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

Diagnosis: Atopic dermatitis.
Treatment: Dupixent SC Injection.
The insurer denied the Dupixent SC Injection.
The denial is overturned. 

Yes, the treatment with Dupixent is medically necessary.

The patient is a female with atopic dermatitis. She has been treated with topical steroids, topical Tacrolimus, systemic steroids and antihistamines. Her provider is requesting treatment with Dupixent (dupilumab).

Dupilumab is United States Food and Drug Administration-indicated for treatment of recalcitrant atopic dermatitis. Dupilumab is a novel interleukin-four and interleukin-13 blocker, which inhibits the arm of the immune system responsible for atopic dermatitis. In clinical trials, after 12 weeks of monotherapy with dupilumab, 85% of patients had a greater than 50% reduction in eczema severity and pruritus scores decreased by 57.1%. In phase III clinical trials, dupilumab led to a 75% improvement in eczema severity, when compared to placebo, and decreased symptoms of anxiety and depression. It also led to a significantly decreased use of topical corticosteroids. The safety and efficacy were supported in a recent meta-analysis of all published dupilumab paper.

Given the current pandemic, and the patient's inability to perform phototherapy, Dupixent is an approved, safe and effective therapy. Systemic immunosuppressants are not ideal in the coronavirus pandemic. Therefore, the treatment with Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma, Viral Bronchitis
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is upheld.

This is a female patient with a history of immunocompromised status and mild intermittent asthma. She presented to the Emergency Department (ED) with complaints of shortness of breath, productive cough, fever and some weakness. Her presenting vital signs were: temperature was 100.9F, heart rate was 110, respiratory rate was 20, blood pressure was 148/90 mm Hg and oxygen saturation was 98%. The patient was awake and oriented. She was in no respiratory distress. A lung exam revealed bilateral wheezing. The white blood cell (WBC) count was 13.5K, the sodium level was 132 and electrolytes were within normal limits. A chest x-ray was performed that showed no acute infiltrates. The patient was treated with steroids, bronchodilators and Tamiflu. An influenza screen came back negative. Parainfluenza was positive. A deep vein thrombosis (DVT) study was negative and the EKG had no acute changes. The patient was admitted for asthma and viral bronchitis.

This patient did not need acute hospitalization. She could have been placed on Observation status while diagnostic testing and treatment were initiated. The patient was treated with steroids, bronchodilators and antibiotics. The patient remained afebrile and hemodynamically stable after admission.  The patient was afebrile and hemodynamically stable. The temperature was 98.8F and oxygen saturation was 97%. The patient was in no acute distress. Lung exam revealed bilateral wheeze. The patient was alert and oriented x 3. There was no evidence of pneumonia. A deep vein thrombosis study was negative, an influenza screen was negative and parainfluenza was positive. The patient was tolerating oral intake.

The patient could have been placed on oral Azithromycin. The patient was on oral Prednisone. The patient did not need acute inpatient hospitalization. She could have continued on maintenance medications and discharged home with close follow-up in an outpatient setting. The prior denial is upheld. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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

Diagnosis: Central Nervous System / Neuromuscular Disorder.
Treatment: Skilled Nursing Facility (SNF).
The insurer denied: continued SNF inpatient care.
The denial is: Overturned in whole.

The patient is a female with diagnosis of weakness and urinary tract infection. The patient was admitted to skilled nursing facility from an extended hospital stay. The patient was hospitalized as a result of multiple sclerosis which has caused a decline in the bilateral lower extremity (BLE) strength, ambulation, standard balance/tolerance, and functional independence. The patient remained at the skilled nursing facility and the issue at hand is the denial of the continued skilled nursing facility inpatient care.
The subject under review is the medical necessity for the continued skilled nursing facility care.

The health plan's determination is overturned in whole

The requested service of continued skilled nursing facility inpatient care is medically necessary for this patient.
The patient is a female with a medical history significant for multiple sclerosis.  Therapy noted that patient required maximum assistance for hygiene, minimum assistance for upper body dressing, maximum assistance for lower body dressing, setup for grooming, dependent toileting, and functional transfers.  Bed mobility was maximum assistance of 2.  Given her history of multiple sclerosis it is expected that rehabilitation gains be at a slower pace.  With that being said, the patient did make functional progress.  Three and half weeks later the patient had progressed to moderate assistance (MODA) for hygiene (from maximum assistance [MAXA] ), contact guard assist (CGA) for upper body dressing (from minimal assist [MINA]), MODA for lower body dressing (from MAXA) and MODA from bed mobility (from MAXA).  In addition, this continued skilled stay is medically necessary and in the best interest of the patient since during weekly wound rounds, it was documented that the patient had developed a "Stage three pressure ulcer with 50% slough noted in wound bed, size noted to increase slightly, no pain medium amount of drainage noted."  The patient's new stage three pressure ulcer now required dressing change every shift and as needed (PRN) which means that continued skill nursing is medically necessary for skin care management. 
The requested continued skilled nursing facility inpatient care is medically necessary for this patient. The patient has a diagnosis of multiple sclerosis and while progress was slow it continued to be functional.  In addition,  she had documentation of new stage three pressure ulcer that required dressing change every shift and needed close monitoring to prevent progression.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Primary Ciliary Dyskinesia (PCD); chronic bronchitis; asthma 
Treatment: Airway Clearance Device (E0483RR) 

