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

Diagnosis: Psoriasis.
Treatment: Skyrizi, Pre-service.

The insurer denied the Skyrizi, Pre-service.  The denial is overturned. 

The patient is a male with severe psoriasis affecting 65% body surface area and involving sensitive areas of the face and genitals. He has tried and failed topical steroids, topical antifungals, and tar shampoo. He has no significant comorbidities and does not drink alcohol. The request is for Skyrizi.

Yes, the proposed treatment with Skyrizi is medically necessary.

The patient has severe psoriasis for which systemic therapy is indicated. In the era of biologic therapies for psoriasis, the use of methotrexate, cyclosporine or acitretin is not the most appropriate first-line treatment because their long-term safety and efficacy are inferior to biologic therapies. Because of involvement of sensitive areas, phototherapy is not appropriate.

Skyrizi (also known by its generic name risankizumab-rzaa) was approved by the Food and Drug Administration (FDA) for the treatment of moderate-to-severe plaque psoriasis in adults. Skyrizi works within weeks.  Three out of 4 of patients saw 90% clearer skin within four months (16 weeks). In clinical trials, Skyrizi helped people achieve both clearer skin and psoriasis symptom relief. A majority achieved 100% clear skin at one year. At four months (16 weeks), on average, people reported a significant improvement in the pain, itching, burning, and redness of psoriasis. 

Biologics show superior results to conventional systemic therapies (70% improvement versus 40% improvement) for the treatment of patients with moderate to severe psoriasis, as measured by decrease in S-MAPA (physician's global assessment [PGA] multiplied by body surface area [BSA]) at week 24. These results were observed despite the fact that patients on biologics had a greater baseline severity and had a greater number of previous treatments.

Based on this data, Skyrizi is medically necessary.

The patient has severe psoriasis for which systemic therapy is indicated. In the era of biologic therapies for psoriasis, the use of methotrexate, cyclosporine or acitretin is not the most appropriate first-line treatment because their long-term safety and efficacy are inferior to biologic therapies.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned. 

The patient is a male with a past medical history (HX) of coronary artery disease (CAD), atrial fibrillation (AFib), hyperlipidemia (HL), hypertension (HTN), and benign prostatic hyperplasia (BPH). The patient awoke with severe left (L) abdominal pain and L sided chest pain and presented to the emergency department (ED). The patient denied vomiting, diarrhea, leg swelling, and rashes. His vital signs (VS) on presentation were a heart rate (HR) at 110, blood pressure (BP) was 110/76, respiratory rate (RR) was 18, blood pressure (BP) was 121/77, and pulse oxygen (O2) saturation was 98% on room air (RA). The physical exam (PE) noted the male patient was in discomfort, but no cardiac, pulmonary, or abdominal abnormalities were noted. 

His labs noted a sodium (Na) at 140, potassium (K) was 4.3, chloride (Cl) was 105, carbon dioxide (CO2) was 22, blood urea nitrogen (BUN) was 23, creatinine (Cr) was 2.01, white blood cell count (WBC) was 14.2, hemoglobin (Hgb) was 17.3, platelets (Plt) were 190, and Troponin T level was 11. The electrocardiogram (EKG) showed a right bundle branch block (RBBB) and left axis deviation. The patient underwent a computed tomography (CT) scan of the chest, abdomen and pelvis which revealed left hydronephrosis and perinephric stranding due to a 5-millimeter (mm) calculus.
He was admitted for management of acute kidney injury secondary to obstructing nephrolithiasis. He was started on morphine for pain control, alpha blockers and intravenous (IV) hydration to assist with stone passage. The patient was seen by urology who noted that the stone had not passed and given his chest pain and AFib with rapid ventricular rates on admission, the patient underwent stent placement while awaiting cardiology consult. The patient was recommended to continue diltiazem for rate control. He underwent stent placement and was discharged home with plans to follow up with urology for lithotripsy. 

At issue is the Inpatient Stay for medical necessity. 

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

The requested health service/treatment of Inpatient Stay was medically necessary for this patient. 

The patient was admitted for obstructive uropathy with acute kidney injury. The patient had no history of prior kidney disease and presented with a glomerular filtration rate (GFR) of 35 milliliters (ml)/minute (min). In a patient without kidney disease, a normal GFR would be greater than (>)100ml/min. [1] The patient had some improvement on day 2 with his GFR at 42 ml/min but was well below normal for a patient without chronic kidney disease (CKD). Thus, the patient warranted urologic intervention given the acuity of renal injury before permanent damage was done. 

