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

Diagnosis: Skin Disorders - Psoriasis.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Skyrizi.
The health plan's determination of medical necessity is overturned in whole.

The patient is a male with psoriasis, treated with topicals. His provider is recommending Skyrizi. The health plan requires a trial and failure to systemic immunosuppressant therapy.
At issue is the medical necessity of Skyrizi (150 milligrams (MG) Dose) 75MG/0.83 milliliters (ML) subcutaneous (SC) pre-filled syringe (PSKT).

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

Yes, the requested health service/treatment of Skyrizi (150 MG Dose) 75MG/0.83ML SC PSKT is medically necessary for this patient.
Skyrizi is an approved, appropriate, and effective medication for psoriasis. A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. It is generally considered medically necessary and the standard of care to continue a patient on a therapy to which they have favorably responded.
According to the meta-analysis by Sbidian et al, compared to placebo, the biologics infliximab, ixekizumab (Taltz), risankizumab (Skyrizi), bimekizumab, secukinumab (Cosentyx), guselkumab (Tremfya) and brodalumab were the most effective treatments for achieving psoriasis area and severity index (PASI) of 90 in people with moderate-to-severe psoriasis on the basis of moderate- to high-certainty evidence.
Therefore, the requested health service/treatment of Skyrizi (150 MG Dose) 75MG/0.83ML SC PSKT is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arm weakness due to stroke.
Treatment: Powered custom brace .
The insurer denied a powered custom brace. 
The health plan's determination is overturned. 

This is a female with history of meningioma status/post (s/p) resection with subsequent bleed. She has left hemiparesis and seizures. She has undergone extensive physical and occupational therapy as well as botulinum toxin injections. She has limited functional use of her left upper limb and has applied for coverage for a Myopro myoelectric elbow/wrist/hand orthosis.

Durable medical equipment: powered custom brace is medically necessary for this patient.
This patient has exhausted all conservative attempts to improve function of her left upper limb. She had a tumor resection with subsequent bleed which caused spasticity and left arm weakness. The only chance of recovering any functional use of her left arm is with the myoelectric elbow/wrist/hand/finger orthosis. There is literature showing the beneficial effect of this device on patients with upper motor neuron pathology.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis
Treatment: Inpatient hospital admission 
The insurer denied coverage for inpatient hospital admission  
The denial is upheld

The patient presented with right upper quadrant (RUQ) abdominal pain, nausea, and vomiting. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. The sonogram and hepatobiliary iminodiacetic acid (HIDA) scan showed acute cholecystitis. She was started on antibiotics and her symptoms improved. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone according to Milliman Care Guideline (MCG) (M-555) include having acute cholecystitis. This needs to be manifested by both RUQ abdominal pain and systemic signs of inflammation. The systemic signs of inflammation include having a fever or white blood cell (WBC) count over 10,000. This patient did not have systemic signs of inflammation. In addition, she did not have hemodynamic instability, common bile duct obstruction, severe vomiting, severe pain, or bacteremia.

This patient had gallbladder disease. She was started on antibiotics and improved. Treatment could have been provided with observation status. She did not meet MCG criteria for admission for Gallbladder or Bile Duct Stone or Inflammation. An inpatient admission was not medically necessary.

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 inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic pancreatic cancer. 
Treatment: FoundationOne Liquid CDx Testing (0239U). 
The insurer denied: FoundationOne Liquid CDx Testing (0239U). 
The denial is upheld. 

The patient in this case is an adult male who was diagnosed with metastatic pancreatic cancer. He underwent omental biopsy and this confirmed metastatic pancreatic cancer.  This biopsy consisted of a fine needle aspiration and also multiple core biopsies. FoundationOne Liquid Biopsy testing was requested. 

The proposed treatment was not medically necessary. 

This patient was diagnosed with metastatic pancreatic cancer by tissue biopsy. He had FoundationOne Liquid Biopsy testing done. This is not a standard test for patients with advanced pancreatic cancer and has not been show able to improve health outcomes in patients with that disease based on the results of any prospective clinical trial. Furthermore, there is no documentation indicating that this patient could not have had either tissue testing done by a repeat biopsy or tissue based testing, if the initial attempt was unsuccessful. Tissue based testing is superior to blood based testing (FoundationOne).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head trauma
Treatment: Hospital admission
The insurer denied the hospital admission.
The determination is upheld.