The insurer denied coverage for Airway Clearance Device (E0483RR). The denial is reversed. 

This patient is a female with a diagnosis of chronic bronchitis and asthma. The patient had been on Symbicort, and required prolonged treatment with antibiotics. The patient's pulmonary function testing dropped significantly to 55% during a respiratory illness from her baseline of 89%. There was a history of a chronic cough with sputum production. The Pediatric Pulmonologist performed a chest computed tomography (CT) scan which demonstrated that the patient had bronchiectasis in the right middle and lingulair lobes. The patient was then started on airway clearance with the Aerobika airway clearance device. The patient was referred to a hospital for a consultation to evaluate for a diagnosis of Primary Ciliary Dyskinesia (PCD). 

The patient's nasal nitric oxide test was low on two occasions. The patient's PCD genetic testing detected one PCD mutation and the patient's electron microscopy of her cilia was tested normal. Since the patient's chronic cough and purulent sputum did not improve with use of the Aerobika, the patient was ordered the VEST airway clearance device to help treat her bronchiectasis and prevent worsening of her lung disease and bronchiectasis. 

According to the literature review, the VEST therapy is accepted and considered the standard of care to improve airway clearance in children with Cystic Fibrosis, PCD and other causes of bronchiectasis. In this case, the patient had bronchiectasis confirmed by computed tomography (CT) scan of the chest. The patient's history of chronic cough with purulent sputum, and persistent pulmonary infections compromising respiratory status and function prompted the patient's workup for a possible diagnosis of polycystic ciliary dyskinesia (PCD). Though the patient's electron microscopy studies and PCD genetics did not confirm the diagnosis, the patient was noted to have a low nasal nitric oxide. The patient was trialed on Aerobika airway clearance device with no improvement. With this patient's severe respiratory symptoms refractory to standard treatments, the patient was trialed on the VEST airway clearance in the office. The patient's airway clearance responded well to this treatment. Thus, the patient was continued on treatment with the VEST airway clearance device at home. Based on the review of the literature and this patient's positive response to the VEST airway clearance device, the requesting airway clearance device is considered medically necessary for this patient. 

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

The carrier's denial of coverage for the Airway Clearance Device (E0483RR) for dates of service specified is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Inpatient admission

The insurer denied the inpatient admission

The denial was upheld.

This is a male patient with history of alcohol abuse and traumatic brain injury. He was brought to the Emergency Department (ED) by Emergency Medical Services (EMS) after having a witnessed seizure after falling down from his bike. His presenting vital signs were: a pulse rate of 104, a blood pressure of 128/62 and his oxygen saturation was 97%.  A physical examination was performed that revealed the patient was alert and oriented with no focal or motor deficits noted; he was a poor historian with a poor memory. Neurology was consulted. A computed tomography (CT) scan of the head was performed and noted to be unremarkable.  The patient was admitted for observation.  The patient was given Depakote. An electroencephalogram (EEG) was performed with normal results. Laboratory studies were done that revealed elevated liver function testing with white blood cells present in the urine.  The patient reported that he had been lightheaded since his prior traumatic brain injury. The patient experienced no seizure activity during his hospital admission. The patient was medically stable and discharged.

The acute inpatient admission for seizure is not medically necessary. The patient presented to the Emergency Room after a seizure. He was alert and oriented. No post-ictal confusion or weakness was noted. A CT scan of the head was unremarkable. There were no outstanding labs or vital signs. It was recommended that the patient start the anticonvulsant Depakote. There was no acute inpatient need for admission based on the history. The patient did not have repeat seizures. Depakote could have been started from the Emergency Room and the patient could have followed up with Neurology as an outpatient. He did not have any other comorbid conditions. He did not require acute rehabilitation. He did not have acute nursing needs. There was no clear justification for an extended admission for several days. 

The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.

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: Abdominal Pain, Ruptured Ectopic Pregnancy
Treatment: Inpatient admission
The insurer is denied coverage for the inpatient admission.
The denial is upheld.

