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


Diagnosis: Hidradenitis suppurativa
Treatment: Humira 80 milligrams (mg) weekly
The insurer denied Humira 80 milligrams (mg) weekly.
The determination is overturned.

The patient has hidradenitis suppurativa (HS). She has been using Humira every two weeks for one year without improvement. She has tried and failed surgery, metformin, intralesional triamcinolone, clindamycin lotion, and benzoyl peroxide 5% cleanser. The medication under review for medical necessity is Humira 80 milligrams (mg) weekly.

The requested health service/treatment of Humira 80 mg weekly is medically necessary for this patient.

Based on the standard of care and evidence-based literature, the Humira 80 mg once weekly is medically necessary. The patient has tried and failed the conventional therapies including but not limited to surgery, metformin, intralesional triamcinolone, clindamycin lotion, and benzoyl peroxide 5% cleanser.

Use of Humira at higher doses is considered standard of practice after treatment failure of oral therapies for this member's diagnosis of hidradenitis suppurativa. She has failed all other conventional topical and systemic therapies (including metformin). Hidradenitis suppurativa is a scarring, debilitating and disfiguring skin disease.

The evidence is strong enough for Humira to be used for treatment for hidradenitis suppurativa in this patient. There are several reports in the dermatology peer-reviewed literature that show that Humira is effective for the management of hidradenitis suppurativa, and it is indicated for this purpose (1-3). Kimball et al writes "Treatment with adalimumab (40 mg weekly), as compared with placebo, resulted in significantly higher clinical response rates in both trials at 12 weeks; rates of serious adverse events were similar in the study groups" (1). Zouboulis et al writes in "Adalimumab (ADA) dose intensification in recalcitrant hidradenitis suppurativa/acne inversa" that "Continuous weekly dosing with ADA, 40 mg, is a reasonable treatment option for long-term control of moderate-to-severe HS" (2).

The patient has not responded to the standard dose of Humira. Therefore, the Humira, at the increased dose, is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Charcot's joint, right ankle and foot
Treatment: Consumer directed personal assistance services (CDPAS), 24 hours/week
The insurer denied CDPAS, 24 hours/week.
The determination is upheld.

The patient has a medical history notable for Charcot's joint of the right foot and ankle. The patient is currently approved for 7 hours/week of personal care services (consumer directed personal assistance services [CDPAS]). The patient and his care team requested an increase to 24 hours/week and this request was denied by the health plan.

The patient was previously receiving 24 hours/week based on the social change caused by the Coronavirus 2019 (COVID-19) state of emergency. When this ended, the health plan reduced the hours to 7 hours/week, which was recommended by the most recent standardized assessment.

There were no letters of medical necessity or information regarding unmet personal care needs provided as part of this appeal.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was cognitively intact. For his instrumental activities of daily living (IADLs), he requires maximal assistance for meal preparation, housework, and shopping. He is independent in other areas. He is independent for all activities of daily living (ADLs). His aide does all of the cooking and housework; he cannot stand for prolonged periods due to pain in his foot and ankle. He is now independent in bathing and dressing (an improvement from prior). He is continent of stool and urine. A task tool associated with the most recent UAS recommended 6.5 hours/week to meet his personal care needs, a decrease from 8.5 on a prior assessment. At issue is the medical necessity of 24 hours/week.

The requested health service/treatment of CDPAS, 24 hours/week has not been demonstrated to be medically necessary for this patient.

The patient is approved for CDPAS in the number of hours recommended by the UAS. He is independent in all ADLs and receives assistance as needed for his IADLs through CDPAS. There is no documented evidence that he has unmet personal care needs. The assessment suggests recent falls as a reason he is requesting further hours. Safety monitoring outside of a personal care function is not an approved use of CDPAS.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient has a history of congestive heart failure (CHF), chronic obstructive pulmonary disease, coronary artery disease, diabetes and hypertension. Two weeks prior the patient was implanted with an automatic internal cardiac defibrillator (AICD). The patient presented to the hospital with complaints of chest pain, shortness of breath and dizziness. The patient was in some distress and his vital signs were Temperature 37.4 degrees Centigrade, Heart Rate 86, Respiratory Rate 20, Blood Pressure 161/96 and oxygen saturation 93 percent (%) on room air. Bilateral pitting edema to the knees was observed. Lungs were clear, heart sounds normal and the patient was awake and alert.