Therefore, the health treatment of Inpatient Stay was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-seizures.
Treatment: Inpatient hospital stay.

The health plan denied the inpatient stay as not medically necessary.  The reviewer has overturned in whole the health plan determination.

The patient has a history of psychiatric symptoms, including bipolar affective disorder, cluster B personality disorder, attention deficit hyperactivity disorder, and possible frontal lobe epilepsy. She was having recurrent spells consisting of staring and hyperventilation, or of rage attacks. The spells were occurring several times per day. Her physician thought that the patient's spells might be epileptic seizures. This consideration was bolstered by the fact that an earlier electroencephalogram (EEG) was abnormal and suggestive of generalized epilepsy. Because the patient was having frequent spells that might be seizures, she was admitted to the hospital and underwent continuous video-EEG monitoring. During the hospitalization, her anticonvulsant medication, Depakote, was discontinued. Over the course of the next three days, she had several of her spells, including staring spells and rage attacks. The spells were not associated with any electrographic changes, thus suggesting that the spells were behavioral and not epileptic in nature. The patient was discharged. The insurance company has denied coverage of the inpatient admission on the basis that the admission was not medically necessary.

Admission for continuous video-EEG monitoring was medically necessary in order to determine whether her paroxysmal events were epileptic or not. Admitting patients who are having paroxysmal events for video-EEG monitoring is a common and conventional approach to assessing these patients. It is a well-accepted practice among neurologists.
When a patient is having recurrent paroxysmal events, it is often difficult or impossible to tell from the description of the events alone, whether the spells are epileptic or due to some other cause, such as anxiety or a conversion disorder. In many cases, the only way to distinguish between epileptic and non-epileptic events is to conduct long-term video-EEG monitoring in the hospital. By capturing a spell on EEG, it is often possible to determine whether it is epileptic or not, thus allowing the patient to be properly treated. This patient was having recurrent spells suggestive of epileptic seizures. It was appropriate for her to be admitted to the hospital and to undergo continuous video-EEG monitoring.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Microscopic Colitis
Treatment: Fecal Calprotectin 
The insurer denied the Fecal Calprotectin 
The denial is upheld.

The patient is a female patient who has the diagnosis of microscopic colitis. As management for the patient's condition, the provider ordered a fecal calprotectin test. The plan denied coverage for this service, as the use of fecal calprotectin for the management of microscopic colitis is considered experimental/investigational.

No, the health plan should not cover the Fecal Calprotectin.
There is insufficient medical literature to show that the use of fecal calprotectin has a positive effect on healthcare outcomes for microscopic colitis. The articles available do not conclude as such, but rather suggest a benefit, and they are insufficient in size of patients evaluated to draw definitive conclusions.

No, the Fecal Calprotectin is not likely to be more beneficial.
The standard approaches to microscopic colitis evaluation are as beneficial as this proposed test.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Microscopic Colitis
Treatment: Fecal Calprotectin 
The insurer denied the Fecal Calprotectin 
The denial is overturned.

The patient is a female with a history of celiac disease and collagenous colitis, with chronic diarrhea. Her provider requested fecal calprotectin for further evaluation of the etiology of her diarrhea.

Yes, the health plan should cover the Fecal Calprotectin.
Per ACG (American College of Gastroenterology) Guidelines, fecal calprotectin has been shown to be a helpful test that should be considered to help differentiate the presence of inflammation (such as collagenous/microscopic colitis) from irritable bowel syndrome (IBS). It is a strong recommendation with moderate level of evidence. Therefore, as the test was ordered to determine if the patient's diarrhea was from inflammation, the requested fecal calprotectin was in accordance with generally accepted standards of medical practice in the United States. It is clinically appropriate and considered effective for the diagnosis of the patient's symptoms. Therefore, it was medically appropriate and should be covered by the health plan.

Yes, the Fecal Calprotectin is likely to be more benficial.
Standard therapy in the evaluation of chronic diarrhea to assess to see if the diarrhea is due to microscopic/collagenous colitis is to obtain stool studies and if negative, then proceed to a colonoscopy or flexible sigmoidoscopy and biopsy. As a fecal calprotectin in this situation could lead to avoiding an invasive procedure, it would be more likely to be beneficial than proceeding to colonoscopy or sigmoidoscopy and therefore is likely to be more beneficial for the enrollee than any available standard therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Emphysema, Chronic Obstructive Pulmonary Disease.

