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

Diagnosis: chronic cellulitis

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is overturned. 

This patient is a male with multiple medical problems that presented to the hospital with bilateral leg pain due to non-healing ulcers. The patient has a history of peripheral vascular disease, non-ischemic systolic congestive heart failure with a left ventricular ejection fraction (LVEF) of 17%, severe mitral regurgitation and polysubstance abuse.  The patient was hospitalized for acute on chronic cellulitis, and was noted to have worsening lower extremity edema.  The patient's brain natriuretic peptide (BNP) was elevated and treatment for an acute on chronic exacerbation of systolic congestive heart failure was initiated. Following diuresis, the patient's condition improved.

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. This patient presented with bilateral leg pain and swelling along with decompensated congestive heart failure. Given the multiple ulcers on this patient's leg, worsening pain and fluid overload as demonstrated by an elevated BNP level and physical examination, this patient could not have been managed at an alternate level of care and required inpatient treatment/follow up. There have been several studies including a meta-analysis of more than 50,000 patients demonstrating poor outcomes for patients that are discharged from the emergency department after presenting with congestive heart failure.  These findings were true in both systolic and diastolic congestive heart failure (CHF). In conclusion, acute inpatient admission was necessary to treat acute on chronic heart failure that resulted in lower extremity edema, pain and acute on chronic cellulitis.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis.
Treatment: Inpatient hospital stay.

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

This is a female patient who presented to the hospital with abdominal pain and fever.  By the time of admission, the patient was afebrile.  The patient's vital signs were stable.  There was no abdominal rebound or guarding.  The patient's white blood cell (WBC) count was 17.76.  The patient's computed tomography (CT) scan was read as acute severe uncomplicated distal descending/proximal sigmoid diverticulitis.  The patient was given intravenous (IV) hydration and antibiotics. The patient was started on a clear liquid diet.  The patient felt better and the diet was advanced.

Clinical indications for admission for Acute Diverticulitis according to Milliman Care Guidelines (MCG) include hemodynamic instability, peritoneal signs, persistent gross bleeding, and an imaging abnormality including fistula, obstruction, perforation or abscess.  In this case, the patient did not have these conditions.  The patient also did not have severe vomiting, severe dehydration, or an inability to maintain oral hydration.

Based on the review of the medical record and literature, inpatient hospital stay was not medically necessary for this patient. This patient had an uncomplicated diverticulitis.  IV hydration could have been given in the Emergency Room (ER) with observation status.  Afterwards, the patient could have been treated with a course of oral antibiotics as an outpatient.  The patient did not meet the MCG clinical criteria for admission for acute diverticulitis.  

The health 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 should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia. 
Treatment: Hospital Admission.

The insurer denied coverage for the Hospital Admission.  The denial is upheld. 

This is a female patient with a history of pulmonary embolism (PE) on rivaroxaban.  The patient presented to the Emergency Room (ER) with complaints of critically low hemoglobin and hematocrit levels.  The patient had been seen the day prior for interventional radiology (IR) of lung, but it was aborted due to anemia.  The patient reported dyspnea on exertion (DOE) for the last month and worsening menstrual cycles.  The patient had a hemoglobin level of 5.2.  The patient's physical exam and vital signs were unremarkable.  The patient was admitted to the hospital for anemia. 

Based on the review of the medical record and literature, hospital admission is not medically necessary for this patient.  This patient could have been managed in a lower level of care such as observational status on the date of service (DOS) in question.  The patient would have been able to receive Amicar, blood transfusions and monitoring of her vaginal bleeding under observational status.  As this patient was hemodynamically stable and could have been managed in a lower level of care, acute hospitalization was not medically necessary for the DOS in question.

