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

Diagnosis: Incontinence
Treatment: Increase of CDPAP (consumer directed personal assistance program) services to 5 hours/day - 5 days/week, for a total of 25 hours per week
The insurer denied coverage for an increase of CDPAP services to 5 hours/day - 5 days/week, total of 25 hours per week.

The denial is overturned.

This is a patient who lives with her spouse and daughter.  She currently is approved for 3.5 hours/day, 5 days/week for consumer directed personal assistance program (CDPAP) services. She is requesting an increase of CDPAP services to 5 hours/day - 5 days/week, for a total of 25 hours per week, which is currently under review. 

The Uniform Assessment System (UAS) report was reviewed and compared to the previous report. The patient's cognition is described as "modified independence." She requires extensive assistance for bathing and lower body dressing. Upper body dressing, toilet transfers and walking requires limited assistance. The patient is at the independent to supervision level for eating, personal hygiene and toilet use. She is occasionally incontinent of bladder and continent of bowel. Her functional status has declined; particularly with bathing, dressing and toilet transfer/use. The patient's significant impairments with documented functional decline support the medical necessity of increasing CDPAP services from 3.5 hours/day, 5 days/week to 5 hours/day - 5 days/week, for a total of 25 hours per week.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  

From a physical medicine and rehabilitation perspective, the requested consumer directed personal assistance program (CDPAP) services, 5 hours per day - 5 days a week, total of 25 hours per week is medically necessary.  

The insurer's denial of coverage for consumer directed personal assistance program (CDPAP) services, 5 hours per day - 5 days a week, for a total of 25 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Immunologic Disorders/Alopecia
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested medication as experimental/investigational. 
The health plan's determination is upheld.

The patient is a female with alopecia universalis (AU). Her scalp is affected. She has tried and failed Minoxidil tablets, Triamcinolone cream, and Fluocinonide gel. She has also failed intralesional Kenalog.
The medication under review is Xeljanz.

The health plan's determination regarding the proposed health service or treatment is upheld, in whole.

The proposed health treatment Xeljanz is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Xeljanz is not appropriate for this patient's alopecia. There are no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Xeljanz for this patient's condition as an accepted standard of practice in the U.S. prior to the conventional alternatives. There is no documentation the patient has exhausted all topical options, and that it would therefore be appropriate to start systemic treatment with Xeljanz, which would carry a higher side effect profile.

Moreover, according to the dermatology literature, the standard of care medicines, Methotrexate (MTX) and oral corticosteroids (OC) covered by the patient's insurance plan are effective treatments for the management of alopecia areata (AA) [3-5].
Within the peer-reviewed literature, Anuset et al 2016 writes "MTX combined with low- to moderate-dose OC may be an efficient and well-tolerated treatment for severe AA." Thus, Methotrexate and corticosteroids are an effective first-line treatment for the management of severe alopecia [4].
Additionally, according to Phan et al "Methotrexate for alopecia areata: A systematic review and meta-analysis," published in the Journal of the American Academy of Dermatology early 2019, "Methotrexate has reasonable effectiveness in patients with severe AA...Combination treatment results in a higher complete response rate than methotrexate stand-alone treatment...Methotrexate is an effective monotherapy or adjunct therapy in combination with corticosteroids in the treatment of severe AA" [5].
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Immunologic Disorders/Alopecia
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested medication as experimental/investigational. 
The health plan's determination is upheld.

The patient is a female with alopecia areata universalis, and who has tried and failed topical, intralesional, and oral steroids. The patient has had full regrowth of her while on Xeljanz.
The requested medication, Xeljanz is under review to determine if it is likely to be more beneficial for this patient than standard treatment.

The health plan denial of Xeljanz coverage is recommended to be upheld.

Xeljanz is being used for alopecia areata universalis, which is neither physically life-threatening, or physically/functionally-impairing, despite the profound and prominent social/psychological impacts of this disease on patients who have severe cases.
While understandable to consider Xeljanz for this patient's condition, the requested medication is investigational at this time, and merits further study before being presumed acceptable for widespread clinical use. At this time, the long-term safety of this medication is not as confirmed as short-term efficacy in the use of Xeljanz for this condition.
Alopecia areata is notoriously difficult and unpredictable to treat, as well as unpredictable in its response to treatment. Oral immunosuppressants, light therapy, contact allergen treatment and related therapies have all resulted in variable and unsatisfactory outcomes, and self-resolution is often the only choice a patient has (along with hairpieces) for severe cases.

