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

Diagnosis: Hydronephrosis

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient has a history of hypertension (HTN), and kidney stent procedure.  The patient presented to the Emergency Department (ED) complaining of right flank pain, nausea/vomiting, and heart rate 111 beats per minute.  He was noted to have elevated white blood cell (WBC) count and serum creatinine.  Computed Tomography scan revealed right hydronephrosis consistent with right ureteropelvic junction (UPJ) obstruction.  Urinalysis was sent, the patient was started on intravenous (IV) Rocephin and the patient was admitted for a urinary tract infection (UTI).  Urology recommended keeping the patient nothing by mouth (NPO) for possible procedure. Bladder scan revealed post void residual (PVR) of 100 milliliter (ml).  Renal scan done revealing 30 percent (%) function right kidney, 70% on the left.  The patient improved, and did not require a stent placement.  The patient was stable for discharge home. 

The insurer denied coverage for the inpatient hospital admission as not medically necessary.  They noted the UTI vital signs (VS) were stable, elevated WBC count is noted.  There was no indication that the patient did not improve after observational treatment and the patient could have been safely treated at the observation level.  The appeal on behalf of Brookdale University Hospital and Medical Center is noted and read in detail.

This patient has a history of right pyeloplasty in for right Ureteropelvic junction (UPJ) obstruction.  After such surgery, the collecting system will almost have a hydronephrotic appearance on CT scan or renal ultrasound, and usually only a Lasix renal scan can determine if the obstruction still exists in that kidney.  

Per Milliman Care Guidelines (MCG): Urinary Tract Infection (UTI) and Urologic Disease - GRG, the patient fails to meet clinical indications for admission to inpatient care. The patient's urinalysis was abnormal in the Emergency Department but all blood/urine cultures were negative for acute infection.

The healthcare plan acted reasonably and with sound medical judgment and in the best interests of the patient. The inpatient hospital admission was not medically necessary.
The insurer's denial of coverage for the inpatient hospital admission is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myocardial injury

Treatment: Emergent hospital admission

The insurer denied coverage for emergent hospital admission

The denial is overturned

This patient was awoken from sleep by severe chest pain. Pain lasted for 8 hours, was accompanied by nausea and vomiting as well as dyspnea.  Upon arrival to the Emergency Department (ED), vital signs were stable (Blood Pressure [BP] 139/92, Pulse [P] 74, and room air oxygen saturation 99%) and physical examination revealed no abnormal findings.  The patient noted 10/10 pain that did not subside with ketorolac therapy. Electrocardiogram (ECG) revealed normal sinus rhythm without evidence of ischemic ST or T wave changes.  Serial blood testing revealed an elevated and rising trend in Troponin level: 0.174, 0.251, and 0.318 nanogram per milliliter (ng/ml). The patient was admitted to the hospital for further work up and treatment.  Computed tomography angiogram ruled out pulmonary embolism and aortic dissection.  Echocardiogram revealed a left ventricular ejection fraction of 70-75% without wall motion abnormalities and without valvular abnormalities. Cardiac catheterization revealed no coronary artery obstruction.  The patient was ultimately discharged home with follow up.

This patient presented to the hospital with severe chest pain and clear biochemical evidence of myocardial injury.  Serum troponins continued to climb on three consecutive samples.  Several studies have demonstrated an association between myocardial injury and poor prognosis. (2)  The differential diagnosis of myocardial injury not only includes myocardial infarction but can be seen in other serious conditions such as myocarditis, coronary artery spasm and sepsis. (1) Emergent admission to the hospital for observation, diagnostic testing and treatment 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 emergent hospital admission is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Personal Care Worker (PCW)
The insurer denied Personal Care Worker (PCW) Service: 24-hour split shift. The health plan's determination is overturned. 

The Patient is a female with past medical history of hyperlipidemia, depression, bioprosthetic aortic valve, permanent pacemaker, knee osteoarthritis, chronic obstructive pulmonary disease (COPD), and urinary incontinence who had undergone a left total knee replacement with subsequent wound dehiscence and infection. The patient required washout and debridement. There was a request for PCW (personal care worker) services and the patient was assessed at maximum assistance with meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing medication, stairs, transportation, bathing, dressing upper/lower body. The patient was assessed at limited assistance with tasks of managing finances, phone use, equipment management, personal hygiene, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. Notes indicated that the patient was in the process of appeal to increase PCW hours. 

