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

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

This is a female patient who presented to the emergency department (ED) with the complaint of abdominal pain. Her past medical history was notable for asthma and arthritis. She was evaluated with an examination, labs, and imaging. This assessment revealed right lower abdominal tenderness and computed tomography (CT) findings of acute appendicitis. Her vital signs were normal at the time of presentation. The white blood cell count (WBC) was normal at 8.24 thousand (K). Surgical consultation was obtained. The patient was admitted to the hospital and started on intravenous (IV) antibiotics. The patient continued to receive antibiotics as non-surgical treatment for acute appendicitis.
The patient's vital signs were consistently normal during the period of monitoring. The WBC count remained normal. She was transitioned to oral medications and diet. She was discharged from the hospital with instructions for surgical follow up and plans for an outpatient colonoscopy and CT scan.
At issue is the medical necessity of an inpatient stay.
Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored and treated with a lower level of care without the need for full inpatient admission.
This patient presented with abdominal pain. The evaluation with examination, lab data, and CT scan supported the diagnosis of acute appendicitis. It was decided to pursue a non-surgical treatment with antibiotics rather than acute surgical intervention and she was therefore treated with intravenous (IV) antibiotics. She was clinically stable and was tolerating a diet. She was discharged from the hospital with instructions for surgical follow up and plans for an outpatient colonoscopy and another CT scan.
The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care would have provided for surgical assessment and provision of antibiotics. This lower level of care would have also allowed for overnight monitoring (if needed).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

According to the clinical documentation provided for review, the patient is a child. The patient has the medical diagnosis of sickle cell disease (SSD) with vaso-occlusive crisis. The patient has a history of hemoglobin (hbg) SSD, who presented to the hospital with leg pain that was unresponsive to Motrin and/or Tylenol. The patient was admitted and given intravenous fluids (IVF) and narcotics. The patient was discharged (d/c) the following day. The treating provider ordered full hospital admission which was denied. The treating provider is requesting plan approval for full hospital admission.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient, as the request was not medically necessary.      

This patient presented with an acute uncomplicated vaso-occlusive crisis (VOC) and pain crisis. These patients can typically be managed in a lower level of care (LOC), such as observation, as this typically improves within 24 to 48 hours. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate. The request is denied.

Sickle cell anemia is an inherited disorder caused by a point mutation (affecting a single nucleotide) in the gene that encodes the globin chain of hemoglobin (Hb). Two globin chains and two globin chains form a hemoglobin, the multisubunit protein in red blood cells that carries oxygen. The mutation results in the replacement of negatively charged glutamate by a neutral, hydrophobic valine that produces sticky patches on the protein surface. Upon delivering oxygen to the tissues, the mutant hemoglobin (HbS) polymerizes into fibers, which distort ("sickle") red blood cells and cause blockage of the circulation, resulting in acute, severe pain called a sickle cell crisis. Pauling and colleagues reported the molecular basis of sickle cell anemia in 1949, giving birth to the field of molecular medicine. Research on sickle cell anemia has again taken center stage because of new drug therapies, cures through stem cell transplantation, and the promise of gene therapy.

Current treatment options focus largely on best supportive care, including blood transfusions and pain medication (Tisdale, J. F. et al. 2020).   
                                                      
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, heart disease and migraine headaches
Treatment: 35 hours per week, Consumer Direct, 1 Client
The insurer denied coverage for 35 hours per week, Consumer Direct, 1 Client
The denial is upheld 

This is a geriatric patient with chronic medical problems including diabetes, heart disease and migraine headaches. The patient lives with family (spouse, daughter and grandchildren). The plan approved increasing care hours to 21 hours per week, Consumer Direct, 1 Client. The request is for 35 hours per week.  

