccation causing right neural foraminal and right lateral recess stenosis. The physician detailed in the letter of medical necessity the patient is appropriate to receive the requested injections given the failure of conservative care with imaging findings. Additionally, the physician detailed on physical exam he had decreased lumbar flexion and extension tenderness. There was positive straight leg raise on the right.

The request for epidural steroid injection (ESI) does not meet medical necessity because the pain pattern does not correspond to the findings on the imaging report. While the patient reports low back pain with radiation in both lower extremities, the MRI does note nerve compression on the left. ESI is indicated for the relief of radicular pain when advanced imaging shows radicular compression corresponding to the clinical pattern. ESI is not indicated for back pain alone. 

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

The insurer's denial of coverage for epidural steroid injections (64483, 64484) for low back pain is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Atopic dermatitis

Treatment: Dupixent 300 milligram (mg)/2 milliliter (ml) subcutaneous (SC) soluble syringe (SOSY)

The insurer denied coverage for Dupixent 300 milligram (mg)/2 milliliter (ml) subcutaneous (SC) soluble syringe (SOSY)

The denial is overturned

The patient has a history of severe atopic dermatitis with numerous superinfections necessitating emergency department (ED) visits.  The patient has failed therapy with topical steroids and tacrolimus.  The requested medication is Dupixent.  

Dupixent is medically necessary for the treatment of the patient's diagnosis, atopic dermatitis.  The patient has decreased systemic treatment options available which could safely be administered given her age and severity of atopic dermatitis which has resulted in multiple superinfections.  The patient has failed topical therapy with steroids as well as non-steroidal anti-inflammatories tacrolimus.  The severity of her disease requires systemic therapy.  Dupixent is approved for use in the treatment of the patient's atopic dermatitis under close medical supervision and at an appropriate dosing schedule at the discretion of the treating physician.  The decision is overturned in whole.    

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 Dupixent 300 milligram (mg)/2 milliliter (ml) SC SOSY
 is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Home health care
The insurer denied Home Care / Personal Care: HHC Level 2 Personal Care Services (PCS) 24 Hours per Day (Live In). The health plan's determination is overturned. 

The patient is a female with past medical history of osteoarthritis, wheelchair dependence, dementia, urinary incontinence, hyperlipidemia, hypertension, coronary artery disease and gastroesophageal reflux disease (GERD) who had been assigned PCS (personal care services) based on telephonic assessment tool performed assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing medication, stairs, and transportation. With tasks of bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at limited assistance while supervision with tasks of managing finances. The patient was assessed at set up help only with task of phone use while independent with tasks of bed mobility and eating. recently, the patient's husband died of COVID-19 and there was a request to increase PCS services for the patient.

Home Care / Personal Care: HHC Level 2 Personal Care Services 24 Hours per Day (Live In) are medically necessary for this patient.
There is documentation from the patient's PCP (primary care physician) and psychologist of a functional and psychological decline. The patient previously had informal help from her husband who passed away. The patient requires assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL) except personal hygiene, bed mobility, and eating according to the recent assessment although the patient's PCP and daughter-in-law indicate that she needs assistance with all ADLs and IADLs. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCS services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care / Personal Care: HHC Level 2 Personal Care Services 24 Hours per Day (Live In)are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Frontotemporal Dementia
Treatment: Personal care aide (PCA), 8 hours per day, 7 days per week (56 hours per week)

The insurer denied coverage for personal care aide (PCA), 8 hours per day, 7 days per week (56 hours per week).
The denial is overturned.

According to the medical records, the patient is an elderly male with a history of Alzheimer's disease, frontotemporal dementia, coronary artery disease, diabetes mellitus, hypertension, biventricular implantable cardioverter-defibrillator, severe hearing loss, hallucinations, gait abnormalities and suprapubic catheter. He is totally dependent and needs 24-hour, 7 day per week care. The patient is currently approved for consumer directed personal assistance services (CDPAS) at 35 hours per week. Personal care aide (PCA), 8 hours per day, 7 days per week at 56 hours per week are requested.

"Frontotemporal Dementia (FTD) is a heterogeneous disorder with distinct clinical phenotypes associated with multiple neuropathologic entities. Presently, the term FTD encompasses clinical disorders that include changes in behavior, language, executive control, and often motor symptoms. The core FTD spectrum disorders include: behavioral variant FTD (bvFTD), nonfluent/agrammatic variant primary progressive aphasia (nfvPPA), and semantic variant primary progressive aphasia (svPPA). Related FTD disorders include frontotemporal dementia with motor neuron disease (FTD-MND), progressive supranuclear palsy syndrome (PSP-S) and corticobasal syndrome (CBS). In this chapter we will discuss the clinic presentation, diagnostic criteria, neuropathology, genetics, and treatments of these disorders" (Olney, N. T. et al.).