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

The carrier's denial of coverage for the Hospital Admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Endocrine
Inpatient hospital

Diagnosis: Hyponatremia
Treatment; Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a woman with history of diabetes who was admitted to the hospital. She was referred from urgent care for a sodium level of 118. She reported having nausea and vomiting for several days. She also reported having diarrhea and said she had been drinking substantial amounts of water. Review of systems was negative for fevers and chills. Vital signs showed temperature 98.4 Fahrenheit, heart rate 104, and blood pressure 116/74. On physical exam, heart was regular, breath sounds were normal and there was no cranial nerve deficit. Abdomen was soft and nontender. The patient was admitted for hyponatremia. 

The Emergent Hospital Admission was medically necessary for this patient.

The reason is that the patient had a sodium level less than 120 mEq (milliequivalents) per liter, and therefore had severe hyponatremia. Patients with severe hyponatremia can develop life-threatening complications such as cerebral edema and neurologic disability from osmotic demyelination during the process of correction. These patients require the inpatient level of care for close monitoring and frequent checks of sodium levels.

Severe hyponatremia is treated at the inpatient level of care and requires careful correction to ensure that the sodium level does not change by more than approximately 8 mEq per liter per day. Patients with rapid correction may develop osmotic demyelination, mental status changes, and neurologic disability. When sodium levels are below 120 mEq, patients are typically managed at the inpatient level of care and are sometimes managed in the intensive care unit with hypertonic saline.
Appeal type: Medical necessity
Decision: Upheld

Endocrine
Inpatient hospital

Diagnosis: Hyperglycemia.
Treatment: Inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a man with a history of hypertension and end stage kidney disease status post renal transplant who presented to the hospital with a chief complaint of hyperglycemia. He reported two days of urinary frequency. He denied chest pain, shortness of breath, nausea, vomiting, and diarrhea. He was referred to the emergency department by an outpatient physician due to a blood glucose reading of 455. Vital signs showed blood pressure 155/77, heart rate 75, and temperature 99.2 Fahrenheit. On physical exam, heart was regular, breath sounds were normal, and the abdomen was soft. Labs showed sodium 134, creatinine 1.65, glucose 427, lipase 137, and troponin negative. White blood cell count (WBC) 5.1, hemoglobin 13.0, and platelets 188. An electrocardiogram (EKG) showed normal sinus rhythm with premature supraventricular complexes and a left anterior fascicular block. Chest x-ray was negative for pneumonia. The patient was admitted for hyperglycemia. 

The inpatient admission was not medically necessary.

The patient presented with hyperglycemia found incidentally on laboratory testing and had no significant symptoms associated with this hyperglycemia. He did not have diabetic ketoacidosis and the attending admission note states that the patient did not need to be hospitalized. In addition, there was no evidence of acute infection or acute myocardial infarction, or other acute diagnoses that can trigger hyperglycemia. Creatinine was modestly elevated, consistent with acute kidney injury, and the diagnosis of diabetes was new, but these diagnoses alone would not require inpatient level of care.

The patient had an incidentally identified case of hyperglycemia with no evidence of diabetic ketoacidosis or other complications triggering hyperglycemia. He did receive additional care for an elevated creatinine along with diabetes teaching, but isolated hyperglycemia without other complications that are significant does not require inpatient level of care. The patient could have been cared for at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope
Treatment: inpatient interfacility transfer 
The insurer denied the inpatient interfacility transfer. The health plan's determination is overturned. 

This woman was hospitalized after a syncopal episode. Her cardiac risk factors included hypertension and hyperlipidemia. Cardiac monitoring revealed frequent ventricular premature complexes. Myocardial perfusion imaging showed a decreased left ventricular ejection fraction and reversible anterior, inferior and lateral wall perfusion defects, as well as a fixed apical defect. Neurologic evaluation, including magnetic resonance imaging (MRI), magnetic resonance angiography (MRA) and electroencephalogram (EEG), was unrevealing. Given the abnormal myocardial perfusion study, the patient was transferred to another facility for cardiac catheterization. 