The Uniform Assessment System (UAS) report was reviewed, the patient's cognition is described as "independent." The patient requires maximal assistance for Instrument Activities of Daily Living (IADL) including meal preparation, ordinary housework and shopping. The patient requires extensive assistance for bathing. The patient is independent for personal hygiene, dressing, eating, bed mobility, locomotion, toilet transfer/use and ambulation (with a cane). The patient is continent of bladder and bowel. Subsequent clinical records indicated the patient is incontinent of bladder. There is no evidence of a functional decline that would warrant an increase in Personal Care Aide hours to 35 hours per week. The patient's intact cognitive status and independence for much of the activities of daily living (ADL) tasks do not support the medical necessity of increasing the hours to 35 hours/week. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the currently approved 21 hours/week, Consumer Direct, 1 Client.  

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. From a physical medicine and rehabilitation perspective, the requested 35 hours/week, Consumer Direct, 1 Client is not medically necessary.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 35 hours per week, Consumer Direct, 1 Client is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Rhinitis, difficulty swallowing.
treatment: Dexlansoprazole 60 mg Capsule.
The insurer denied Dexlansoprazole 60 mg Capsule. 
The health plan's determination is overturned. 

The patient is woman with a history of gastroesophageal reflux disease causing secondary heartburn, laryngopharyngeal reflux, and laryngeal edema. A fiberoptic endoscopic evaluation of swallowing test showed active reflux despite high dose Omeprazole 40 milligrams (mg) daily. She has undergone an upper gastrointestinal endoscopy evaluation which did not reveal any additional causes to account for the patient's symptoms. She has been prescribed a variety of H2- (histamine 2) Blockers and Proton Pump inhibitors including Prevacid, Pantoprazole, Famotidine, and Omeprazole with persistent breakthrough symptoms. 

A formulary exception is indicated in this case.
The patient has been prescribed a variety of H2-Blockers and Proton Pump inhibitors in the past including Prevacid, Pantoprazole, Famotidine, and Omeprazole with persistent breakthrough symptoms. Approximately 1 year earlier, she was prescribed Dexlansoprazole 60 mg daily with significant improvement in symptoms. Thus, prior trials of formulary drugs have been ineffective.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid Obesity, difficulty walking
Treatment: Continued Room and Board in Skilled Nursing Facility
The insurer denied: Continued Room and Board in Skilled Nursing Facility
The denial is upheld

The patient is an adult female with a medical history of hypertension, bipolar disorder, obesity and left-sided tibial plateau fracture requiring ORIF (open reduction internal fixation). The patient was admitted to a skilled nursing facility last year. Therapy documentation dated last month indicates that the patient is requiring set up assistance for lower body dressing, supervision for toileting and upper body dressing, stand by and contact guard assistance for mobility and other daily activities. The patient is ambulating with a walker. The requested skilled nursing facility care was denied coverage by the health plan as not medically necessary per guideline policy, with the rationale that the patient does not require skilled nursing care, physician oversight or therapy services. This decision is being appealed.

The requested Continued Room and Board in Skilled Nursing Facility is not medically necessary.

Admission to a skilled nursing facility is appropriate for patients with conditions that require observation, evaluation of treatment plans, and updating of orders by a physician as well as constantly available skilled nursing services. Patients require skilled nursing services, including wound management, tracheostomy care, bowel and bladder training and tube feeding, and administration of IV (intravenous) medications or medications that cannot be self-administered safely. They also require skilled nursing observation, including regular monitoring of vital signs, skin in the setting of wounds, and intake and output. Patients typically also benefit from skilled therapy services due to physical limitations, a decline in function or impaired cognition and communication. This includes physical, occupational and speech therapies.
The patient does not require the oversight of a physician or skilled nursing care in the setting of a skilled nursing facility. She is taking oral medications and does not require wound management, tracheostomy care, bowel and bladder training and tube feeding, and administration of IV (intravenous) medications or medications that cannot be self-administered safely. The patient does not have the medical acuity to require skilled nursing facility care. She is also requiring primarily supervision for mobility and performing daily activities and does not require skilled therapies in the skilled nursing facility setting. The patient is noted to primarily require supervision given her mental issues and for safety when negotiating stairs and ambulating. However, she does not require skilled nursing care or therapy to provide this. The patient continues to require stand-by assistance to supervision for the majority of her daily activities and mobility. She may require supervision and some assistance with daily activities, but this does not necessitate skilled therapy services.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Otezla 10 & 20 & 30 MG (milligrams) OR (oral) TBPK (tablet pack)
The insurer denied coverage for Otezla 10 & 20 & 30 MG OR TBPK.
The denial is overturned.