This patient presented to the hospital via Emergency Medical Services (EMS) following an accident at a pool in which someone jumped on his head. His past medical history is notable for attention deficit hyperactivity disorder (ADHD). There was a reported loss of consciousness at the scene and he was pulled from the pool by a lifeguard. His vital signs were normal. A Glasgow Coma Score was 15. Evaluation revealed him to be awake, alert and oriented, moving all extremities without focal neurological deficit. He had broken teeth. Imaging with a computed tomography (CT) scan did not identify intracranial or cervical injury. He was admitted to the hospital and provided pain management, and frequent neurological checks. No surgical intervention was planned.
His vital signs were normal. Neurological checks were unchanged and normal. He was tolerating a diet and was ambulating. The patient was discharged from the hospital. At issue is the medical necessity of an inpatient stay.
Acute inpatient admission was not medically necessary for this patient. This patient presented to the hospital following a head injury at a pool. He was neurologically intact at presentation and there was no surgical plan for acute intervention. The patient remained stable during the period of monitoring. The initial head CT scan demonstrated no acute pathology. The care and treatment provided could have been rendered at a lower level of care rather than an inpatient level of care. This would have permitted ongoing evaluation and neurological checks as he was determined to be neurologically and hemodynamically stable and non-operative.
Admission is indicated for a head injury and one or more of the following: Hemodynamic instability, altered mental status that is severe or persistent, post-resuscitation or presenting Glasgow coma score of less than (<) 13, worsening neurologic function, new signs or symptoms, new focal signs on neurologic examination, evidence of increased intracranial pressure, new intracranial pathology on imaging, cerebrospinal fluid (CSF) leak, inpatient wound care needed, skull fracture, that is basilar, open or depressed, intracranial infection, cerebral vasospasm identified or suspected, recurrent seizures, significant respiratory abnormalities secondary to the brain injury, increased intracranial pressure or cerebral edema monitoring. In this case, none of these neurological criteria were present to warrant an inpatient level of care.
This patient was determined by the trauma service to be neurologically and hemodynamically stable and nonoperative. There was no infection, no vertebral fracture, no compartment syndrome, no anticipated surgical intervention, no evidence for limb threatening injury, no suspicion of abuse or neglect and no ongoing severe pain that required inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Pain management (lumbar facet injection)
The insurer denied: Pain management (lumbar facet injection)
The denial is upheld

The patient is an adult male with chronic right sided axial low back pain secondary in part to lumbar facet arthropathy confirmed by findings on his lumbar spine magnetic resonance image (MRI) which showed facet arthropathy in lumbar facets (L3/L4 [lumbar 3 to lumbar 4] - L5/S1 [lumbar 5 to sacral 1]). The treating provider requested approval for facet joint injections on the right side at the levels mentioned previously; however, the procedures were denied for not being medically necessary.

The proposed treatment is not medically necessary.
Per AIM Interventional Pain Management Guideline: Therapeutic intraarticular facet injections may be medically necessary only under the following conditions: 
There is suspected inflammatory facetogenic pain due to systemic arthropathies (e.g., rheumatoid arthritis).
- NOT MET: Although there is magnetic resonance image (MRI) findings of facet arthropathy, there is no documentation of systemic arthropathy mediated facetogenic pain.
Denervation is contraindicated (e.g., young athletic person in whom denervation may result in muscle atrophy that can adversely impact their condition (e.g., spondylolisthesis) or activities of daily living (ADLs).
- NOT MET: Radiofrequency denervation of the lumbar medial branches is not contraindicated in the patient.
Individuals at risk for complications with radiofrequency neurotomy (RFN) treatment (e.g., pacemaker-dependent patients and those with automatic implantable cardioverter-defibrillators, presence of another electronic device such as a spinal cord stimulator or an intrathecal infusion device, older individuals on anticoagulation therapy).
- NOT MET: The patient does not have any implantable devices, such as those mentioned above that would contraindicated radiofrequency denervation of the lumbar medial branches.
Evidence of nerve root compression due to a facet synovial cyst or large effusion. 
- NOT MET: The patient's lumbar spine magnetic resonance image (MRI) shows facet arthropathy, but not a facet synovial cyst or large effusion.
Evidence of nerve root compression due to a facet synovial cyst/large effusion when seen on an advanced imaging study (magnetic resonance image [MRI] or computed tomography [CT]) performed within the previous 12 months that correlates with the clinical findings.
- NOT MET: There is no magnetic resonance image (MRI) evidence of a nerve root compression.
Associated moderate-to-severe radicular pain and functional limitations.
- NOT MET: There is no subjective complaint of radicular pain.
Cyst aspiration/rupture may be repeated once within the 12-month period and only if there is consistent pain reduction of 50% or more for a minimum of three (3) months.
- Not applicable.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Increase Personal Care Aide Level 2: 13 Hours/Day - 7 day(s) per week - Total of 91 Hours per week.
The insurer denied: Increase Personal Care Aide Level 2: 13 Hours/Day - 7 day(s) per week - Total of 91 Hours per week.
The denial is overturned