The inpatient interfacility transfer was medically necessary.
This patient presented after a syncopal spell. She was found to have frequent ventricular ectopy. Myocardial perfusion imaging suggested evidence of extensive myocardial ischemia. Thus, coronary angiography was indicated. The facility the patient originally presented to, per their website, does not offer this service and she was transferred to another institution. Given the high risk myocardial perfusion study results and the patient's recent syncopal spell, which may have been ischemia-related, hospital discharge would not have been appropriate until cardiac catheterization had been performed. This warranted inpatient interfacility transfer.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Talz.

The health plan denied the request for Taltz.  The health plan's determination is upheld.

The patient is a male with moderate to severe psoriasis (over the 20% body surface area involvement) that includes the scalp, knees, and elbows. The patient has tried and failed topical Calcipotriene solution and ointment, Clobetasol foam, Halobetasol ointment, Betamethasone lotion, and Ultravate cream. The patient has a history of elevated cholesterol and statin use, and Methotrexate and Acitretin have therefore been avoided.

The effectiveness of the non-formulary drug Taltz is under review.

The health plan's determination of Taltz coverage is upheld, in whole.

The patient has no documented treatment failure with, or true medical contraindication to, either first-line Methotrexate or Acitretin, in that Methotrexate is not affected by statin use or elevated cholesterol, and Acitretin is acceptable if the patient's cholesterol levels are controlled medically. Furthermore, the patient has no documented treatment failure with, or true medical contraindication to, either of the formulary-preferred second/third-line agents Cosentyx, Enbrel, Otezla, Humira, Cimzia, Skyrizi, Stelara, or Tremfya. These systemic therapies are no less effective, and with no greater incidence of adverse effects, as the requested Taltz.

Modern dermatology literature [1-4] supports use of the formulary and preferred medications as similarly efficacious to the requested Taltz, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Taltz is not considered more effective.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis vulgaris, psoriatic arthritis.
Treatment: Cosentyx.
The insurer denied the Coesentyx.
The determination is upheld.

The patient has longstanding moderate to severe psoriasis (more than 10% body surface area involvement) and arthritis. The psoriasis affects his face, ears, dorsal hands, trunk, lower extremities, gluteal cleft and genitals. Stiffness of the hands, bilateral knees, and multiple metacarpophalangeal (MCP) joints are noted with swelling. The patient has tried and failed topical fluticasone ointment, Protopic, and hydrocortisone, as well as a topical Taparinof clinical trial. The patient has a family history of cancer in his father and mother, so Humira, Cimzia and Stelara have been avoided. Methotrexate has been avoided because of the patient's extensive psoriatic disease. At issue is the medical necessity of Cosentyx.
The Cosentyx is not medically necessary. The patient has no documented treatment failure with, or true medical contraindication to either Methotrexate, Humira, Skyrizi, Stelara, Tremfya, or Skyrizi. The patient does remain a candidate for both Methotrexate and a Non-Steroidal Anti-Inflammatory Drug to treat both the skin and joint symptoms of his psoriasis. The patient's severity is not too extensive for first line methotrexate use. The patient has a family history of cancer, but not a personal history of cancer, so that Tumor Necrosis Factor inhibitors and Stelara are appropriate for treatment with this patient; virtually all patients receiving Tumor Necrosis Factor were treated for rheumatoid arthritis, while those treated for other conditions did not have any significant increase in the incidence of cancer. Stelara is not a Tumor Necrosis Factor inhibitor, and does not have any significant incidence of increased cancer. Simponi is Food and Drug Administration (FDA) -approved for psoriatic arthritis but not for psoriasis, but other formulary alternatives exist for this patient. Tremfya is Food and Drug Administration (FDA) -approved for psoriatic arthritis as well.
Therefore, the requested Cosentyx is not medically necessary. Furthermore, modern dermatology literature [1-4] supports use of the health plan preferred medications as similarly efficacious to the requested Cosentyx, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Cosentyx is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis.
Treatment: Personal Care Aide (PCA) Level 2: 24 hours per day - Live-In per diem - 7 days per week. 