"Conclusion: FTD is an underdiagnosed group of neurological syndromes comprising multiple variants with distinct neurobiological profiles and presentations. Recent advances suggest there is an array of potential novel therapeutic targets, although data concerning their effectiveness are still preliminary or preclinical. Further studies are required to develop pharmacological interventions, as there are currently no US (United States) Food and Drug administration approved treatments to manage FTD syndromes." (Young, J. J. et al.).

This patient is totally dependent, and he has among other issues, Alzheimer's disease, frontotemporal dementia, coronary artery disease, hallucinations, and gait abnormalities.      

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 personal care aide (PCA), 8 hours per day, 7 days per week (56 hours per week) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Pharmacy/prescription Drugs. 

The insurer denied Xtampza. 
The denial is upheld in whole. 

This patient is a male with a diagnosis of epithelioid sarcoma of the left ankle. The patient had undergone a resection with latissimus dorsi free flap procedure. His postoperative course was complicated by necrosis of the flap. He started radiation therapy. The patient is experiencing significant pain and has been evaluated by palliative medicine for management of pain control. The patient appears to have significant anxiety and insomnia due to pain. Also, there is a history of opioid abuse in the family; the fear of opioid abuse due to that history has made the management of this patient complicated.
To manage his pain more efficiently, the treating physician has recommended long-acting pain medication Xtampza. Based on the documentation provided, the health plan has suggested to use formulary alternatives of long-acting opioids such as Morphine extended release, Fentanyl patch, or Opana.
At issue is the medical necessity of Xtampza extended release (ER) 9 milligrams (MG) oral (OR) C12A.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Xtampza ER 9 MG OR C12A is not medically necessary for this patient.
Any long-acting preparation of opioid (formulary alternatives of long-acting opioids such as Morphine extended release, Fentanyl patch, or Opana) can be used in this particular scenario based on the provided documentation and medical history. Xtampza is not the only treatment option for this patient's pain management and therefore not medically necessary. There is no clinical indication to suggest that Xtampza would be superior to other long-acting formulations in this case. The plan has offered other options of the same class of drug (Morphine ER, Fentanyl patch and Opana ER) for management of this patient's pain.
Therefore, the requested health service/treatment of Xtampza ER 9 MG OR C12A is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent 300MG/2mL SC SOPN, Pre-service
The insurer denied the Dupixent 300MG/2mL SC SOPN, Pre-service.
The denial is overturned.

This patient is a male with atopic dermatitis, treated with topical steroids, Eucrisa, and anti-histamines.  He has cleared on Dupixent (obtaining from samples).  The provider is requesting continuation of Dupixent. The health plan denied the request due to lack of trial and failure to oral immunosuppressant therapy such as cyclosporine.  The patient has no other past medical history.

Yes, the proposed Dupixent is medically necessary.
Dupixent would be an appropriate medication in this case and within standard of care.  Dupixent is Food and Drug Administration (FDA) approved for atopic dermatitis, whereas the formulary agents are not.  While these are still used widely, they are not the most appropriate therapies in the current COVID pandemic.  

According to the multidisciplinary review (Gresham et al), vaccine efficacy may be reduced in patients receiving systemic immune-targeting therapies because of the impaired immune response in these patients.  There is a trend toward a decreased immune response and vaccine immunogenicity in patients on systemic immunotherapies, particularly patients receiving azathioprine, cyclosporine, methotrexate, mycophenolate mofetil, or Janus kinase (JAK) inhibitors.  Therefore it would not be advisable to use a systemic therapy in this patient that can decrease vaccine efficacy and place this patient at higher risk of COVID-19 complications when a safer alternative is available.  

Dupixent is not immunosuppressive and is therefore a better choice.  The patient has already cleared on Dupixent. It is generally considered medically necessary to continue a patient on a therapy to which they have favorably responded.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vitiligo

Treatment: tofacitinib compound

The insurer denied coverage for tofacitinib compound

The denial is overturned.

The patient has a diagnosis of vitiligo.  The patient has failed therapy with elidel, topical steroid, betamethasone, as well excimer light therapy (XTRAC).  The requested medication is topical compounded tofacitinib cream.  

Based on the submitted documentation, topical tofacitinib cream is medically necessary for the treatment of the patient's condition.  The patient has failed standard topical therapies, which would include topical steroids as well as non-steroidal option-elidel cream.  Vitiligo is an autoimmune disease and requires appropriate therapy.  The use of topical anti-inflammatory agents is within the standard of care prior to proceeding to systemic therapies with associated increased risks.  The use of topical tofacitinib under the supervision of the dermatologist is medically necessary and the decision is overturned in whole.  