The patient is an elderly female. She reportedly has advanced-stage Alzheimer's disease dementia. The patient needs help with all her ADLs (activities of daily living). The patient has ambulatory issues, and incontinence issues and is at risk of falls. The patient needs frequent reminders to take her medications. The patient is frequently unable to communicate due to her inability to understand what is being said and to articulate her thoughts.
The patient has chronic conditions, and her neurologic condition is not expected to improve.
The request is for coverage for increased personal care aide level services, 13 hours/day, 7 days/week for a total of 91 hours/week. Health plan approved hours is 73.5 hours/week.

The requested personal care aide 91 hours/week is medically necessary.
This is an elderly patient who has advanced-stage dementia. The patient requires assistance with eating, bathing, food preparation, grooming, continence training, and transferring from one place to another place. The patient needs help both during the daytime and nighttime. The patient needs frequent reminders because of her worsening dementia. Her condition is progressive and is not expected to improve. The patient is at risk of falls and trauma. Because of her chronic neurologic condition, she will benefit from the increasing hours of clear to assist her with her needs. Increased home care services are medically necessary and appropriate to ensure the patient's safety.

The patient needs total care for toilet use, changing, and cleaning due to her incontinence issues. Because of dementia and incontinence, she needs help during the daytime and nighttime. The plan-approved personal care aide level 2, 10.5 hours/day for 7 days/week with a total of 73.5 hours/week is not enough. The patient needs more home care services to ensure safety and provide enough care at home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Achilles Pain.
Treatment: Left Ankle MRI (magnetic resonance imaging).
The insurer denied: Left Ankle MRI (magnetic resonance imaging).
The denial is overturned.

This is an adult male patient with left Achilles pain. The duration was months. He reported falling downstairs in March. The patient had tried CAM (Controlled Ankle Motion) boot, medications, and home exercises. 
The physical examination was significant for tenderness to the Achilles tendon and a negative Thompson test. The x-ray report showed a possible lytic area in the distal tibia. The physician recommended a magnetic resonance image (MRI) of the left Achilles to rule out tendon pathology.

The proposed treatment is medically necessary.
The physician has stated the diagnosis is unclear with atypical presentation. The patient has ongoing pain despite several months of conservative treatment. In this case, the patient utilized a CAM (Controlled Ankle Motion) boot and did stretching exercises. It would be important to obtain additional information in establishing his diagnosis. The radiographic report described a 'possible lytic lesion". This by itself in the presence of continued pain would warrant the additional imaging study. 

There was consistency in the records for ongoing subjective complaints, positive physical findings, and the necessity to define the pain generator. A magnetic resonance image would thus be appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Combativeness.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult male with a history of gout, glaucoma, and encephalopathy. He was sent to the hospital with combativeness with staff at his residing facility.
The patient was admitted and noted with a creatinine of 1.32. The patient was denied transfer back to a primary residence.
The health plan denied coverage of the acute inpatient level of care as not medically necessary. The physician is appealing the determination.

The inpatient admission was not medically necessary.
The requested inpatient admission is not medically necessary as supported by current medical literature or standard of care. The requested admission was provided primarily for the convenience of the patient or the practitioner, and it was not the least intensive and/or most appropriate alternative. Diagnosing and treating the patient at a lower level of care setting would have been clinically appropriate.

Based on the available data, the patient's clinical status was not unstable. There was no altered mental status that was severe or persistent, hemodynamic instability, severe hypertension, or cardiac arrhythmias of immediate concern.

There was no documentation of clinically significant electrolyte abnormality or a metabolic abnormality that is severe or persists despite outpatient or observation care treatment or acute treatment of renal failure. Based on available data, there were no other significant findings or manifestations needing inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System - Primary Ciliary Dyskinesia. 
The treatment is genetic testing. 
The insurer denied outpatient procedure (genetic testing for primary ciliary dyskinesia) 
The denial is overturned.

The patient is a female with protracted respiratory distress and insufficiency, in whom primary ciliary dyskinesia (PCD) has been suspected. PCD is a rare multi-organ disease caused by genetic mutations resulting in defects in motile cilia. Among other things, cilia are responsible for clearing secretions from the upper and lower airways. Since mucociliary clearance in PCD is impaired, PCD is characterized by recurrent infections and progressive upper- and lower-respiratory disease, including, if present in this patient, her respiratory insufficiency. In an attempt to diagnose PCD, a ciliary biopsy was sent for microstructure analysis but was nondiagnostic. A few weeks later, she was readmitted with respiratory distress in the context of Influenza A infection, and the suspicion of PCD was again raised. Given the non-diagnostic biopsy, genetic analysis for known PCD mutations was requested and denied by the insurance company as not medically necessary.