Personal Care Worker (PCW) Service: 24-hour split shift is medically necessary for this patient.
The patient has documented need for assistance with all activities of daily living (ADL) and instrumental activities of daily living (IADL). The patient had a complicated course following left knee replacement with subsequent infection and need for prolonged intravenous (IV) antibiotics and subsequent surgery. The patient had a prolonged rehabilitation stay and although she may progress with physical therapy and occupational therapy she continued to require assistance with all ADLs and IADLs. The patient developed a sore on her left heel during her hospitalization and subsequent rehabilitation stay requiring frequent repositioning. The patient is up at night to use the bathroom with needed assistance with ADLs to complete this task at least every 3 hours such that a PCW would not be able to obtain 5 hours of uninterrupted sleep. The increase in PCW hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs. It cannot be assumed that the patient's family can provide formal/informal help during the current hours the patient doesn't have PCW services, which would be up to 16 hours/day. 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, PCW services 24 hours/day, split-shift 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Stage two A (IIA) primary mediastinal B-cell lymphoma. 

Treatment: 45 treatments of simple with compensation, intermediate complex proton beam radiotherapy. 

The insurer denied coverage for 45 treatments of simple with compensation, intermediate complex proton beam radiotherapy. 

The denial is overturned. 

This is a male patient with stage two A (IIA) primary mediastinal B-cell lymphoma status post (s/p) six cycles of DA-R-EPOCH (dose adjusted rituximab, etoposide, prednisolone, vincristine, cyclophosphamide, doxorubicin) chemotherapy. Proton beam radiation therapy (RT) is planned for consolidation RT of total 45 gray units (Gy) to the mediastinal nodes on institutional review board (IRB) approved prospective registry trial (NCT02040467). 

Radiation treatment fields to encompass mediastinal lymphoma include large volumes of heart and lung with significant risks of radiation complications to the heart and lung due to synergistic effects of radiation and chemotherapy. With Bragg-peak physical character of proton beam, proton beam radiation therapy has advantages in the radiation dose distribution compared to photon radiotherapy. Multiple peer reviewed publications on proton beam RT have demonstrated that proton beam radiation offers superior conformity, and side effects of proton beam therapy appear to offer potentially less local side effects compared to photons RT. With delivered dose of 45 Gy to the mediastinal nodes, proton beam RT will decrease dose to bilateral lung and heart and will reduce lifetime risks of developing breast cancer and pulmonary and cardiac complications from radiation treatment in this patient. Proton beam therapy unit at the requesting facility is Food and Drug Administration (FDA) approved to treat cancer. This patient is a good candidate. He has stage IIA primary mediastinal B-cell lymphoma s/p 6 cycles of DA-R-EPOCH chemotherapy. In addition, the patient is undergoing this treatment as part of an IRB approved clinical trial.

Proton beam RT in this case meets the 2017 American Society for Radiation Oncology (ASTRO) model policy for proton beam RT. National Comprehensive Cancer Network (NCCN) guideline for non-Hodgkin's lymphoma 2021 states that treatment with photons, electrons and protons may all be appropriate, depending on clinical circumstances. The guideline further states that proton therapy may offer significant advantages of sparing normal tissues and may decrease the risk of late normal tissue damage. 

Proton beam therapy in this case is consistent with the 2017 ASTRO model policy and NCCN guideline.     

With delivered dose of 45 Gy to the mediastinal nodes, proton beam RT will decrease dose to bilateral lungs and heart, and will reduce life time risks of developing breast cancer and pulmonary and cardiac complications from radiation treatment.     

The requested procedure is likely to be more beneficial than any other existing standard health service.

The carrier's denial of 45 treatments of simple with compensation, intermediate complex proton beam radiotherapy should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment: Lab testing to determine response to Humira (adalimumab)
The insurer denied lab testing to determine response to Humira (adalimumab).
The determination is overturned.

