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

Diagnosis: Psoriatic Arthritis. 
Treatment: Taltz autoinjector 80 mg/ml (milligram/milliliter) auto injct [auto injector] 2.0 for 28 days. 

The insurer denied coverage for Taltz autoinjector 80 mg/ml (milligram/milliliter) auto injct 2.0 for 28 days. 

The denial is overturned. 

This case involves a female with a history of psoriatic arthritis. The physician indicated she has severe disease presenting with fatigue as well as pain in hands, low back, knees, ankles, and elbows. The documentation detailed she has morning stiffness lasting 20 to 30 minutes and has trialed and failed medications that include sulfasalazine, capsaicin, ibuprofen, naproxen, and diclofenac. She also has numerous comorbidities that include diabetes, fatty liver, immunocompromised status, osteopenia, and xerosis of skin. The physician detailed tumor necrosis factor (TNF) inhibitors such as Humira and Enbrel are not appropriate given the black box warnings. The physician has recommended she utilize Taltz to prevent further progression. 

She was seen for a follow-up due to the above. The documentation indicated she had tenderness and edema present to the bilateral wrists. There was tenderness present to the low back with decreased range of motion. There is also tenderness present to the bilateral knees. The recommendation was made to continue with medication. 

Based on the medical record available, this patient's multiplicity of diseases would warrant medication without a black box warning. Taltz is approved by the Food and Drug Administration (FDA) for psoriasis and psoriatic arthropathy and would be a good choice for this particular individual. 

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

The insurer's denial of coverage for the Taltz autoinjector 80 mg/ml (milligram/milliliter) auto injct 2.0 for 28 days is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myeloproliferative neoplasm. 
Treatment: Prevymis (letermovir) 480mg. 

The insurer denied the Prevymis (letermovir) 480mg. 
The denial is upheld. 

The patient in this case is a male with a history of myeloproliferative neoplasm. He underwent allogeneic stem cell transplantation.  He is CMV (cytomegalovirus) seropositive. He developed CMV (cytomegalovirus) viremia, requiring treatment.  His physician has recommended treatment with Prevymis (letermovir) to prevent CMV (cytomegalovirus) reactivation. This request was initially denied because insufficient information was submitted. 

No, the requested treatment with Prevymis (letermovir) is not medically necessary. 
The request in this case is for letermovir as secondary prophylaxis in a patient who has already been treated for CMV (cytomegalovirus) reactivation with IV (intravenous) gancyclovir.  Letermovir has not been very well-studied in this context. It is not a clear standard-of-care treatment for this indication. While there is some evidence of efficacy, it has only been studied in relatively small numbers of patients.  Given the relatively limited supporting data and availability of other more studied options (notably valacyclovir), the request for letermovir in this case is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease (CD). 
Treatment: Stelara every 4 weeks, Pre-service. 

The insurer denied the Stelara every 4 weeks. 
The denial is overturned. 

The patient is a male with moderate to severe Crohn's. He had failed steroids, and started Stelara 90 mg every 8 weeks. He had some but not a complete response, and colonoscopy revealed active ileitis. The attending physician is requesting to increase Stelara to 90 mg every 4 weeks. Stelara was denied as the dose is higher than the Food and Drug Administration (FDA) approved dose. 