The health plan's determination is overturned.

The request for genetic analysis for known PCD mutations is in line with published standards of care for patients in whom diagnosis of PCD needs to be established or ruled out. Both the American Thoracic Society (ATS) [1] and European Respiratory Society (ERS) [2] Guidelines recognize that used in isolation ultrastructural analysis or genotyping can only identify approximately (~) 70% of people known to have PCD, making it difficult to exclude the condition and recommend that a diagnosis of PCD be confirmed by the presence of a recognized electron microscopy defect or pathogenic mutations in a known PCD gene. Specifically, in the case of previous nondiagnostic ciliary biopsy, a genetic analysis is the recommended next step. In the case of this member, a previous ciliary biopsy was nondiagnostic, so the request for genetic analysis was done appropriately. As outlined above, at this point in this member's illness, genetic analysis to diagnose or rule out PCD is indicated. Diagnosing PCD is crucial to appropriate treatment and prognosis, decreasing morbidity and mortality of this condition. It is thus medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Otitis externa
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient had ear pain and had been treated with oral Augmentin. He returned to the emergency room (ER) with ear pain. He was seen by ear, nose, and throat (ENT). His exam revealed mastoid tenderness and edematous ear canal.  A computed tomography (CT) scan demonstrated left otitis externa and minimal fluid in mastoid on the left. The patient was diagnosed with otitis externa and ear drops were recommended. He was admitted. He was treated with intravenous (IV) Ciprofloxacin which was transitioned to by mouth (PO) antibiotics.
At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary.
The patient was diagnosed with otitis externa. He did not have clinical mastoiditis. His vital signs were stable and he was not toxic appearing. Otitis externa is typically treated on an outpatient basis with topical antibiotic drops and possible oral antibiotics. Hospital admission is not standard of care for this diagnosis. This patient could have been managed at a lower level of care. Intravenous (IV) antibiotics and hospital admission are not needed. Therefore, an inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: MS (multiple sclerosis)
Treatment: Wheelchair ramp
The insurer denied coverage for a wheelchair ramp
The denial is overturned.

This is a patient with diagnosed multiple sclerosis, cognitive disorder, and ataxia.  He is wheelchair dependent with assistance from his mother and a health aide.  Under review is the medical necessity of a requested wheelchair ramp.

The requested wheelchair ramp is clinically appropriate and medically necessary for this individual who is unable to independently ambulate, requires assistance for transfer activities and has fallen when attempting to ambulate (with assistance) down his steps at home. According to the Uniform Assessment System (UAS) report, the patient requires extensive assistance for functional mobility. This physician disagrees with the insurer regarding the medical necessity of the requested wheelchair ramp. The requested environmental modification for the ramp installation provides a lifeline for adaptive home ingress and egress. Home ramp instillation is also medically necessary for access to clinical services and the community.  

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the requested wheelchair ramp is 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 an environmental: wheelchair ramp is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative colitis
Treatment: Entyvio 300 milligrams (mg) every 4 weeks
The insurer denied coverage for Entyvio 300 milligrams (mg) every 4 weeks.
The denial is overturned.

This is a patient with a history of ulcerative colitis. The patient was initially on Entyvio 300 milligrams (mg) every 6 weeks to treat his ulcerative colitis. The Gastroenterologist recommended increasing the frequency to 300 mg every 4 weeks.

Clinical Gastroenterology and Hepatology 2019; 17:838-846 has an article titled "Loss of Response to Vedolizumab and Ability of Dose Intensification to Restore Response in Patients with Crohn's Disease or Ulcerative Colitis: A Systematic Review and Meta-analysis." The conclusion states that in a systematic review and meta-analysis it was found that high proportions of patients with Crohn's Disease or ulcerative colitis lost response to vedolizumab maintenance therapy. Dose intensification restores responsiveness in more than half of these patients.

This patient has ulcerative colitis and had increased symptoms on Entyvio at the 4 week point of the cycle. Under this circumstance, it is appropriate to increase the dosing frequency of the Entyvio from every 6 weeks to every 4 weeks. The medical literature supports the dose escalation of vedolizumab in patients who have not responded adequately to every 6-week dose. The health care plan did not act reasonably or in the best interest of the patient. Entyvio 300 mg every 4 weeks is medically necessary. The denial is overturned.

The insurer's denial of coverage for Entyvio 300 mg every 4 weeks is overturned. Medical necessity is substantiated.