Laboratory values: White Blood Cell count (WBC) 6,100, Hemoglobin 11.5, Blood Urea Nitrogen 24, Creatinine 1.79 (close to baseline), Troponin was negative, B-type natriuretic peptide 645, Arterial Blood Gases 7.33/42/85/22. Chest x-ray was positive for cardiomegaly; there was no pleural effusion. Electrocardiogram showed Atrial fibrillation at 85 beats per minute.

Patient was treated with Lasix intravenously (IV) 80 milligrams (mg) in the emergency department (ED) then placed back on 40 mg IV twice a day (BID). Patient was admitted with decompensated CHF and to rule out acute coronary syndrome (ACS). Patient remained stable after admission and started improving by the next day and was discharged home.

This patient did not need acute inpatient hospitalization. He was afebrile and hemodynamically stable. He could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hrs.

Patient could have been discharged home on oral diuretics and other maintenance cardiac medications with close follow-up in an outpatient setting. This patient did not need acute inpatient hospitalization and could have been placed in Observation status (could be for up to 48 hours) and once stable could have been discharged. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I skeletal occlusion, crowding, deep bite
Treatment: D8080 Braces, D8670 Monthly Visit
The insurer denied: D8080 Braces, D8670 Monthly Visit
The denial is overturned

The patient is an adolescent female. The request is for benefits for orthodontic treatment and monthly follow up visits. The patient has a Class I skeletal occlusion, with Class II canines, severely crowded upper and lower arches, and a deep bite. The patient has anterior crossbites of the lower lateral incisors. The prior denial was due to a handicapping index score of 21.

The proposed braces and monthly visits are medically necessary.

The patient has two lower anterior permanent teeth (numbers 23 and 26) in crossbite (reverse bite). This means they are outside of the upper teeth. There is also gingival (gum) attachment loss. 
These are two "automatic qualifiers" according to the handicapping index scale. The patient also has her upper right permanent canine (tooth number 6), totally blocked out of its proper position. It is not touching any lower teeth. Without this tooth in its proper position, there can be no "canine guidance", which is when the lower teeth glide along the inside of the upper canine during the chewing cycle. Without canine guidance, the teeth will bang into each other causing trauma, fractures, temporomandibular joint (TMJ) issues and/or loosening of teeth. The repositioning of tooth number 6 as well as correction of the lower teeth in crossbite, need to be done with orthodontic treatment. 
This case has medical necessity to correct these problems and it also needs the monthly visits to follow the progress of treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthodontic Needs; Impacted Maxillary Canines, Severe Maxillary Crowding, Severe Mandibular Crowding.
Treatment: Braces and Monthly Visits.
The insurer denied braces and monthly visits.
The health plan's determination is overturned.

The patient is a female with impacted tooth number (#)6 and tooth #11. These teeth are impacted in a mesioangular inclination and are in close proximity to the roots of the lateral incisors. She presents with a skeletal Class I malocclusion and crowding. She has treatment planned for 36 to 42 months of orthodontic treatment to address the malocclusion and impacted teeth.

The health plan in its determination of medical necessity has not acted with sound judgment and in the best interest of the patient. It is in the best interest of patients to be referred to an orthodontist and an oral surgeon when an impacted tooth is discovered.(1)

If left untreated the damage that will likely occur to the patient's teeth will be more time consuming and complicated to correct than the patient's existing orthodontic problem. Studies show that impacted canines with a mesioangular inclination have a less than 15 percent (%) chance of spontaneous eruption.(2) Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisors.(3) Given the position tooth #11 relative to tooth #10 and the position of tooth #6 relative to tooth #7, it is expected that tooth #7 and/or tooth #10 will be damaged if the canines are not addressed soon. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dermatitis. 
Treatment: Dupixent. 

The insurer denied Dupixent. The health plan's determination is upheld. 

The patient is a young male with atopic dermatitis (more than 40% body surface area involvement) of the flexural elbows, knees, lower legs, hands, and scalp (associated with patchy hair loss). 

Dupixent is not medically necessary for this patient. 

The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors or more potent topical steroids, and/or standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil) that would obviate the need for further topical therapies. 

The patient has not tried and failed topical nonsteroidal therapy that can allow for a reduction in the need for topical and/or oral steroids. Tacrolimus is the single nonsteroidal topical agent that is Food and Drug Administration FDA-approved for moderate to severe atopic dermatitis, and this has not yet been used to date. Furthermore, consistent with standards of care, first-line oral/systemic therapies and/or phototherapy have not yet been tried to date. 

Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with current medical literature, Dupixent is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, Chronic Obstructive Pulmonary Disease (COPD) and spinal stenosis

Treatment: Personal Care Assistance (PCA) services 24 hours per day, 7 days per week split shift (Monday through Sunday), for a total of 168 hours per week

The insurer denied coverage for PCA services 24 hours per day, 7 days per week split shift (Monday through Sunday), for a total of 168 hours per week

The denial is overturned

The patient has a past medical history of heart disease, COPD and spinal stenosis. The patient is requesting PCA services 24 hours per day, 7 days per week split shift (Monday through Sunday), for a total of 168 hours per week, which is under review.

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as modified independent. However, the patient requires maximal assistance for bathing, lower body dressing, locomotion, ambulation, and toilet transfer. Extensive assistance is needed for personal hygiene, upper body dressing, bed mobility and toilet use. The patient is frequently incontinent of bladder and continent of bowel. The patient's condition has declined compared a previous UAS report. This physician is also persuaded by the medical records including a letter from the patient's treating physician. 

The patient's physician describes the patient's multiple medical conditions and progressive functional decline. The physician notes the patient's multiple falls over the past several months, one of which resulted in a traumatic subdural hemorrhage causing left hemiparesis and rib fracture. The patient's physician also notes routine hospital emergency department visits after the patient was found on the ground in the patient's apartment on multiple occasions. This physician would agree, the combination of the patient's clinical condition and declining functional ability are at a level that are unpredictable and requires the requested PCA services 24 hours per day, 7 days per week split shift. The patient's health and safety are more appropriately provided and maintained by increasing PCA services to 24 hours per day 7 days per week split shift (Monday through Sunday), for a total of 168 hours per week.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based. From a physical medicine and rehabilitation perspective, PCA services 24 hours per day, 7 days per week split shift, for a total of 168 hours per week is medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care assistance (PCA) services 24 hours per day, 7 days per week split shift (Monday through Sunday), for a total of 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, metastatic lung cancer

Treatment: Consumer directed personal assistance services (CDPAS), 24 hours per day (Split Shift)

The insurer denied coverage for consumer directed personal assistance services (CDPAS), 24 hours per day (Split Shift)

The denial is overturned

This is an elderly patient with Parkinson's disease and more recently diagnosed with metastatic lung cancer. The patient also has a history of stroke and is treated for pneumonia. The patient lives with the spouse and daughter in a 2-bedroom apartment. The patient is currently approved for consumer directed personal assistance services (CDPAS) 24 hour live-in and is requesting a change to split shift, which is under review. 

The Uniform Assessment System (UAS) comparison report was reviewed. The patient's cognition has declined to "severely impaired- never or rarely makes decisions." Regarding the activities of daily living (ADL) the patient is now totally dependent for bathing, personal hygiene, dressing and toilet transfer/use. The patient is occasionally incontinent of bowel and bladder. Maximal assistance is required for bed mobility and eating. The patient now requires supplemental oxygen and enteral tube feedings. The patient's medical condition, grave prognosis, and deteriorating ADL status of essentially total dependence to maximal assistance; are at a level or unpredictable as to require the requested CDPAS 24 hours per day, 7 days per week (split shift). Based on the records reviewed, the live-in CDPAS is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain an uninterrupted 5 hours of sleep. The patient's health and safety are more appropriately provided and maintained at home with the CDPAS 24 hours per day (split shift).

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for consumer directed personal assistance services (CDPAS), 24 hours per day (Split Shift) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal cancer
Treatment: Comprehensive Molecular Profile Test (F1CDx Test)
The insurer denied Comprehensive Molecular Profile Test (F1CDx Test). 
The health plan's determination is upheld. 

The patient is a male with metastatic rectal cancer. The patient is receiving FOLFOX chemotherapy. The tumor is known to be PDL1 (Programmed death-ligand) 1 0%(percent), RAS WT (wild type), and MSS (Microsatellite Stable) stable. TMB (Tumour mutational burden) is 5. The Comprehensive Molecular Profile Test (F1CDx Test) was obtained and is under review.

The Comprehensive Molecular Profile Test (F1CDx Test) was not medically necessary for this patient.
The use of next generation sequencing (NGS) gene panels to guide the treatment of patients with metastatic rectal cancer has not been demonstrated to be of benefit. 

Based on the paucity of supporting data, neither the National Comprehensive Cancer Network (NCCN) nor the authors of UpToDate recommend the use of the Comprehensive Molecular Profile Test (F1CDx Test) in this clinical scenario. Treatment based on published literature and guideline recommendations has been encouraged. For these reasons, the use of this assay in this scenario is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease of the small bowel
Treatment: 45399 Colonoscopy with biopsy and strictureplasty
The insurer denied: 45399 Colonoscopy with biopsy and
strictureplasty
The denial is overturned

This patient is an adult male diagnosed with Crohn's disease who has a small bowel and ileocecal anastomosis stricture. This patient underwent stricturotomy and stricturoplasty.

