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


Diagnosis: Ulcerative colitis

Treatment: Stelara 90 milligrams (mg) every 4 weeks

The insurer denied coverage for Stelara 90 milligrams (mg) every 4 weeks

The denial is upheld.

 
The patient is an adolescent with a past medical history notable for gastroesophageal reflux and ulcerative colitis. Esophagogastroduodenoscopy (EGD) and colonoscopy demonstrated gastroesophageal reflux, chronic inactive gastritis, right colonic acute cryptitis and moderate mid/left chronic and active colitis. Laboratories were notable for Erythrocyte sedimentation rate (ESR) 14, C-reactive protein (CRP) 1 and hemoglobin 11.9. The patient was treated with Remicade/steroids without improvement. Due to persistent symptoms, the patient was transitioned to Stelara with a loading dose followed by 90 milligrams (mg) every (q) 8 weeks. The Stelara level was 10.7 and antibodies were not present. The patient was seen and noted to be in clinical remission. The only complaints were intermittent thoracic back pain and shoulder pain. The weight was 36.7 kilograms, and the height was 155.4 centimeters. Laboratories this day were notable for hemoglobin 12.8, CRP less than 0.2, Stelara level 8.7 (7-week level) and absent Stelara antibodies. A point of service intestinal sonogram showed very mild enhancement in the sigmoid. The patient underwent repeat EGD and colonoscopy. The EGD report suggests a normal study. The colonoscopy report and histology were not included for review. 

This patient's diagnosis is ulcerative colitis with a clear response to Stelara 90mg (q) 8 weeks. The patient did not report symptoms of active disease during the office visit as stated in the appeal. The most recent colonoscopy report and histology were also not included for review. Along with this patient's clinical response the biological markers of inflammation are normal. The denial appears to principally be based on the escalated dosing beyond the Food and Drug Administration (FDA) approved maintenance interval in a patient responding to standard treatment.

Articles referenced below suggest that dose escalation may benefit select patients that fail to respond to standard FDA approved maintenance doses of Stelara 90 mg (q) 8 weeks. This patient appears symptom-free during the recent visit with the justification for dose escalation being a perceived partial response (back and shoulder pain). Given the uncontrolled nature of these studies there is insufficient evidence for decreasing dosing intervals in a patient without symptoms. The escalation in dosing interval to (q) 4 weeks appears to be not medically necessary in this particular patient given the favorable clinical response to standard q 8-week dosing. 

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 Stelara 90 mg every 4 weeks is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine. 
Treatment: Diclofenac Oral Powder. 

The insurer denied Diclofenac Oral Powder. 
The health plan's determination is upheld. 

The patient is requesting the non-formulary medication diclofenac powder for the treatment of chronic migraines. At issue is the requested non-formulary medication, Diclofenac Oral Powder. 

The documentation indicates that the patient has tried and failed ibuprofen. The documentation does not indicate that the patient has tried and failed other available formulary alternatives. These include diclofenac sodium, diflunisal, etodolac, meloxicam tablet, nabumetone, naproxen, naproxen sodium, oxaprozin, or sulindac. The patient has tried and failed one formulary alternative. There is no medical reason to believe that the diclofenac powder will be more effective than the available formulary alternatives or that the available formulary alternatives would not be effective for treatment of acute migraine. The clinical guidelines for treatment of acute migraine indicate that nonsteroidal anti-inflammatory drugs are first line agents. The provider indicates that the patient has dysphagia and cannot take tablets; however, the documentation also indicates that the patient is prescribed multiple other oral medication including amitriptyline, a multivitamin, and birth control. All of these are noted to be given by the oral route. Most of the available formulary alternatives can be crushed for administration.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease

Treatment: myocardial perfusion imaging

The insurer denied coverage for myocardial perfusion imaging

The denial is overturned
 

This is an adult with a past medical history that includes coronary artery disease (CAD), percutaneous coronary intervention (PCI) involving drug-eluting stents to the first diagonal branch of the left anterior descending artery, mild mitral regurgitation, obesity, hypertension, bilateral leg edema, remote tobacco abuse (having quit smoking at the time of his PCI), and hyperlipidemia. He has been on an appropriate guideline-directed medical regimen including atorvastatin, aspirin, lisinopril, carvedilol, amlodipine, and chlorthalidone for his CAD and hypertension.