Yes, medical literature supports dose intensification of biologics who lose response to FDA approved dosing. Stelara has been found to be safe and effective at doses as high as 90 mg every 4 weeks. Results from a retrospective cohort study of patients with CD reported that among 122 patients on ustekinumab, 21 (17%) patients on every 8 week maintenance dosing required dose intensification (frequency increased to every 4 weeks, every 6 weeks, or a combination of intravenous (IV) booster and frequency increase to every 6 weeks or every 4 weeks). A total of 11 patients (52%) had clinical response after dose escalation (2 [18%] were primary non-responders to induction while 9 [82%] had poor initial clinical response). A multicenter, retrospective, open-label cohort study of adults with moderate to severe CD was conducted to evaluate the long-term maintenance efficacy of ustekinumab therapy. During the maintenance therapy, dose escalation was required in 16.3% (17/104) of patients and a combination strategy of reinduction and dose escalation was required in 6.7% (7/104) of patients.
The most common escalated maintenance dosing was 90 mg subcutaneous (SC) every 4 or 6 weeks. Clinical response was regained in 52.9% (9/17) of patients who had dose escalation, and 57.1% (4/7) of patients who had combined reinduction and dose escalation. Results from a retrospective, multicenter, open-label study of patients with refractory CD receiving ustekinumab, demonstrated that, among 11 patients who required a dosing interval reduction (includes 90 mg SC every 8 weeks to every 4 weeks, 90 mg SC every 8 weeks to every 6 weeks), clinical improvement was seen in 73% (8/11) of patients. Results from a retrospective, open-label, observational study of ustekinumab for the treatment of anti-tumor necrosis factor (anti-TNF) resistant CD patients, demonstrated that, among patients who achieved clinical response at the last follow-up, dose escalation was required in 35% (7/20) of patients who received ustekinumab 90 mg SC every 8 weeks. As dose intensification of Stelara in patients with inflammatory bowel disease has been found to be safe and effective at doses as high as 90 mg every 4 weeks, and as this patient lost response to Stelara 90 mg every 8 weeks, current medical literature or standard of care supports that the requested Stelara 90 mg every 4 weeks is clinically appropriate, accepted standard of medical care and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left arm/leg weakness, decreased sensation in face
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who presented to the emergency ward with the complaint of left arm and leg weakness and inability to close her eye. At presentation, she had decreased sensation on the left side of her face and she had left facial droop. Computed tomography (CT) of the brain at presentation was negative. Subsequent magnetic resonance imaging (MRI) of the brain was negative.  She was treated for Bell's palsy and discharged.

No, the proposed inpatient hospital admission was not medically necessary.

The patient had signs and symptoms of Bell's palsy. There was no significant deficit to support stroke and subsequent neuro-imaging was normal. There were no concerning features from history of examination to warrant an acute inpatient level of care. The monitoring, treatment, diagnostic studies and neurological consultation could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: weaning ventilator settings as tolerated, condensing feedings as tolerated while continuing with a stable weight gain

Treatment: continued rehabilitation

The insurer is denied coverage for continued rehabilitation.

The denial is upheld. 

This male patient has a history of prematurity, extremely low birth weight, anemia of prematurity, chronic lung disease, feeding difficulties, gastroesophageal reflux disease (GERD), gastrostomy (GT) tube dependence, severe tracheomalacia, tracheostomy dependence, ventilator dependence, opioid dependence with signs of withdrawal, chronic subdural hematoma, and patent ductus arteriosus (PDA).

Even though notes indicate that the patient had a respiratory tract infection, this could very well be managed as observation or outpatient. The patient did not have needs for escalated respiratory support, no need for multiple fluid boluses, no need for cardiorespiratory (CR) monitoring and no need for seizure precautions. If one were to take PEWS (pediatric early warning) score, it would always be 0 which is reassuring. Another risk stratification score is PRISM (pediatric risk of mortality) and that PRISM could have been 0 also which is very desirable. The patient could have been managed as an observational status.

There were no notes showing the condition or treatment. There was no indication that this care could not have been provided in an outpatient setting or in non-rehab bed. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

The carrier's denial of coverage for the continued rehabilitation is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Growth Hormone (GH) Deficiency

Treatment: Norditropin Flexpro 15 milligram (mg)/1.5 milliliter (ml) pen injector

The insurer denied coverage for Norditropin Flexpro 15 milligram (mg)/1.5 milliliter (ml) pen injector.

The denial is overturned.

This is a male diagnosed with growth hormone (GH) deficiency. This request is for Norditropin. His GH stimulation test with arginine and clonidine peaked at 4.28. His magnetic resonance imaging (MRI) showed his pituitary gland is small for age. His height velocity is reported to be 0.658 centimeters/year (cm/yr). His testes were 4 cc [cubic centimeter] bilaterally with Tanner 1. His insulin-like growth factor 1 (IGF1) was 101 (187-599 page 30); Z-score was - 3.0 standard deviation (SD); insulin-like growth factor binding protein 3 (IGFBP3) was 4 (3.3-10). His bone age was adolescence years at chronological age (CA). His height was 154.4 cm (-1.85 standard deviation score [SDS]). His mother's height is 165.10 cm and father's height is 182.88 cm and mid parental height is 180.49 cm (+0.51 SDS).

