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

Diagnosis: Focal Epilepsy

Treatment: Epidiolex

The insurer denied the Epidiolex. The denial was reversed.   

This patient is a male child with a medical history that includes focal epilepsy that is intractable, developmental delay, microcephaly, short stature, gastroesophageal reflux disease (GERD), seizure disorder and abnormal thyroid function. It was reported that the patient takes Vimpat, phenobarbital, and Clobazam as medical management for his seizure disorder, and despite the treatment he continues to have breakthrough seizures activity. His provider added Epidiolex to his medicine regimen, and a significant improvement was noted. 

Epidiolex is considered medically necessary for this patient. This drug is approved for use in patients with seizures associated with Lennox-Gastaut syndrome (LGS) or Dravet syndrome in patients 2 years or older. This patient meets the clinical criteria and since he has failed 3 drugs, he is deemed intractable. The further indication is previous positive response which supports continued use of the drug. 

Literature indicates Lennox-Gastaut syndrome is a rare but often debilitating form of childhood-onset epilepsy that is highly treatment-resistant with characteristic failure of several medications. The patient has intractable partial epilepsy with associated developmental delays and an abnormal electroencephalogram (EEG) characteristic of this disorder. It is characterized by multiple seizure types and moderate to severe cognitive impairment. Individuals living with Lennox-Gastaut syndrome experience an increased risk of serious injury because of frequent falls associated with uncontrolled seizures. The patient has failed 3 drugs including Lacosamide, Phenobarbital and Clobazam. Epidiolex is a drug approved for this indication above the age of 2 years and hence is a reasonable choice in this clinical indication. The current improvement in seizure frequency supports the continued use. 

The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient. The patient has intractable epilepsy and has failed 3 previous medications. 

Based on the above, the medical necessity for Epidiolex is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, urinary incontinence
Treatment: 150 pull-ups/month 
The 150 pull-ups/month is deemed medically necessary. 

The patient is an male with a history of Alzheimer's disease, urinary incontinence and nocturia secondary to benign prostatic hypertrophy. For these reasons, he requires the use of incontinence pulls ups/briefs. An appeal review was requested for potential approval of an increase in pull-ups/month to 150 to allow for improved treatment of this condition.

Recent documentation from the patient's Primary Care Physician indicates that the patient has been experiencing worsening nocturia and urinary incontinence. For these reasons, the currently approved quantity of 60 pulls up/month is insufficient to meet the patient's needs. Hence, the proposed treatment of an increase in pull-ups/month to 150 is deemed medically necessary to allow for improved treatment of this condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Central Nervous System/Neuromuscular disorder
Treatment:  Nursing Services (including Private Duty Nursing)

The patient is a female with past medical history significant for osteoarthritis, hyperlipidemia, hypertension, diabetes mellitus type 2, congestive heart failure, renal failure stage V, non-hemorrhagic stroke, and cancer of the skin and cervix.  Disabilities secondary to a left cerebral vascular accident include a facial dysarthria and right-sided loss.  She is unable to walk independently.  The patient is currently approved for 12 hours a day  7 days a week for a total of 84 hours a week of personal care services.  The patient is requesting 12 hours split shift  7 days a week.

The health plan's determination is upheld.  The personal care hours, 12 hours a day split shift 7 days a week is not medically necessary.  The patient's medical needs can be met during the time allotted by the health plan.

The Uniform Assessment System (UAS) noted that the patient required help with both Instrumental activities of daily living (IADLs) and activities of daily living (ADLs).  It was noted that the patient required a total of 38 hours per week.  The patient is currently receiving 84 hours a week.

The patient has multiple medical problems most notably depression and anxiety along with chronic renal failure and subsequent cerebrovascular accident (CVA) with neurological deficits.  The patient is able to ambulate with assistance.  She has 84 hours a week of nurses aide hours.  These hours are adequate for the patient's ADLs and IADLs.  There are no noted nocturnal needs that would necessitate ongoing care with a nurses aid through the nighttime shift.  In specific, the patient has no open wounds or need for frequent wound changes.  There is noted urinary incontinence; however, this can be managed through alternate means with incontinence products, such as adult diapers which are provided.  Nocturnal services for observation are preventing falling without specific ADLs or IDLs being performed at the same time.  As noted above, the patient's medical needs can be met during the time allotted by the health plan.
Appeal type: Medical necessity
Decision: Upheld

Cancer 
Nursing Services (including Private Duty Nursing) 

This is a female with metastatic melanoma. The patient has had significant treatment-related toxicities including Guillain-Barre syndrome. She has also had cytopenias, fevers, and myonecrosis. The patient is an ECOG (Eastern Cooperative Oncology Group) 2. The patient requires the use of an assistive device and another individual for ambulation. Best supportive care has been recommended and home health aide hours have been recommended. The use of 28 Home Health Aide Hours is under review. 