The patient has ulcerative colitis (pancolitis). She has been on Humira. The fecal calprotectin was elevated at 283 micrograms per gram (mcg/g). She has had recurrent flares of ulcerative colitis, including presentation with urgency, diarrhea, hematochezia, and cramping abdominal pain. She had testing for the Humira level and the anti-Humira antibody level, with finding of a Humira level of 8.3 micrograms per milliliter (g/mL) and anti-Humira antibody titer of 43 nanograms per milliliter (ng/mL). At issue is whether the proposed lab testing to determine response to Humira (adalimumab) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The patient was taking Humira (adalimumab), an anti-tumor necrosis factor (TNF) medication, for the treatment of ulcerative colitis; she had signs and symptoms of active disease, including elevated fecal calprotectin. In this case, Humira levels and anti-Humira antibody levels were performed to evaluate for causes for loss of response to Humira, which is appropriate. According to the American Gastroenterological Association (AGA) Guideline on Therapeutic Drug Monitoring in Inflammatory Bowel Disease, "In adults with active inflammatory bowel disease treated with anti-tumor necrosis factor agents, the AGA suggests reactive therapeutic drug monitoring to guide treatment changes" [Feuerstein, et al]. According to the AGA Clinical Care Pathway guidelines for the treatment of Crohn's disease, drug concentration and anti-drug antibody levels should be checked if there is a loss of response to an anti-TNF medication such as Humira, with a subsequent change in management (switch within drug class, assess for inflammation, or increase dose) [AGA Institute]. American College of Gastroenterology guidelines for the treatment of Ulcerative Colitis also state "In patients with moderately to severely active Ulcerative Colitis who are responders to anti-TNF therapy and now losing response, we suggest measuring serum drug levels and antibodies (if there is not a therapeutic level) to assess the reason for loss of response" [Rubin, et al]. In this case, there were signs and symptoms of active disease, with loss of response to Humira [Roda, et al].

The request is therefore supported as likely to be more beneficial than any standard treatment or treatments for the evaluation of this enrollee's ulcerative colitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This case involves a male who was initially admitted for aggressive behavior. The documentation indicated he was admitted as an inpatient to the telemetry unit for further observation due to the possibility of syncope. The documentation indicated the patient has a past medical history of hypertension as well as asthma and bipolar disorder. According to the documentation, the patient was in the company of peers on the psychiatric unit when he reportedly "placed himself on the floor". There were no reports of jerky limb movements or tongue biting. The documentation indicated vital signs taken at the time of the incident revealed a heart rate of 112 with a blood pressure at 120/76. Oxygen saturation was 94%. The documentation detailed the patient was a poor historian. The examination revealed a young obese man who was sweating excessively. The documentation detailed the patient was awake, however non-communicative. He was recommended to be admitted for further treatment. The documentation indicated the patient was recently started on risperidone and Depakote for psychosis. He did develop vomiting 2 days prior to the incident; however, it was noted to have resolved. He has since had decreased appetite with decreased fluid intake. It was recommended the patient undergo a computed tomography scan, however the patient was lying on the floor refusing to get up. The documentation detailed the patient should continue with treatment and monitoring. The documentation indicated he continued with treatment and he was seen and examined. There were no significant findings noted. The recommendation was made to continue treatment which included holding psychotropic medication. The documentation also detailed he did eventually undergo a computed tomography scan of the head revealing no acute intracranial abnormality. Given the period of stability he was transferred back to the psychiatric unit.

The submitted documentation indicated this patient was initially admitted to the psychiatric unit due to aggressive behavior. The documentation indicated he was transferred due to a possible pre-syncopal event requiring additional observation. However, the submitted documentation does not indicate this patient had any clinical evidence of a medical emergency requiring an inpatient admission. The patient was stable and there were no significant findings upon laboratory work imaging reviewed. 

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Stelara at a Dosage of 90 mg (milligrams) Every Four (4) Weeks The insurer denied at a Dosage of 90 mg Every Four (4) Weeks. The health plan's determination is overturned.

The patient is a female with fistulizing Crohn's disease diagnosed and sacroileitis. She failed budesonide, Pentasa, and weekly Humira. She was started on Stelara. She presented with constipation and lack of hematochezia, bloating, nausea, vomiting, diarrhea, and abdominal pain. A recent Colonoscopy for the indication of Crohn's disease on Stelara therapy (for 6 months) showed ileal erythema and friability with ulceration and edema, as well as an unremarkable colon and rectum.