He had a stress echocardiogram performed, which was essentially normal, with no evidence of ischemia or prior infarct. 

When he was seen by his cardiologist she noted that "he is getting fatigue and feels SOB [short of breath]." Hypotension was noted, as well, with blood pressure of 100/60. She arranged for an exercise nuclear stress test with sestamibi.

The exercise nuclear stress test (aka myocardial perfusion imaging test) was rejected by the insurer. 

The fact that the patient is having symptoms in the setting of guideline-directed medical therapy indicates that further workup is appropriate; the first step in treating such symptoms is the initiation of this medical therapy, and further workup is indicated if that medical therapy has failed, as it may have done in this case.

For these reasons, myocardial perfusion imaging is necessary for assessing the patient's symptoms. Specifically, he had symptoms concerning for possible active cardiac ischemia, with known CAD and intermediate pre-test probability. While his stress echocardiogram from almost a year earlier was reassuring, that reassurance was no longer predictive in the setting of new symptoms.

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

The medical necessity for myocardial perfusion imaging services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a history of recurrent urinary tract infections (UTI) who presented with a fever, abdominal pain, dysuria, and vomiting.
She developed abdominal pain and dysuria. She had pain in the pelvic region that was 7-8 out of 10 in intensity. She also had urinary frequency and incontinence, with some blood in her urine. She had completed treatment for a UTI one week prior. Two days prior to presentation she developed a fever up to 103 degrees Fahrenheit (F) at home. She began to vomit, with 7-8 episodes of emesis. She was, therefore, brought to the emergency department for evaluation. Her past history was significant for multiple episodes of UTIs. She also had an asthma diagnosis.
She continued to have vomiting, and therefore was admitted to the hospital for treatment and monitoring.
In the hospital, she was treated with intravenous ceftriaxone and intravenous fluids. She continued to have fevers on and off and was given acetaminophen. Intravenous fluids were discontinued on the third hospital day. An ultrasound showed normal kidneys. She was felt to be back to baseline and ready for discharge to home with continued treatment and follow up as an outpatient.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was medically necessary for this patient.
 
This is a patient with a history of recurrent UTIs who presented with a fever, abdominal pain, and dysuria which was thought to be consistent with pyelonephritis. She received an intensive evaluation in the emergency department and continued to vomit. She, therefore, required hospital admission for the prompt initiation of parenteral antibiotics, intravenous fluids to maintain her hydration status, and monitoring with additional treatments as needed. The decision making at the time of admission for this patient was consistent with her young age, the presence of probable pyelonephritis with vomiting, and the need for parenteral treatments along with close monitoring for potential deterioration of clinical status.
Patients with urinary tract infections and pyelonephritis require hospitalization in the presence of vomiting or inability to tolerate oral medication. This patient had a fever and pain and was vomiting. She required admission for parenteral treatments to ensure appropriate management of a potentially serious infection. She also had a history of multiple prior urinary infections, thus appropriate treatment and evaluation in an inpatient setting was needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian Cancer
Treatment: CT (computed tomography) Scan of Chest without dye (71250), CT (computed tomography) Scan of Abdomen and Pelvis without dye (74176)
The insurer denied: CT (computed tomography) Scan of Chest without dye (71250), CT (computed tomography) Scan of Abdomen and Pelvis without dye (74176)
The denial is upheld.

The patient is an adult female with an International Federation of Gynecology and Obstetrics (FIGO) Stage IA serous endometrial cancer and intra epithelial fallopian tube cancer who has undergone treatment with surgery and adjuvant chemotherapy. The patient was recommended to also undergo surveillance imaging by chest, abdomen and pelvic computed tomography (CT) scans.

The proposed treatment is not medically necessary.