The health plan's determination is upheld. The 28 Home Health Aide Hours are not medically necessary for this patient. 

Performance status is a measure of a patient's functional capacity. This patient is stated to be an ECOG 2, which is defined as "...Capable of all self-care but unable to carry out any work activities. Up and about >50% of waking hours..." As it appears that the patient is able to attend to all self-care, the additional home health aide hours should not be required and, therefore, medical necessity cannot be established. At this time, the health plan has approved 10 home health aide hours. This is sufficient to meet the needs of this patient.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/ Neuromuscular Disorder
Inpatient Hospital


The patient is an adolescent female with psychiatric problems, functional neurologic symptoms, abnormal movements, conversion disorder, disordered eating, mutism, and malnutrition. She was admitted for acute-on-chronic malnutrition and functional neurologic symptoms, including mutism and ambulatory dysfunction requiring a wheelchair. During her hospitalization, she was evaluated by the neurology service, who determined that her neurological deficits were psychogenic in origin. During the hospitalization, she also received psychotherapy. While admitted she made some gradual weight gain, but had no significant improvement in her functional neurologic symptoms. She was discharged and transferred to another hospital for continued treatment of her functional neurologic symptoms. During her stay, she made little progress, and she participated little or not at all in her rehabilitation programs. The health plan covered 33 days of the stay but denied the continued stay beyond that as not medically necessary.

The health plan's determination is upheld. The patient was not participating in the rehabilitation program and she was making no significant gains. 

To be successful, inpatient rehabilitation requires that the patient participates in the therapies being offered. The patient was not participating in the therapies. She was not engaged and she would only grunt in response to attempts at communication. To justify continuing inpatient rehabilitation, the patient must be making some meaningful progress. Throughout her stay, the patient made little or no progress toward resolution of any of her psychiatric problems.

Therefore, it was not medically necessary for her to continue at this level of care. She could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibromyalgia and osteoarthritis
Treatment: Phentermine

Summary:
The patient is a female with fibromyalgia and osteoarthritis.  She has been treated with phentermine by her rheumatologist for impaired concentration and decreased energy.  She is also treated with hydrocodone/APAP (acetaminophen), tizanidine and Effexor.  Her BMI is 27.8.  She is allergic to Provigil and Nuvigil.  The patient indicates that phentermine helps with energy so that she can work, and she only takes half of a pill so that it does not increase her heart rate too much.  The appeal is for continuation of phentermine daily for the treatment of fibromyalgia.

Phentermine is FDA-approved for the short-term treatment of obesity.  It is not FDA-approved for the treatment of fatigue due to fibromyalgia, as requested for this specific patient.  The off-label use of phentermine for the treatment of fibromyalgia is not clinically appropriate, or in accordance with standard of care in the rheumatology community.  Upon search of www.pubmed.gov using search terms "phentermine" and "fibromyalgia," no published literature was identified.  Furthermore, the safety of long-term anorexiant therapy such as phentermine has not been conclusively established beyond 12 weeks of administration.  This patient has already far exceeded this duration of treatment.  Therefore, the proposed continuation of phentermine for the treatment of fatigue due to fibromyalgia is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient Hospital

The patient has a history of atrial flutter, atrial fibrillation, diabetes, and diverticulitis who presented to the hospital for an elective ablation under general anesthesia for atrial fibrillation. The ablation was performed without complication. The patient was admitted post-procedure and was observed uneventfully overnight and discharged.

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

No. the requested health service/treatment of the inpatient stay was not medically necessary for this patient. This patient had an elective radiofrequency ablation to treat atrial fibrillation. It was reasonable to observe the patient on telemetry for several hours after the procedure. However, this could have been performed at a lower level of care. The patient had an ablative procedure that requires a lower level of care to allow for observation for several hours following the procedure. However, there is no medical necessity for inpatient status as the expectation is that such observation at a lower level of care requires less than 24 hours and is of low frequency for severe complication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ears/Nose/Throat - Dizziness, Vertigo 
Treatment: Inpatient Hospital 

The patient is a woman with a history of lupus, rheumatoid arthritis, Raynaud's disease, nonobstructive coronary artery disease, and hyperthyroidism who presented to the emergency department with lightheadedness and syncope. She reported similar episodes in the past and also reported increased urinary urgency and frequency. In addition, she reported chest discomfort. Other past medical history included tobacco and marijuana use. The patient was admitted for syncope. A note indicates that the patient became upset and stated that she had to leave the hospital. The risks of leaving the hospital were discussed including the possible risks associated with recurrent syncope. She then left against medical advice. The health plan has denied the inpatient stay as not medically necessary. 