At this time, Xeljanz is only (Food and Drug Administration) FDA-approved for rheumatoid arthritis patients who have failed Methotrexate, for juvenile idiopathic arthritis, for psoriatic arthritis, for ankylosing spondylitis, and for ulcerative colitis--all five conditions have indications whereby the safety risks of not using treatment are significantly greater than treatment itself. On a related note, Xeljanz has been recommended to be used with lower dosing in rheumatoid arthritis patients because of concerns about excessive blood clotting.
The same cannot be said for Xeljanz in the treatment of alopecia areata, where physical/functional impairment and overall health impacts are minimal to nonexistent--despite the social/psychological impacts that can occur in some patients. The proper dosing, anticipated side effects and long-term outcomes are not known at this time for Xeljanz in the treatment of alopecia areata, as well as short-term and long-term safety risks of relevance to this patient's overall health. There are no large, randomized, controlled, prospective trials demonstrating and proving the safe and effective treatment of alopecia areata with a specific dosing of Xeljanz.
Therefore, as per the evidence-based literature, Xeljanz is acceptable only within the investigational setting and not appropriate for less-monitored outpatient clinical use.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Immunologic Disorders/Alopecia
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested medication as experimental/investigational. 
The health plan's determination is overturn.

The patient is a female with alopecia universalis, treated with oral and topical Minoxidil, intralesional Kenalog, and Xeljanz with regrowth. The provider is requesting the continuation of Xeljanz.
At issue is whether the requested medication, Xeljanz is likely to be more beneficial for this patient.

The health plan's determination is overturned, in whole.

Yes. A wide range of treatments have been used for the management of alopecia areata (AA), most of which are not highly effective. Treatments include topical or intralesional corticosteroids, topical Minoxidil (2% or 5%), topical Anthralin, systemic corticosteroids, Cyclosporine, and other immunosuppressants. A dependable and safe treatment for extensive disease (totalis or universalis) has yet to be found. Given the rarity of the disease, large randomized controlled trials are extremely difficult.

Tofacitinib first demonstrated efficacy in alopecia areata in the article published in 2014. A patient with concomitant psoriasis and alopecia areata was treated with the medication and serendipitously his alopecia areata reversed. Since then, further case reports have emerged documenting its efficacy, which has led to the very recently published retrospective studies involving adults and adolescents, as well as others, summarized below.

Published in January 2017, the adult study involved 65 patients, defined as those with alopecia totalis or alopecia universalis. 77% achieved a clinical response, with 58% of patients achieving greater than 50% change in SALT (severity of alopecia) score over 4 to 18 months of treatment. Patients with AA experienced a higher percent change in SALT score than did patients with alopecia totalis or alopecia universalis (81.9% vs 59.0%). Tofacitinib was well tolerated, and there were no serious adverse events.

Several case reports have also documented substantial hair regrowth leading to reestablishment of eyelashes and other functional hair reducing incidence of corneal abrasions, etc.

Alopecia areata and its variants is an extremely distressing disease. With further case reports of "off-label" uses of medications such as Xeljanz, more treatment options can become available. Xeljanz is currently Food and Drug Administration (FDA) -approved for Rheumatoid arthritis and undergoing approval trials for psoriasis and psoriatic arthritis. It is known to be safe and effective in the conditions for which it is FDA approved. Biologic medications as a whole have many off label uses, leading to better outcomes in rare diseases for which large, randomized trials are not readily available.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer.
Treatment: Proton Beam Radiation Therapy (77387, 77525, g6002).
The insurer denied the Proton Beam Radiation Therapy (77387, 77525, g6002).
The denial is upheld.