Treatment: Inpatient Subacute Rehabilitation Services.

The insurer denied coverage for Inpatient Subacute Rehabilitation Services.

The denial is overturned.

This is the case of a male patient who was admitted to the rehabilitation facility after being discharged from the hospital. He reported he lost his ability to ambulate and bear weight two weeks before the admission. The discharge documentation revealed the patient ran out of food and was unable to care for himself. He lay at home for two to three weeks. He reported dyspnea, cough, and urinary frequency. He stated he was previously wheezing weeks before the evaluation; however, he denied recent wheezing. The physical examination revealed the patient was cachectic and disheveled. He was alert and oriented to person, place and time. He underwent treatment with nursing, physical therapy, occupational therapy, speech therapy, and social work services. 

The patient was able to ambulate 75 feet with a front wheel walker with minimum assistance. He was able to transfer with minimum assistance. He was contact guard assisted for dressing and minimal bathing. He could ambulate 125 feet with a rolling walker. He was standby assist with transfers and ambulation. He had decreased cadence and a step toe pattern. His balance was fair. He was diagnosed with emphysema, chronic obstructive pulmonary disease, hypertension, heart failure with reduced ejection fraction, ischemic heart disease, anorexia, and physical disability, adult failure to thrive, weakness, difficulty in walking, not elsewhere classified, and other lack of coordination.

The records indicated that for the time period under review, the inpatient subacute rehabilitation services were medically necessary. The insurer stated the patient was admitted to a skilled nursing facility after being hospitalized for an altered mental status and dehydration. The insurer stated that the patient did not meet the criteria for an inpatient skilled nursing facility for the time period under review. 

The patient needed ongoing assistance with ambulation. He needed supervision for dressing/bathing. The patient also had ongoing significant life-threatening medical conditions that needed to be monitored, including severe chronic obstructive pulmonary disease, ischemic heart disease and anorexia. These ongoing disabilities and medical diagnoses required the need for ongoing skilled nursing.

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

The insurer's denial of coverage for the inpatient subacute rehabilitation service is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic Fibroids

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient is a female patient with a past medical history of symptomatic fibroids, who underwent a scheduled Laparoscopic Total Hysterectomy and Bilateral Salpingo-oophorectomy for fibroid uterus. The procedure was uncomplicated. The estimated blood loss was 100 milliliters (mL). The patient was stable post-operatively and was transferred to the post anesthesia care unit (PACU) and ultimately admitted to inpatient level of care, Gynecological service. The patient's hospital course included routine post-operative care. The patient was discharged with Obstetrics and Gynecology follow-up. 

Progress note indicated the patient was comfortable, no complaints, tolerating oral intake, and examination unremarkable.

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions.

Laparoscopic hysterectomies are outpatient procedures unless a complication arises. 

Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary.

According to Milliman Care Guidelines, Inpatient and Surgical Care 23 Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure.  Inpatient stay may be needed for:

-	Surgical complications (bladder ureter or bowel injury or hemorrhage)
-	Conversion to abdominal hysterectomy
-	Complex surgery (staging of endometrial cancer)
-	Wound complications
-	Comorbidities.

This patient did not meet any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. Post operatively, the patient was stable. Nothing in the submitted clinical information suggested any serious problem that warranted admission. 

Please note that laparoscopic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.

Based on the above, the inpatient admission was not medically necessary.
    
The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Home Health Care. 

The insurer denied increase in personal care assistance hours to 91 per week live in. 
The denial is upheld. 

The patient is a female with past medical history significant for breast cancer, hypothyroidism, dementia, depression, epilepsy, neuropathy, hypertension, cervical myelopathy, chronic subdural hematoma and abnormal gait. The patient has been approved for personal care assistance (PCA) services 7 days a week  x 8 hours a week for a total of 56 hours per week. The patient is requesting an increase in hours to 7 days per week x 24 hours live in for a total of 91 hours per week. The services were denied based upon lack of medical necessity. The subject under review is the medical necessity for the increase in hours. 

The Uniform Assessment System (UAS) State of New York was reviewed. The tasking tool - dated was reviewed. The UAS noted that the patient required a total of 56 hours a week for activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). This did not take into account any additional caregiver needs provided by her sister. Whether or not her sister provided informal care, documented medically necessary care was determined to be 56 hours a week. This was noted to be sufficient to meet her needs. Additional services are not medically necessary. 