The health pan's determination is upheld. 

The patient had uncomplicated syncope, which is routinely managed at a lower level of care. She had negative cardiac enzymes, a known history of nonobstructive coronary disease with no significant stenosis, negative cardiac enzymes, and no imaging evidence of acute infection or other acute complication. There was no evidence of sepsis and her orthostatics were negative and bradycardia was borderline. This patient could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip pain
Issue under review: MRI

Determination:
The MRI was not medically necessary.

The patient is an adult female. She presented with left greater than right hip pain. She was evaluated by a physician for second opinion. Her diagnosis was hip dysplasia and preoperative imaging was recommended, i.e., MRI, CT scan. The studies were completed and revealed no abnormality. 

The indications for MRI have not been met. 

MRI utilization is of benefit if additional information assists in establishing a diagnosis. The scientific literature describes MRI should be recommended if conservative treatment has not been beneficial. The diagnosis can alter the decision, prognosis and plan of care. The necessity for more invasive procedures (surgical treatment) can be assessed.

The medical record did not document a course of conservative treatment. Although the patient was referred for a second opinion, there was no report of prior imaging nor course of care. 

There was no report of x-ray nor conservative treatment. There were no extenuating circumstances documented to substantiate the testing completed
Appeal type: Step Therapy
Decision: Upheld

Diagnosis:  Psoriasis
 
Treatment:  Skyrizi

The insurer denied coverage for Skyrizi.  The denial is upheld. 

This patient is a female with a past medical history of psoriasis, joint pain in the lower back, and diabetes.  The areas affected include the elbows, shins, face, scalp, ears, extremities, nails, and groin.  The patient has a body surface area of 11%.  She was previously treated with tar.  The patient endorsed occasional joint pain in the lower back.  The physician noted that the patient would be evaluated for psoriatic arthritis.  If the patient does not have psoriatic arthritis, then Skyrizi would be initiated for the treatment of psoriasis. 

According to the insurer, in order to be approved for Skyrizi the patient must try, fail, have a contraindication to, documented adverse effect to or provide any clinical reason why the preferred plan medications (methotrexate, cyclosporine, acitretin for phototherapy if the plan preferred medications are contraindicated or do not work) are not appropriate.  

Based on the medical records submitted for review, there are no documented contraindications, or clinical reasons why the patient cannot try the required step therapy alternatives.  The treating provider listed the dangers associated with the use of those therapies; however, the provider did not list how those dangers are pertinent to the patient's current clinical setting.  All medications to treat psoriasis have a form of danger associated with use or listed adverse reactions, including Skyrizi.  

The patient was previously treated with tar.  The patient has not tried the insurer's required/formulary prescription drugs (acitretin, methotrexate, or cyclosporine) under the current or previous health insurance coverage, or another prescription drug in the same pharmacologic class or with the same mechanism of action, and was that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event.     

The patient is not stable on a prescription drug selected by her health care professional for her medical condition.  There is no indication or documentation as to how effective or successful the preferred medication is or will be with this patient, as it is not a continuation of therapy.  Current medical literature does not support the use of Skyrizi over the available formulary alternatives.      
  
The insurer's denial of Skyrizi is upheld.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal
Inpatient Hospital

This is a male who presented to the emergency room initially status post motor vehicle accident. He had local wound care. His work-up was negative for fracture and he was discharged with 10-day course of oral Augmentin and to follow-up in the outpatient setting. At follow-up with the orthopedist, the patient reported increasing right knee pain, swelling and stiffness hence, he was sent to the emergency department (ED) for possible intravenous (IV) antibiotics and washout. The patient denied any fever chills, weight loss or loss of appetite.

The health plan's determination is upheld. The inpatient stay was not medically necessary. There is no compelling reason why the patient could not have safely and appropriately received evaluation and treatment at this facility at a lower level of care, rather than admission to inpatient level of care. There was no evidence of severe sepsis, hemodynamic instability, limb threatening infection, immunocompromised state, or rapid progression of the disease. There was no need for emergent intervention or surgery. An x-ray of the knee showed no acute fracture and the MRI showed soft tissue edema. There was no evidence of a septic joint. All of the care received could have been done at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dyspnea
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was not medically necessary.

The patient is an adult female whose inpatient admission is under review.  The patient presented with dyspnea.  Her presentation was signification for hemoptysis/productive phlegm.  She has history of asthma.  She has history of tonsillectomy/adenoidectomy.