The patient is a man with a rise in PSA (prostate-specific antigen) to 8. He had prostate biopsies that revealed a Gleason 7 adenocarcinoma.  He was staged T1cN0M0 (stage 1, not spread to lymph nodes or elsewhere). Radiation therapy is recommended as definitive treatment, and proton beam approach was requested.

No, the requested Proton Beam Radiation Therapy is not medically necessary.
There are a lack of significant clinical trials completed and published to support this type of treatment for this patient's diagnosis.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The requested proton beam radiation therapy for this patient with localize prostate carcinoma is not considered a standard of care treatment option. It is considered unproven, as there are lack of significant clinical trials completed and published supporting the benefits and safety of proton beam radiation therapy for this clinical scenario. There are ongoing clinical trials that need to mature and be evaluated and published in peer-reviewed journals to determine the efficacy and safety of proton beam radiation for this clinical scenario. Given this, the requested proton beam radiation therapy for this patient is not medically necessary.

Conventional photon IMRT (intensity-modulated radiation therapy) can safely deliver the needed radiation and is able to spare the surrounding critical structures such as the rectum, bladder and hips. Proton beam radiation is stated as a reasonable treatment option by ASTRO (American Society for Radiation Oncology) guidelines where sparing the surrounding normal tissues cannot be adequately achieved with photon based radiotherapy and is of added clinical benefit to the patient. This is not the case for this patient and his prostate disease.

There is also statement of need for proton beam radiation due significant family history of cancers and the need for this patient to have regular colonoscopies. The use of proton beam radiation for this patient will not decrease the amount of radiation to his colon to alter his risk of cancers as compared to photon beam IMRT (intensity-modulated radiation therapy) to that specific area. There are no studies published in peer reviewed journals supporting differences in specific areas of risk of malignancies with the use of either protons or photons. There are only the studies published in peer-reviewed journals that shows a decreased risk of secondary radiation induced malignancies many years down the road when comparing protons and photons mainly in children.

Therefore, given the above the requested proton beam radiation therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVD-19 (coronavirus disease 2019) pneumonitis
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission.
The denial is overturned.

The patient has a past medical history of arthritis, multiple sclerosis, osteoporosis, and rheumatoid arthritis who presented to the emergency department with complaints of body aches, fever, chills, and nausea for 2 days. 

Vitals on presentation included: Temperature-98.6 degrees F (Fahrenheit) , BP (blood pressure) -143/65, Pulse-109, Respiratory Rate-20, oxygen saturation was 99% on room air. Laboratory values were notable for the following: WBC (white blood cell count) -5.0, Hgb (hemoglobin)-14.0, Hct (hematocrit) -41.6, creatinine-0.8, glucose-289, AST (aspartate aminotransferase)-1043, ALT (alanine transaminase) -963, and COVID-19 positive.

The patient was admitted to the hospital for possible COVD-19 pneumonitis. A Chest X-ray (CXR) showed minimal left base atelectasis versus infiltrate. She was treated with a monoclonal infusion, intravenous methylprednisolone, and bamlanivimab/etesevimab. She developed a fever to 102.4 degrees F. Procalcitonin was elevated to 23.92. Ferritin 2610, CRP (c-reactive protein) 106.92, LDH (lactate dehydrogenase)-594. The urine culture grew Escherichia coli. She was discharged to continue outpatient management. 

Although COVID treatment and management guidelines continue to evolve, the decision to hospitalize patients with COVID infection is typically based on presence of severe dyspnea (dyspnea at rest, interfering with the ability to speak in complete sentences), oxygen saturation on room air <= 90% (regardless of severity of dyspnea), alternations in mentation (i.e., confusion, change in behavior), and other signs of hypoperfusion or hypoxia. Although the patient had stable O2 (oxygen) saturation, she had other signs and symptoms of COVID-related complications. She was described as "ill-appearing," developed fever to 102.4 F, laboratory results had numerous abnormalities including elevated liver transaminases, glucose, procalcitonin, CRP, ferritin, and LDH. Moreover, urine cultures suggested a urinary tract infection. 

Based on above findings in a high-risk, immunocompromised patient, hospital admission was medically necessary. 