The insurer denied Personal Care Aide (PCA) Level 2: 24 hours per day - Live-In per diem - 7 days per week.  The health plan's determination is upheld. 

The patient is a male with past medical history significant for brain tumor (schwannoma), osteoarthritis, urinary incontinence, chronic obstructive pulmonary disease (COPD), asthma, coronary heart disease, hypertension, neuralgia and neuritis, cerebrovascular disease with previous transient ischemic attack (TIA).

Personal Care Aide (PCA) Level 2: 24 hours per day - Live-In per diem - 7 days per week is not medically necessary for this patient. There are inconsistencies in the data provided. In the complaint, it states that the patient's daughter and granddaughter are supportive and not involved in the care and that the patient lives alone and has no informal care givers. However, viewing the logs of the patient's needs at night, they were signed by the patient's daughter who is providing the care. So, it appears from information provided that the patient's daughter is available to provide care informally at night. These were listed in the logs of 9 PM to 9 AM shift.

It was also noted that the patient can walk 2 streets down the block. Toilet use noted limited assistance, and the patient notes that he needs light touch guidance for bed mobility and toilet use due to unsteady gait.

The patient reports bladder incontinence only occurs a few times a week. However, he denies having bowel incontinence. The patient is contact guidance for toilet use and uses a seated roller walker indoors.

The services allotted by the plan are sufficient to meet the patient's needs. It does appear that the patient can ambulate indoors with a roller walker and can ambulate outside. It does not appear that he has had significant change in his medical ability. There is no evidence that the patient needs nocturnal care such as changing diapers for bedsores or other open wounds at night. Informal care is being provided by family members according to patient logs which were provided.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Aortic stenosis, bladder cancer, coronary artery disease and bladder cancer.
Treatment: Increase Home Care/Personal Care to 84 Hours Per Week
The insurer denied the Increase Home Care/Personal Care to 84 Hours Per Week.
The denial is overturned. 

The patient is a male with a history of aortic stenosis, bladder cancer, coronary artery disease and bladder cancer. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 84 hours/week Personal Assistance Services is deemed medically necessary.

Recent documentation from the patient's medical provider indicates that due to progressive functional decline and worsening mobility, the patient is now chronically homebound and requires extensive/maximal assistance with all activities of daily living. Hence, the currently approved plan of 56 hours/week Personal Assistance Services is insufficient to meet the patient's current needs.

For these reasons, the proposed treatment 84 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied the Braces.
The determination is upheld.


The patient has a Class I occlusion with deep overbite. She has minor maxillary and mandibular spacing. Teeth number 7 and 10 are undersized and she is missing a mandibular incisor. She is treatment planned for 36 months of orthodontics to correct her malocclusion. At issue is the medical necessity of the braces.
There is no medical reason to correct her malocclusion with braces. While the patient has minor spacing, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence (1), however, this patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. (2) If her teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health.
For these reasons, the treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Tukysa. 
The denial is upheld.

The patient is a male with metastatic gastroesophageal junction (GEJ) adenocarcinoma. The tumor is human epidermal growth factor receptor 2 (HER2) positive. The patient has progressed after multiple line of therapy including Herceptin. Tukysa has been recommended and is under review for medical necessity.

The health plan's determination is upheld in whole.

Treatment with Tukysa is not medically necessary for this patient.
There is a paucity of data indicating that tucatinib (Tukysa) is efficacious for the treatment of metastatic, recurrent GEJ cancers. The proposed approach is not supported by the peer-reviewed literature as there are no randomized trials that have demonstrated an outcomes benefit to this approach. The use of tucatinib in this diagnosis remains the subject of ongoing study in multiple trials including, but not limited to, National Clinical Trial (NCT) 04499924. The National Comprehensive Cancer Network (NCCN) does not recommend the use of this agent in this setting. For these reasons, medical necessity cannot be established for tucatinib in this clinical scenario.