This is a female patient who presented to the hospital with abdominal pain. She underwent an emergency laparoscopy with a right salpingectomy and evacuation of a hemoperitoneum. The operative procedure was uncomplicated. Postoperatively, the patient was stable. Her medical management included intravenous (IV) Morphine, IV fluids, IV Metoclopramide and IV Ondansetron. Once the patient was medically stable she was discharged with outpatient follow-up.

The patient presented with a straightforward diagnosis of an ectopic pregnancy necessitating immediate surgical management. The patient underwent a laparoscopic right salpingectomy. The procedure was uncomplicated. At no point was the patient unstable and no blood transfusion was needed. The surgical management of an ectopic pregnancy is an outpatient procedure. The surgery most commonly involves a laparoscopic procedure which is an ambulatory surgery.

According to MCG, Inpatient and Surgical Care, Laparoscopic Gynecologic Surgery, including Myomectomy, Oophorectomy and Salpingectomy, laparoscopic procedures are ambulatory procedures. Inpatient stay may be needed for:

1)  Older patients (> 65)
2) Conversion to abdominal procedures
3)  Surgical complications
4) Comorbidities

This patient did not have any of these criteria. She is young and healthy. Her procedure was uncomplicated. There was no evidence of any injury to other organs. There was no medical reason given for the admission.

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

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

Diagnosis: Obstructive sleep apnea
Treatment: Oral appliance
The insurer denied the oral appliance. 
The denial is upheld. 

No, the proposed treatment was not medically necessary

The patient is a female with snoring.  The patient had a home sleep study with an apnea hypopnea index (AHI) of zero and respiratory distress index (RDI) of 7.6.  There were no oxygen desaturations.  A request is made for an oral appliance.

Medical necessity for an oral appliance was not established by the patient's sleep study which did not demonstrate clinically significant sleep apnea.

In a 2006 review of the literature, there is support for use of oral appliances in mild to moderate sleep apnea.  Higher severity of obstructive sleep apnea (OSA) was identified to be associated with less efficacy of oral appliances.  The range of reviewed studies reported efficacy in severe sleep apnea was 14 - 61%.  Some problems were reported in studies with success not always defined as AHI below ten but rather 50% reduction in apneic events which can still mean severe sleep apnea in some patients.  Of note, the basis for success in most studies was reducing the patients' severity of sleep apnea to a level below ten events per hour. This patient did not meet the criteria for sleep apnea with a baseline AHI of zero.  This review offers a comprehensive bibliography on this subject.  No large scale clinically controlled trials since that date displace the results of this review.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ischemic Cardiomyopathy, Coronary Artery Disease 
Treatment: Wearable automatic external defibrillator life vest (K0606RR)
The insurer denied coverage for wearable automatic external defibrillator life vest (K0606RR).
The denial is upheld. 

This is a male patient with a history of ischemic cardiomyopathy, hypertension, coronary artery disease status post percutaneous intervention (PCI) with 2 stents and myocardial infarction (2018) with PCI x 3 and hypertension. The patient's echocardiogram performed showed an ejection fraction (EF) of 30-35%. A Life Vest was ordered, with an estimated length of need of 4 months. Per the Treatment Plan, there was a planned date to re-assess the patient's EF. The patient was waiting for an echocardiogram and EF after his last percutaneous coronary intervention, while being managed medically. The plan was to reassess his EF and to place an implantable cardioverter device (ICD) as indicated by his EF.

The Life Vest is FDA approved for prevention of sudden cardiac death. However, the use of Life Vest for the dates under review is not medically necessary. The patient was diagnosed with ischemic cardiomyopathy, with ejection fraction of 30-35%. This technology has not been shown to be clinically beneficial when compared with standard-of-care medical therapy for prevention of sudden cardiac death in patients with newly diagnosed cardiomyopathy. For the dates under review, Life Vest technology is not medically necessary. There is no clinical research evidence documenting incremental benefit of this technology over conventional medical therapy in prevention of sudden cardiac death. This technology would therefore be considered experimental and/or investigational in this clinical setting and does not represent the standard of care for such patients. The patient's clinical presentation and the absence of extenuating circumstances do not support the medical necessity for use of the requested, Life
Vest for the dates under review.

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 wearable automatic external defibrillator life vest (K0606RR) is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sinusitis
Treatment: Inpatient admission
The insurer is denied coverage for the inpatient admission. 
The denial is upheld.