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 the full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse, atrial fibrillation
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of hypertension (HTN), congestive heart failure (CHF), atrial fibrillation, and alcohol abuse who was admitted with a desire to detox from alcohol and heroin. In the emergency department (ED), the Clinical Institute Withdrawal Assessment (CIWA) was 2 and the patient denied any medical symptoms on admission documentation. The vital signs were notable for hypertension (HTN). The physical exam was notable for tremors. Lab work was notable for an elevated creatinine. A chest x-ray (CXR) showed no acute pathology. An electrocardiogram (EKG) showed prolonged QTc (measurement interval on EKG) and atrial fibrillation. The patient was diagnosed with alcohol withdrawal and treated with benzodiazepines (BZDs) as needed (PRN). The patient was discharged against medical advice (AMA). At issue is the 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 a desire to detox from heroin and alcohol. The patient did not have an acute co-morbid illness requiring inpatient treatment, high risk for delirium tremens, long-term intake of large amounts of alcohol, serious psychiatric condition (e.g., suicidal ideation, psychosis), or severe alcohol withdrawal symptoms. This patient was found to have mild alcohol withdrawal with documented CIWAs of 2-3, treated with CIWA protocol, BZDs, intravenous fluids (IVF), and telemetry. These interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: bowel obstruction.

Treatment is an inpatient admission. 

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

The patient has Crohn's disease and a history of ileal surgery and a perirectal abscess. He presented with abdominal pain, nausea, and vomiting. There was decreased output in his ileostomy bag. He was afebrile and the vital signs were stable. A computed axial tomography (CAT) scan showed a small bowel obstruction extending into a parastomal hernia. There was no abdominal rebound or guarding. The hernia was not reducible at bedside. He refused placement of a nasogastric tube. The lactic acid was initially elevated but returned to normal. A repeat CAT scan was done the following day and there was improvement in the air-filled bowel loops. The abdominal x-ray was negative for intestinal obstruction. He was able to tolerate a diet. He left the hospital against medical advice. 

Milliman Care Guideline (MCG) indications for admission for Intestinal Obstruction (MCG M-210) include having signs and symptoms of bowel obstruction that are severe. These include feculent vomiting, hypotension, electrolyte abnormalities, bowel ischemia, or bowel perforation. In addition, persistent symptoms that require prolonged use of a nasogastric tube is also an indication for admission. This patient did not have severe symptoms or require long term use of a nasogastric tube. He did not meet MCG criteria for admission for intestinal obstruction. He could have been monitored with observation status. 

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

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

Diagnosis:  Status Asthmaticus.
Treatment:  Inpatient Admission.

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

This is a male child who had a previous hospitalization with bronchiolitis. He had a cough for one day and then developed increased work of breathing. His mother administered two doses of albuterol in the home, and when there was no improvement in the breathing, she brought him to the emergency room (ER) for an evaluation.

In the ER, he was pale, grunting and lethargic. On physical examination he was noted to have a pulse oximeter reading of 92% (percent) on room air and increased work of breathing. There was wheezing audible bilaterally. He was treated with albuterol and atrovent inhalation treatments, steroids, racemic, epinephrine and magnesium sulfate. He also received 2 intravenous (IV) boluses of normal saline. He was started on oxygen supplementation via high flow nasal canula at 5 liters. A chest x-ray was normal. Respiratory Syncytial Virus (RSV) was detected on a respiratory viral panel. A white blood count was elevated at 22,000. When the increased work of breathing did not improve, he was started on bilevel positive airway pressure (BiPAP), and the decision was made to admit the child to the hospital with a diagnosis of status asthmaticus with a plan to continue BiPAP, oxygen supplementation, albuterol every 2 hours and atrovent every 6 hours.

The patient was treated appropriately in the ER for a respiratory illness with increased work of breathing and wheezing. He had a previous admission with bronchiolitis one month prior to this illness. He required oxygen supplementation for hypoxemia. When his wheezing did not improve, he was started on BiPAP therapy, and the decision was made to admit him to the hospital for ongoing respiratory support. The child was not stable enough to be discharged and required ongoing treatment for status asthmaticus He was not stable enough to be discharged home safely.

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 the inpatient admission is overturned. Medical Necessity is substantiated.