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2, [3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 yr more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr in children over 2 yr of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml [nanogram per milliliter].

This patient met biochemical criteria. GH stimulation testing peaked at less than 10ng/ml and IGF-I was low. The patient met height criterion 2 as his height is more than 1.5 SD below target height SD. Furthermore, his decline in height from the 22nd percentile to the 2.7 percentile is consistent with growth failure. The patient met both height and height velocity and biochemical criteria for the diagnosis of GH deficiency. GH in the treatment of GH deficiency is medically necessary.

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

The insurer's denial of coverage for Norditropin Flexpro 15 milligram (mg)/1.5 milliliter (ml) pen injector is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Humira Pen 40mg/0.8ml SC SOAJ, Pre-service
The insurer denied the Humira Pen 40mg/0.8ml SC SOAJ, Pre-service
The denial is overturned

The patient is a male with severe psoriasis for whom Humira is requested. He is obese.

Yes, the proposed Humira is medically necessary.
The patient has severe psoriasis for which systemic therapy is indicated. He is not a candidate for phototherapy because of the location of psoriasis in the scalp, which cannot be reached by phototherapy. In the era of biologic therapies for psoriasis, use of methotrexate (relatively contraindicated due to obesity), cyclosporine (relatively contraindicated due to history of hypertension) or acitretin is not the most appropriate first line treatment because their long term safety and efficacy are inferior to biologic therapies.

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 simple-measure for assessing psoriasis activity (S-MAPA) (physician global assessment [PGA] multiplied by body surface area) 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 the above data, Humira is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Subglottic Stenosis.

Treatment inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This was patient has a past history of asthma, allergic rhinitis, and iron deficiency anemia. The patient experienced dyspnea for some time which was misdiagnosed as asthma.  The patient was observed in the emergency department and on the ward with the clinical findings of dyspnea, difficulty talking, and stridor. She noted that her dyspnea had worsened over the past few days. She had been on prednisone.  
 Computed tomography (CT) revealed a subglottic stenosis. A repeat CT obtained found:

"HYPOPHARYNX/LARYNX: The valleculae and piriform sinuses are well-aerated. Epiglottis and aryepiglottic folds are normal. False and true cords are normal. There is narrowing of the subglottic airway. Circumferential soft tissue is noted along the inner aspect of the proximal trachea. Soft tissue is approximately 2 cm [centimeters] in length by up to 6 mm [millimeters] in thickness. At point of greatest narrowing the airway measures 8 mm anterior to posterior by 4 mm in width"

During her hospital course she was treated with steroids and other appropriate medications. Her respiratory symptoms improved, and she was discharged for follow-up by an otolaryngologist.  The peer revied literature1,2 recommends a trial of conservative therapy, e.g., oxygen and medication for initial care to avoid an unnecessary operative procedure such as a tracheostomy. The Milliman Care Guidelines (MCG) Health Recovery3 states that :

"Stridor or laryngospasm unresponsive to emergency management" is a criterion for admission. 

The patient was at high risk for airway obstruction as she had obvious increasing signs - dyspnea, stridor, difficulty speaking and symptoms - stridor and objective evidence of subglottic stenosis. Her hospitalization allowed for observation and medical treatment to improve her airway to prevent obstruction.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient had objective evidence of subglottic stenosis and had progressive symptoms of air way obstructions. She required hospitalization for proper care and observation that to ensure her safety if her obstruction progressed3.

The inpatient hospital admission was considered medically necessary for this patient. Her progressive airway symptoms required the proper medication and observation for possible progression her airway obstruction2,3.

The denial should be overturned as the hospitalization for the patient was necessary and in the best interest of the patient. The health plan did not act reasonably.

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

Diagnosis: Persistent Vomiting

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is a female with a past medical history significant for diabetes mellitus, retinopathy, peripheral neuropathy, hyperlipidemia, gastroparesis, colitis, and cholecystectomy who presented to the emergency department with complaints of abdominal pain and diarrhea after eating a chicken wrap. Vitals on presentation included: Temperature-98.3 Fahrenheit, Blood Pressure-127/82, Pulse-105, Respiratory Rate-16, Oxygen (O2) saturations-98% (percent) on room air. Laboratory values were notable for the following: white blood count (WBC)-6.1, hemoglobin (Hgb)-13.2, hematocrit (Hct)-40.4, creatinine-0.82, glucose-238. 