This is a female patient with history of sinusitis and chronic lower back pain. She presented to the Emergency Department (ED) with complaints of fever, sore throat, and neck pain. The patient's vitals on presentation included: temperature 100.1 F, blood pressure 124/75, pulse 90, respiratory rate 20, and an oxygen (O2) saturation of 99% on room air. The patient's laboratory results showed white blood cell (WBC) count 15.6, hemoglobin 12.2, hematocrit 36.8, creatinine 0.69, glucose 96, and influenza A, B negative. The patient was started empirically on intravenous (IV) antibiotics (i.e. Unasyn) for possible sinusitis. The patient's computed tomography (CT) scan of the sinus was unremarkable without evidence of mastoiditis or sinusitis. All cultures remained negative. The patient's repeat laboratory results were normal. The patient remained afebrile and hemodynamically stable. The patient was discharged with the clinical diagnosis of viral syndrome.

According to documentation, the patient presented with upper respiratory infection (URI)
symptoms. Otherwise, the patient had a low-grade fever of 100.1 F, and was hemodynamically stable and resting comfortably. Similarly, the patient's laboratory results only showed a nonspecific elevation of white blood cell (WBC) count. The patient had no clinical evidence for a systemic infection, was able to tolerate oral intake, and had no significant co-morbid conditions that warranted inpatient admission. Based on above findings, the patient could have been treated at the Observation level of care. Thus, inpatient admission was not medically necessary for this patient. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal 
Prosthetics

Diagnosis: Above the Knee Amputation 
Treatment: Above Knee (AK), Molded Socket, Open End, SACH Foot, Endoskeletal System, Single Axis Knee 

The insurer denied the Above Knee (AK), Molded Socket, Open End, SACH Foot, Endoskeletal System, Single Axis Knee. The health plan's determination is upheld. 

The patient is a male with past medical history significant for left above the knee amputation. He received a Plie 3 Microprocessor knee with Kinterra foot. Documentation noted that it lost suction despite attempts to fix and adjust. "Knee unit is malfunctioning and leaking fluid again after two repairs in the last year. Foot is leaking fluid." Therefore, a Linx microprocessor knee, ankle foot system by Endolite was recommended and then obtained 3 years ago. 

The requested Above Knee (AK), Molded Socket, Open End, SACH Foot, Endoskeletal System, Single Axis Knee is not medically necessary for this patient as the patient has a relatively new Linx microprocessor knee, ankle foot system by Endolite that was received 3 years ago and does not have any documentation of it being broken. There is no documentation regarding its repair or possible inability to be repaired.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck Pain, Type 2 Diabetes Mellitus, Anemia
Treatment: Consumer Directed Personal Assistance Services (CDPAS)
The insurer is denied coverage for Consumer Directed Personal Assistance Services (CDPAS)
The denial is overturned.

This is a female patient with the following diagnoses: neck, thoracic, low back pain, type 2 diabetes mellitus, anemia, obesity, shortness of breath (SOB), chronic migraine, chronic fatigue, hypertension (HTN), gout, dizziness, hypothyroidism, bilateral knee pain, insomnia, left shoulder pain, urinary incontinence, and gait abnormality. As per the review of the Uniform Assessment System (UAS) of the patient, the patient's condition deteriorated and she was prone to falls. The patient's gait was documented to be unbalanced, and the patient was not able to walk more than one block. The patient's provider recommended that this patient needed Home Health Aide assistance 7 hours per day, 7 days per week to avoid trauma and complications of her condition.

The patient had osteoarthritis and she reported arthritis pain in her hands which limited her ability to perform tasks requiring hand dexterity and strength, including household tasks and personal care. The extent of the patient's arthritis was not fully described, but it was noted in the UAS that the patient also had pain in her legs and back, and the physician's letter reported bilateral knee pain. Back and lower extremity pain can adversely affect mobility including transfers, walking, toileting, bathing, dressing and most household tasks. The patient reported pain as 7 out of 10, in severity with only partial improvement to 5 out of 10, in severity with mediation and at rest. It was noted that the patient did not want to take strong pain medication. As per UAS medication list, the patient was taking tramadol, diclofenac (topical) and Tylenol. The patient was receiving physical therapy at the time of the 1/ UAS. It was likely that one of the goals of physical therapy (PT) was to help with her pain relief. 

The patient lived alone and had no informal caregivers to help her with daily activities. When the aide leaves for the day, the patient needs to perform all daily activities without help. When she is having pain or feels unsteady during daily activities, performing each task can become a physical burden. Older people who are functionally impaired and live alone also have higher risk of depression and anxiety. In this case, the patient had a history of mood disorders, and it was noted in the UAS that she often felt sad and anxious due to her poor health.

Based on the review of the medical record and literature, extended coverage of Consume
Directed Personal Assistance Services is considered medically necessary for this patient. 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 49 hours per week of Consumer Directed Personal
Assistance Services (CDPAS) should be reversed. The medical necessity is substantiated.