The patient is an adult with a diagnosis of psoriasis affecting > (greater than) 90% (percent) of the total body surface area (TBSA). The patient has failed topical steroids (clobetasol). The patient has a past medical history significant for diabetes and kidney disease. The request is for therapy with Otezla for treatment of the patient's psoriasis.  

The use of Otezla is medically necessary in this clinical scenario based on the standard of care and the documentation provided. The patient has a documented diagnosis of psoriasis with significant involvement necessitating systemic therapy. The laboratory tests provided indicate a contraindication to methotrexate or systemic agents which may adversely affect renal or hepatic function. As such, the use of Otezla, which requires no systemic monitoring, is within the standard of care. The decision is overturned and the use of Otezla to treat the patient's psoriasis and psoriatic arthritis is approved.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for Otezla 10 & 20 & 30 MG (milligrams) OR (oral) TBPK (tablet pack) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Common variable immunodeficiency (CVID)

Treatment: J1559 Hizentra 24 gram (gm) subcutaneously every 2 weeks for 1 year, for a total of 6240 HCPCS (Healthcare Common Procedure Coding System) units

The insurer denied coverage for J1559 Hizentra 24 gram (gm) subcutaneously every 2 weeks for 1 year, for a total of 6240 HCPCS units

The denial is upheld
 

The patient has been treated for common variable immunodeficiency for several years. Her gamma globulin treatment dosing has changed. She was approved for 15 grams Hizentra, then approved for 20 grams every 2 weeks six months later. In notes, recurrent sinus infections were described, also, diarrhea. The past medical history is extensive and includes chronic sinusitis (refusing surgery), Crohn's/Crohn like disease, repeated low  immunoglobulin A  (IgA) and  Immunoglobulin M (IgM) levels, low memory B (cells) and NK (natural killer) cells, iron B12 deficiency, and Epstein-Barr virus (EBV) viremia. The patient also reported fatigue, difficulty walking, hand cramping/dysesthesias. The assessment was that the patient may need an increased gamma globulin dose. In a recent note, the patient history states the patient has had sinus infections with 2 courses of antibiotics, and still has fatigue, hand/cramp sensation. Also noted on this visit was abdominal pain worse with diarrhea and abdomen distension. 

In a recent UpToDate article, treatment and prognosis of common variable immunodeficiency, it is stated that indications for higher dosing include continued refractory infection, chronic lung disease, enteropathy and 3rd trimester pregnancy. The note states that the assessment is that CVID is rather mild with no major infections on low dose SCIG (Subcutaneous IgG). There is no evidence for enteropathy (protein losing), chronic lung disease or 3rd trimester pregnancy. Furthermore, the article in Up to Date also notes that "Gastrointestinal infections and/or complications are relatively unaffected by immune globulin replacement, for reasons that are not well understood. Immune globulin replacement therapy may exert a protective effect in those with autoimmune disease, although it is not known to alter the development of malignancy or to impact granulomatous disease." Later in the discussion they highlight therapies for GI (gastrointestinal) disease which include anti -inflammatory or immunosuppressive therapy.

Therefore, the grounds for overturning the denial of higher dosing are inadequate.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for J1559 Hizentra 24 gram (gm) subcutaneously every 2 weeks for 1 year, for a total of 6240 HCPCS units is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ankylosing Spondylitis. 
Treatment: Xeljanz. 

The insurer denied Xeljanz. The health plan's determination is upheld. 

The patient is a woman with ankylosing spondylitis (AS). The issue in this case is Xeljanz is being denied by the health plan. Prior tx (treatment) has included: methotrexate (MTX) (no improvement), Enbrel (stopped due to inability to tolerate self-injections) and Rinvoq (some improvement but stopped due to worsening depression). There is no documentation of a failed trial or intolerance to the other preferred agents, such as Cosentyx and Humira. 