The patient was given intravenous fluids, Zofran, and intravenous antibiotics (metronidazole). Computed tomography (CT) scan of abdomen/pelvis showed non-specific findings and no obstruction, diverticulitis or appendicitis. Stool evaluation was negative for Clostridium difficile but positive for Cyclospora. Infectious Diseases consulted and recommended oral Bactrim. Ophthalmology also evaluated patient for chronic diabetic retinopathy. The patient remained afebrile, hemodynamically stable; she was discharged to continue antibiotics as an outpatient.

According to medical records, patient was admitted with gastrointestinal symptoms after consuming a chicken wrap. Otherwise, she was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC. Stool work-up was positive for Cyclospora, a parasitic infection typically self-limiting (recover without treatment) in immunocompetent patients. This patient had no evidence of dehydration. Based on above findings, patient met criteria for observation level of care management.  

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blurry vision to the left eye with mild headache, nausea.

Treatment inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This patient presented to emergency department complaining of a sudden onset of blurry vision to the left eye with mild headache, nausea, and numbness to the left cheek.  The documentation indicated she was concerned due to elevated blood pressure.  She reported a blood pressure of 146/90 and 164/100.  She did indicate her headache had resolved.  There was no difficulty with speaking, with balance and no evidence of weakness of the arms.  The physical examination revealed she was alert and oriented and in no apparent distress.  She seemed to have difficulty with left temporal gaze.  There was full range of motion and she had clear speech with a normal gait.  There was mild to moderate sensory loss, and it was recommended she undergo laboratory diagnostic studies.  She did not have any significant findings upon laboratory evaluation.  A computed tomography (CT) scan of the head revealed no acute intracranial pathology identified.  A CT angiogram was also performed indicating mild atherosclerotic plaque with an otherwise unremarkable angiogram of the neck and brain.  The patient also underwent a chest x-ray revealing no acute pulmonary disease.  An EKG (electrocardiogram) revealed a normal sinus rhythm at 77 beats per minute (bpm).  Upon reexamination it was noted she was utilizing left-sided facial muscle strength speech and facial expression however when asked she still has some difficulty.  She was admitted for further evaluation.  The documentation indicated she continue treatment and the following day was cleared for discharge due to a lack of further significant adverse events.

Regarding the requested inpatient admission, according to referenced literature, patient may be admitted when there is evidence of hemodynamic instability that is not corrected within the emergency department.  Additionally, if there are focal neurologic signs that recur or findings on imaging requiring inpatient care a patient may be admitted to an inpatient status.  The submitted documentation does not indicate the patient has the above findings.  The documentation indicated she presented initially and was evaluated with no significant findings that would warrant an inpatient admission.  Laboratory studies and diagnostic studies did not reveal any acute abnormalities warranting the requested admission.  Therefore, as there were no documented severe abnormalities on imaging, laboratory studies, or evidence of altered mental status or focal neurologic signs warranting the requested level of care. 

The health plan acted reasonably with sound medical judgment 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: Acute cholecystitis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient presented to the Emergency Department (ED) with complaints of intermittent epigastric abdominal tenderness for months. The patient had similar symptoms days prior and was discharged home with Protonix. The patient was admitted, was given bowel rest, and intravenous (IV) hydration, IV antibiotics, and pain control. He was taken to the operating room on hospital and underwent successful laparoscopic cholecystectomy.

Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year, and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. [5] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6]

Per clinical documentation, this patient presented to the ED with epigastric abdominal pain for 4.5 hours. There was associated nausea but no vomiting. Vital signs in the ED were within normal limits. An ultrasound demonstrated findings consistent with acute cholecystitis. Liver function tests were within normal limits. White blood cell count was 10.5. The patient was taken to the operating room for a laparoscopic cholecystectomy. There were no reported complications. There are no indications for a cause for delay of the surgical procedure. According to clinical documentation, the patient did not have any medical indications for an acute inpatient admission. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. The hospital acted reasonably with sound medical judgment 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.