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 Tofacitinib Compound is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, nausea and emesis.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

The patient is a male. He underwent a full acute hospitalization. The patient presented with the complaints of abdominal pain, nausea and emesis. An endoscopy had been done as an outpatient prior to this admission, which showed a clean based gastric ulcer and gastritis. He developed subsequent emesis of dark blood twice. The patient was admitted, and he received supportive care, IV (intravenous) fluids, and IV (intravenous) antacids. The patient was started on a diet day three.

No, the Inpatient admission was not medically necessary. The treatment was medically appropriate but not medically necessary at the level at which it was provided.

The patient received supportive care that did not require a full acute level of service.  The patient did not undergo a repeat endoscopy to provide risk stratification. The care could have been rendered at a lower level of care in its entirety.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.

The patient received supportive care that did not require a full acute level of service. The patient did not undergo a repeat endoscopy to provide risk stratification. The care as provided could have been rendered in its entirety at a lower level of care. The patient had an upper GI (gastrointestinal) episode of bleeding with a known diagnosis of gastric ulcer; however, the patient did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such the care could have been rendered at a lesser level. The care could have been rendered at a lower level of care in its entirety.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Worsening Shortness of Breath and Intermittent
Left Sided Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a male. He presented with one week of left-sided chest pain and shortness of breath. His co-morbidities include hypertension, hyperlipidemia, smoking and new onset atrial fibrillation.

The patient's BNP (brain natriuretic peptide) was elevated at 1290, and troponin was elevated at 0.11. CXR (chest x-ray) showed pulmonary congestion. Echocardiogram showed EF (ejection fraction) less than 25% and moderate to severe MR (mitral regurgitation).

Catheterization showed triple vessel CAD (coronary artery disease).

A staged PCI (percutaneous coronary intervention) was performed. Medical therapy was adjusted, Lifevest was placed.

Groin pain occurred secondary to hematoma from Catheterization; and patient had SOB (shortness of breath) on exertion. 

Yes, the Inpatient admission was medically necessary.
Milliman criteria for inpatient level of care were met.

The patient did have evidence of a NSTEMI (non-ST-elevation myocardial infarction). Also, the patient had a new diagnosis of systolic CHF (congestive heart failure) with an abnormal echo showing severe LV (left ventricle) dysfunction, moderate to severe MR (mitral regurgitation) (new), AR (aortic regurgitation) moderate, TR (tricuspid regurgitation) moderate; and PAF (paroxysmal atrial fibrillation) (new). He underwent a complex intervention of triple vessel disease CAD (coronary artery disease) in the setting of depressed LV (left ventricle) function. He had a symptomatic complication post catheterization with documented groin hematoma patient on DAPT (dual antiplatelet therapy) that needed to be continued, placement of Lifevest, symptoms of DOE (dyspnea on exertion), CXR (chest x-ray) showing pulmonary congestion, and abnormal EKG (electrocardiogram). He was symptomatic post intervention.

The severity of these findings, and the required intervention, and post procedure care in this case did require inpatient level of care.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
In this case, based on complexities, complications, and treatment requirements, inpatient level of care was required.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: CHF (congestive heart failure) and COPD (chronic obstructive pulmonary disease)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He presented with shortness of breath. This was thought to be related to his previous history of CHF (congestive heart failure) and COPD (chronic obstructive pulmonary disease). The patient was a smoker and had chronic kidney disease. His past medical history was significant for CHF (congestive heart failure), CRF (chronic renal failure) and PAF (paroxysmal atrial fibrillation).

The patient's exam showed mild hypertension, oxygen saturation of 97%- 100% on room air, leg edema, and decreased BS (breath sounds). His lab showed elevated creatinine of 2.2. CXR (chest x-ray) showed pulmonary congestion.

IV (intravenous) Lasix was given, and outpatient medication was resumed. The patient was admitted in no acute distress, and had good response to intervention. He was hemodynamically stable without significant arrhythmias throughout his stay. He was placed back on his PO (oral) meds and discharged.

No, the Inpatient admission was not medically necessary.
Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care.

In this case, the patient's presentation was consistent with known disease. He responded quickly to simple standard intervention. He was hemodynamically stable, and normal treatment was resumed.

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care that was provided was telemetry and IV (intravenous) diuretic, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care.

Milliman criteria requirements were not fulfilled, as criteria for inpatient care were not met.

All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent to be in a lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.

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

Diagnosis: Seizure

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission.

The denial is upheld. 

This male patient has a history of pre-diabetes, mild intermittent asthma, attention deficit hyperactivity disorder (ADHD), hyperlipidemia, and obesity.

The current literature indicates a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe/persistent or there is evidence of hemodynamic instability. Within the documentation, it was noted the patient presented with seizure like activity.

However, the submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. The patient was back at his baseline and elected to self-discharge. The requested inpatient admission would not be the most appropriate level of care and therefore, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for full hospital admission is upheld. The medical necessity is not substantiated.