Xeljanz is not medically necessary for this patient. There is no medical reason the patient cannot try the drugs on the health plan's formulary. 

As per Up-To-Date, 'in patients with symptoms due to active axial spondyloarthritis (SpA) and an inadequate response to initial therapy with two different nonsteroidal anti-inflammatory drugs (NSAIDs), we suggest a tumor necrosis factor (TNF) inhibitor rather than continuing NSAIDs alone or conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine (SSZ). In patients who do not respond to anti-TNF agents, IL-17 (interleukin 17) antagonists are excellent options. As published in American College of Rheumatology (ACR) Open Rheumatol in 2022, 'secukinumab (300 and 150 milligrams (mg)) provided sustained improvements through 3 years in the signs and symptoms of active AS. Improvements with secukinumab 300 mg were numerically higher compared with the 150-mg dose for some higher hurdle end points and in TNF-IR (inadequate responder) patients. The safety profile of secukinumab was consistent with previous reports'. 
In addition, needle phobia is not a contraindication to Humira or Cosentyx, which are used in the treatment of ankylosing spondylitis. Often what is done in these cases is a family member or friend will help administer the medication and/or the patient will come in for teaching in the office and the medication will be administered with the patient until they are comfortable with injecting it on their own.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell crisis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld
 
According to the clinical documentation provided for review, the patient is an adult who presented with a past medical history of sickle cell disease (SSD), avascular necrosis (AVN) of the femur, asthma, and acute chest syndrome (ACS). This patient with SSD presented to the Emergency Room (ER) with complaints of pain. The work-up was concerning for a biliary obstruction. The patient was found to have a urinary tract infection (UTI). The patient was admitted to the hospital and given intravenous (IV) antibiotics, and pain medications. The patient was discharged 3 days later. The treating provider ordered inpatient admission which was denied. 

The inpatient admission was not considered medically necessary for this patient.  The uncomplicated vaso-occlusive crisis and uncomplicated UTI do not require acute level of care. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate. Therefore, the request is denied and not medically necessary for this patient at this time.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain.

Treatment: Intraosseous basivertebral nerve ablation (procedure codes: 64628 and 64629) and coverage for the requested treatment.

The insurer denied coverage for intraosseous basivertebral nerve ablation (procedure codes: 64628 and 64629) and coverage for the requested treatment.

The denial is upheld.

This is a patient with a history of low back pain. The patient had a physician visit for back pain. The physician recommended the intracept procedure to treat lower back pain. The note stated that the patient's back pain has been chronic and is worse with flexion. The patient has 6 months of medication and physical therapy with minimal relief. A magnetic resonance imaging (MRI) was performed and it demonstrates Modic type I (1) changes at disc spaces lumbar (L)4- L5 and L5- sacral (S)1.

The procedure is essentially a thermoablation performed within the vertebral body. 
There are several level 1 studies showing the benefit of this procedure up to 2 years after treatment compared to controls. However, all of these studies were either funded by the manufacturer and/or authored by consultants from the manufacturer. No high-quality study exists that does not have a significant conflict of interest with the manufacturer. As such, at this time the Intracept procedure is not appropriate for this patient at this time.

There are several studies however no conclusions can be made. No definite statement nor guidelines showing definitive efficacy have been reported.

No defined pain generator is present. The records show chronic back pain with several sites of pathology. Injections and multiple conservative treatments have been completed for facet disease, disc disease, stenosis and herniations. There is evidence of nerve compression to several levels. The patient also has instability patterns. The patient reported relief of the pain from the Epidural Steroid Injection (ESI) consistent with a radicular synrome. The report of axial pain vs (versus) radicular pain is inconsistent. The likelihood of the basivertebral nerve causing the back pain is not credible.

The procedure is invasive. There have been reported complications of infection, broken hardware and retroperitoneal hematoma. 

The requested service is not likely to be more beneficial than any of the standard treatment/procedures. 

In summary, the denial of intraosseous basivertebral nerve ablation (procedure codes: 64628 and 64629) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.