In the ER the patient's vitals were as follows:  1)  T (temperature) - 97.8  BP (blood pressure) - 111/67; 2)  P (pulse) - 76; 3)  RR (respiration rate) - 16; 4)  O2 sat (oxygen saturation) - 98% RA (room air).  On general examination, the patient was NAD (no acute distress).  Examination of the patient's CVS (cardiovascular system), chest, and abdomen were normal. 

The patient's labs were as follows:  1)  WBC (white blood count) - 18.54 (HIGH); 2)  Hg (hemoglobin) - 14.0; 3)  Hct (hematocrit) - 43.4; 4)  Plt (platelets) - 408; 5)  Na (sodium) - 138; 6)  K (potassium) - 4.0; 7)  Cl (chloride) - 103; 8)  CO2 (carbon dioxide) - 29; 9)  BUN (blood urea nitrogen) - 7; 10)  Cr (Creatinine) - 0.7; 11)  Sputum gram stain- GPC (gram positive coccus); 12)  GPR (gram positive rods).

The patient's CXR (chest x-ray) revealed RUL (right upper lobe) pneumonia.

The patient was thought to have community acquired pneumonia (CAP).  She was treated with IV ceftriaxone and azithromycin.  The patient improved and was sent home on PO (oral) antibiotics.

The patient had a low CURB-65 (confusion, BUN, respiration rate, BP, Age 65+) score and low risk for mortality.  Therefore, admission was not justified (1).  There were no extenuating circumstances in the medical record requiring admission.  Thus, this admission was not warranted, as stated in the IDSA guidelines.  This patient could have been treated as an outpatient with PO antibiotics.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma Exacerbation

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was reversed. 

This is an infant patient with a history of asthma and ingesting alkali fluid in which an endoscopy was performed. The patient presented to the Emergency Department (ED) with complaints of coughing and wheezing for three days. It was reported that the patient had been seen in the ED a few days earlier for the same symptoms. He received albuterol treatment and was discharged with albuterol and prednisone. He continued with persistent symptoms and was evaluated in an outpatient clinic. He was referred to the ED for further treatment. Upon arrival it was reported that he was in respiratory distress with accompanied wheezing. A venous blood gas was performed which revealed mild acidosis; a pH of 7.32 and a pCO2 51. A chest x-ray was performed with negative results.  He received intravenous (IV) magnesium and albuterol and duoneb. It was reported that the patient did have improvement with the implemented treatment; however, he continued to have increased work of breathing. He was treated with steroids and albuterol every three hours and was discharged after a period of medical stability.

According to literature, the use of intravenous magnesium sulfate to patients is limited to severe asthma exacerbations that would require inpatient admission for continuous treatment and observation because of the poor response to symptoms after initial therapy with beta agonists and systematic glucocorticoids. This includes patients who continue to have significant wheezing and retracting, poor aeration, or altered mental status, such as drowsiness or agitation. These patients were at risk for worsening respiratory status, and require continuous treatment and monitoring.  

Based on the review of the literature, this patient was treated appropriately in the ER for an exacerbation of asthma that did not respond to outpatient therapy, including three days of steroids and albuterol treatment. The patient required intravenous magnesium for his status asthmaticus. Despite aggressive ER treatments, the patient was noted to have persistent wheezing and work of breathing. Thus, it was medically appropriate and consistent with the standard of care to admit the patient for ongoing treatment with albuterol every 3 hours. The patient was not stable enough to be sent home due to the patient's need for frequent albuterol administration and monitoring that could not have been safely administered at home or at an outpatient setting.

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

The carrier denial of coverage for the inpatient hospital services is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Closed ankle fracture  
Treatment: Inpatient hospital stay  

The insurer denied coverage for inpatient hospital stay.  The denial is upheld. 

This patient is a female who presented to the Emergency Room (ER) with right ankle pain after falling off of a 3-4 step ladder and landing on her right ankle.  The medical record demonstrated the patient sustained an isolated closed injury to her right lower extremity.  There were no open wounds or problems with her nerves or blood circulation.  The Emergency Department (ED) records demonstrated no evidence of a closed reduction.  She was evaluated by Orthopedics and a posterior splint was applied. She underwent a CT scan and was provided with oral pain medication.  She was able to ambulate with a walker.  

These findings do not substantiate acuity of condition to warrant a hospitalization.  The patient did not require treatment for other underlying medical conditions.  Her additional diagnostic testing (ex: CT scan) could have been completed as an outpatient.  She did not require intravenous pain medication.  Her fracture pattern was non-displaced with no urgency for immediate operative management.  Observation for swelling in her splint could have been completed at home.  A semi-elective admission for an operative intervention could have been scheduled as an outpatient.  There were no extenuating circumstances to warrant this admission and length of stay.  

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

The carrier's denial of coverage for the inpatient hospital stay is upheld.  The medical necessity is not substantiated.