Stelara at a Dosage of 90 mg Every Four (4) Weeks is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Stelara 90 mg every 4 weeks is supported in this case by current medical literature. Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease. Guidelines for the treatment of Crohn's disease recommend the use of Stelara. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response. 

In this case, the patient has severe disease based on the presence of fistula, and has failed Stelara every 8 weeks after initial improvement given finding of ileal inflammation and ulceration on recent colonoscopy. Continuation of Stelara 90 mg every 8 weeks, or discontinuation of Stelara (even if an alternative is immediately attempted), may result in complications such as recurrent fistula, active disease symptoms, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this patient with moderate to severe disease. For all of these reasons, dose escalation to Stelara 90 mg every 4 weeks is likely to be more beneficial than any standard treatment or treatments for the insured's Crohn's disease in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Stelara at a Dosage of 90 mg (milligrams) Every Four (4) Weeks The insurer denied at a Dosage of 90 mg Every Four (4) Weeks. The health plan's determination is overturned.

The patient is a female with Crohn's Disease. The patient was diagnosed with Crohn's disease. A colonoscopy demonstrated terminal ileitis and sacroileitis. The patient failed therapy with Humira and Pentasa. The patient later developed flank pain and was found to an entero-enteric fistula. The patient unfortunately is an every day smoker of tobacco. The patient was started on Stelara 90 milligrams (mg) Q (every) 8 weeks. Clinically, the patient experienced significant improvement. A colonoscopy in 3/2021 demonstrated a couple of centimeters of ileal inflammation with shallow ulcerations with a normal entire colon. Based on this colonoscopic finding, the provider wished to increase the dose of ustekinumab.

Stelara at a Dosage of 90 mg Every Four (4) Weeks is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
There are no randomized controlled data comparing continuing Stelara at Q 8 weeks versus. dose escalation to Q 4 weeks. However, the observational data is compelling and has been published in high quality peer-reviewed journals.
Ollech and others, obtained data from 110 patients who initially received subcutaneous ustekinumab 90 mg every 8 weeks and then had their interval shortened to every 4 weeks. Following dose interval shortening, the patients' median disease activity decreased from 4.5 to 3, the median level of C-reactive protein (CRP) decreased from 8 mg/L (milligrams/liter) to 3 mg/L, and median level of fecal calprotectin decreased from 378 to 157. After the dose interval was shortened, 28% achieved clinical remission, 22% had a normal level of CRP (< 5 mg/dL), 50% had reduced levels of fecal calprotectin, and 36% achieved endoscopic remission.

As mentioned by thought leaders such as Dalal and others, dose escalation is required frequently and ustekinumab should be dose escalated to Q 4 weeks if an optimal response is not obtained with Q 8 week dosing.
Appeal type: Experimental/Investigational
Decision: Overturned

Digestive System
Pharmacy/prescription drugs

Diagnosis: Crohn's disease
Treatment: Stelara at a Dosage of 90 mg (milligrams) Every Four (4) Weeks
The insurer denied at a Dosage of 90 mg Every Four (4) Weeks. The health plan's determination is upheld.

The patient is a female with Crohn's disease requesting Stelara every four week dosing. The case notes describe persistent disease activity despite Stelara every eight weeks. The appeal letter describes literature for support of Stelara every four weeks. She has active Crohn's disease despite standard every four week dosing. A progress note describes anxiety, abdominal pain, depression, migraine, and a benign abdomen. The colonoscopy described 2 centimeter (cm) of inflammation of the distal ileum, more proximal ileum looked normal, and the entire colonic mucosa was normal. 

Stelara at a Dosage of 90 mg Every Four (4) Weeks is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Standard options in this case  remain including use of standard dosing of Stelara with combination immune suppressant agents such as methotrexate, azathioprine, Mercaptopurine and/or high dose mesalamine. There was no clear failure of standard Stelara dosing with only 2 centimeter (cm) of ileum showing inflammation on the recent colonoscopy examination. The patient has no diarrhea, no pain, is maintaining weight, and currently has constipation which is not suggestive of poorly controlled Crohn's disease. Stelara every four week dosing is not indicated.
At this time, there is insufficient high-quality scientific literature to support the safety and effectiveness of every four-week dosing of Stelara. There are a lack of randomized controlled studies or well-designed cohort studies that show an improvement in health outcome, safety, and effectiveness with this approach.