The health plan should cover the proposed treatment of 45399 colonoscopy with biopsy and strictureplasty.
 
This patient underwent stricturotomy and stricturoplasty for a small bowel stricture. Endoscopic stricturoplasty is an alternative to surgical small bowel resection. The procedure has an 
advantage over surgical resection as it avoids removing part of the small bowel and avoids complications associated with surgery.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease of the small bowel
Treatment: 45399 Colonoscopy with biopsy and strictureplasty
The insurer denied: 45399 Colonoscopy with biopsy and
strictureplasty
The denial is overturned

This patient is an adult male diagnosed with moderate to severe Crohn's Disease status post resection, with anastomotic stricture. The patient's provider is requesting colonoscopy with 
stricturoplasty.

The health plan should cover the proposed treatment of 45399 colonoscopy with biopsy and strictureplasty. 

Endoscopic strictureplasty in Crohn's patients is an accepted technique which can obviate the need for surgery in this patient population. The patient's provider supplied cogent medical literature describing this technique. This service is appropriate for this patient's condition, in keeping with the generally accepted standards of medicine, and is not considered more costly than alternative treatment options. Additionally, this service is for no one's convenience. There is extensive cogent medical literature on this subject as cited below. There is no medical reason not to support this approach to Crohn's strictures specifically in this patient and in general.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease of the small bowel
Treatment: 45399 Colonoscopy with biopsy and strictureplasty
The insurer denied: 45399 Colonoscopy with biopsy and
strictureplasty
The denial is overturned

This patient is an adult male diagnosed with moderate to severe Crohn's Disease status post resection, with anastomotic stricture. The patient's provider is requesting colonoscopy with 
stricturoplasty.

The health plan should cover the proposed treatment of 45399 colonoscopy with biopsy and strictureplasty. This patient has Crohn's with an ileocecal anastomotic stricture. Fousekis et al. concluded that both endoscopic balloon dilatation and endoscopic stricturoplasty are considered minimally invasive and safe and are associated with a small risk of complications. On the other hand, the surgical approach, is indicated in patients not suitable for endoscopic therapy. Lan et al. showed that while therapy with endoscopic balloon dilation usually requires frequent repeat treatments, needle knife stricturotomy is safe, effective and less invasive than surgery. Therefore, as it is considered clinically appropriate, an accepted standard of care and medically necessary, the health plan should cover the proposed endoscopic stricturoplasty.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: I35.0 Nonrheumatic aortic (valve) stenosis
Treatment: Transcatheter Aortic Valve Replacement (TAVR) 
with associated Full Hospital Admission
The insurer denied: Transcatheter Aortic Valve Replacement (TAVR) with associated Full Hospital Admission
The denial is overturned

The patient is an adult male who developed unstable angina. Catheterization demonstrated normal coronary arteries. The function was normal. He was diagnosed with severe aortic stenosis as the cause of his angina. A transcatheter aortic valve replacement (TAVR) is under review.

The proposed transcatheter aortic valve replacement (TAVR) with associated full hospital admission was medically necessary.

Transcatheter aortic valve replacement (TAVR) is a nonsurgical percutaneous procedure for an aortic valve replacement for individuals with symptomatic severe aortic stenosis (AS) at prohibitive surgical risk. There are some established risk assessment guides to determine those eligible for the procedure (i.e., Society of Thoracic Surgeons [STS] risk score and European System for Cardiac Operative Risk Evaluation [EuroSCORE]). They are based primarily on clinical factors such as, for example, severe pulmonary disease, severe renal disease, extent of coronary artery disease (CAD), cardiac function, immunosuppressive therapy, and other valvular disease. There are also technical factors related to sternotomy contraindications that are considered, such as a previous sternotomy, porcelain aorta, and past chest radiation. These technical factors are not necessarily part of clinical risk assessment criteria but are important considerations. 
In this case, the patient developed symptomatic severe aortic stenosis requiring correction. He was not high surgical risk. However, there is recent evidence (Popma et al.) that transcatheter aortic valve replacement (TAVR), compared to surgical aortic valve replacement, in those at low surgical risk is associated with a lower rate of a composite endpoint of mortality, stroke, and recurrent hospitalizations. It was, therefore, considered medically necessary in this case. As the procedure was necessary, the inpatient hospitalization was also medically necessary.