The services provided are adequate to meet the patient's medical needs in the time noted. Additional services for "prevention of falls" for "monitoring" due to worsening cognition without functional services being provided are typically not covered. In order for services to be considered medically necessary, the aid must be performing a service such as a medically necessary ADL or IADL.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who presented to the emergency department with a chief complaint of dysphasia. The patient's wife reported that one hour prior to presentation, the patient was not speaking intelligibly. This episode lasted approximately two minutes and the patient's symptoms resolved afterward. Recent history was notable for a kidney biopsy. The patient also reported having a headache that he rated as an eight out of 10 in severity, originating from the posterior aspect of the head and radiating to the front. Other past medical history included asthma, lower back pain, thoracic aortic aneurysm, and coronary artery calcification. Vital signs showed blood pressure 191/93, heart rate 100, temperature 36.7 Celsius, and respiratory rate 16. On physical exam, heart was regular, breath sounds were normal, and there was no focal neurologic deficit. Head computed tomography (CT) was negative for acute stroke. Labs showed sodium 135, potassium 4.2, creatinine 1.95, glucose 95, and calcium 8.6. The patient was admitted for suspected transient ischemic attack (TIA). 

The inpatient hospital stay was not medically necessary. The reason is that the patient was hemodynamically stable, had no evidence of acute imaging abnormalities, was not septic or having seizures, and was overall stable. In addition, there was no evidence of hypertensive urgency or hypertensive emergency, and there was no evidence of other hemodynamic abnormalities that could have justified inpatient level of care. Neurology did state that small lacunes were viewable on the brain magnetic resonance imaging (MRI), but these were not acute. In addition, the dysphasia resolved by the time the patient arrived in the emergency department. Overall, care could have safely and effectively been provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar Radiculopathy and degenerative disc disease

Treatment: Current Procedure Terminology (CPT) codes 64483 and 64484, epidural steroid injections to treat back pain

The insurer denied coverage for CPT codes 64483 and 64484, epidural steroid injections to treat back pain

The denial is overturned

The patient is a woman with a history of lumbar radiculopathy and degenerative disc disease. The patient presented to the pain management physician's office for a lumbar transforaminal epidural injection to treat back pain. The procedure was performed without complications. She previously had epidural injections. The health plan denied the last 2 injections as exceeding a three per year limit.

Matte, et al.(1) reviewed how many epidural steroid injections (ESI's) are prudent. They concluded:" The most prudent principle is to utilize repeat steroid injections only in those who experience significant measurable benefit in pain and function from the index injection, and to space subsequent injections at intervals sufficient to allow full expression of the intended beneficial effect as well as recovery of adrenal function."
	
"Repeat ESI may be performed for recurrence of radicular pain with the expectation of recovery of most or all previously achieved benefit. Acute pain patients will likely recover all prior benefit. Repeat ESI, within three months of the index injection, can provide cumulative benefit." Similarly, Pandey(2) did not endorse a limit of the number of injections per year.

The Centers for Medicare and Medicaid Services (CMS) has promulgated local coverage determination (LCD) L34890 which states: "no more than six injections per year." The procedure provided was medically reasonable and necessary.

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

The insurer's denial of coverage for CPT codes 64483 and 64484, epidural steroid injections to treat back pain is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a man who presented to the hospital for scheduled cardiac catheterization and percutaneous coronary intervention (PCI). The patient's medical history was remarkable for hypertension, diabetes and hyperlipidemia. A cardiac catheterization had shown multi-vessel disease. Bypass graft surgery was recommended but the patient declined. During the procedure, PCI was performed for obstruction in the distal right coronary artery/posterior descending artery and for a chronic total occlusion of the first obtuse marginal artery. The procedure was uncomplicated. Post-procedure, the patient was admitted to the hospital. He was discharged the following day.

The inpatient hospital stay was not medically necessary.

This patient presented for scheduled percutaneous intervention after cardiac catheterization performed approximately three weeks prior showed multi-vessel disease. He was clinically stable at presentation. The procedure was uncomplicated. While some period of observation immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment (interval between ventricular depolarization and ventricular repolarization) elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications.

This patient met none of these criteria. Moreover, per the 2018 update to this document, patients who undergo uncomplicated PCI, including PCI for a chronic total occlusion, can be observed until they are at their baseline functional and mental status and their comorbidities are stable and then discharged. An inpatient level of care is not medically necessary in the absence of serious procedural complications or ST segment elevation myocardial infarction.