The patient was recommended to undergo surveillance imaging by chest, abdomen and pelvic computed tomography (CT) scans. However, there are no data that in patients with early stage endometrial and ovarian cancer, surveillance imaging studies improve outcomes. The use of imaging as in this case is not supported by peer reviewed data, it is not standard of care, and it is not supported by professional organizations.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease

Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services

The denial is upheld.

The patient is geriatric patient who has a history of chronic obstructive pulmonary disease (COPD), on home oxygen (O2), continuous positive airway pressure, hypertension, hyperlipidemia and diabetes. The patient presented to the hospital with complaints of shortness of breath. The patient was found to have oxygen saturation in the 80's. The patient was treated with Duonebs and Steroids and was admitted.

The patient was afebrile (without fever) at presentation. Blood pressure was elevated. Lung exam revealed some decreased air movement and bilateral wheezes. The patient was alert and oriented x (times) 3. The patient received Duonebs, Steroids, Magnesium and Epinephrine in the Emergency Department (ED) and was placed on bilevel positive airway pressure (BIPAP). The patient was subsequently switched to nasal canula and noted to be saturating to 94% (percent) on 2 liters.

The patient was admitted to the hospital for COPD exacerbation. White blood cells were 13.9 and venous blood gas 7.25/84/63. The patient was found to be Coronavirus-19 (COVID) positive incidentally. Remdesivir intravenous (IV) 1 dose was planned. In addition, the patient was started on Azithromycin. The chest x-ray (CXR) did not reveal any acute infiltrates.

The patient improved with initial treatment and had an improved gas exchange to 7.38/64/38. By the next day the patient had improved significantly, oxygen saturation was 95% on 2 liters nasal canula. Air entry had improved, and mild wheezing was noted.

The patient did not have pneumonia, so antibiotics were discontinued. The patient was switched to oral (PO) steroids and bronchodilators. The patient was tolerating PO and ambulating. This patient was discharged home with follow-up in the outpatient setting on PO Paxlovid.

This patient did not need acute inpatient hospitalization. The patient was already on home O2 and the O2 requirements were stable during the hospital stay. The patient was afebrile and hemodynamically stable. This patent could have been evaluated, treated and monitored on an observation level of care while diagnostic studies and treatment were initiated. Observation could be for up to 48 hrs.

This patient improved quickly after the admission and was discharged within a day of the hospitalization. The patient was stable to be placed in observation. Once the patient was deemed stable, the patient was discharged home on PO medications with close follow-up as outpatient.

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 inpatient hospital services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypertension, diffuse scleroderma, CREST syndrome, chronic obstructive pulmonary disease (COPD), breast cancer, sleep apnea, systemic lupus erythematosus (SLE), and obesity

Treatment: consumer direct personal assistance services (CDPAS) 56 hours per week

The insurer denied coverage for consumer direct personal assistance services (CDPAS) 56 hours per week

The denial is upheld. 

This patient has a diagnosis of scleroderma in addition to a history of hypertension, diffuse scleroderma, CREST syndrome, chronic obstructive pulmonary disease (COPD), breast cancer, sleep apnea, systemic lupus erythematosus (SLE), and obesity. The patient was receiving 44 hours of home care per week. There is a request for direct personal assistance services (CDPAS) 56 hours per week. Notes indicate the patient requires maximal assistance with meal preparation, housework, shopping, bathing, and lower body dressing. The patient requires extensive assistance with stairs, transportation, personal hygiene, upper body dressing, and toilet use. The patient uses a rollator indoors and outdoors. The patient is infrequently incontinent.

The patient receives 44 hours of direct personal assistance services per week. Documentation did not support the need for additional hours at this time. 

The consumer direct personal assistance services (CDPAS) 56 hours per week is not considered medically necessary for this patient. The need for additional hours is not supported. The diagnosis requires assistance for meal preparation, assistance to leave the house, appointments and daily chores. There is no information to support the need for more than 44 hours. 

As healthcare professionals, we must recognize the importance of home health aides in supporting older adults at home. Home health aides' consistent and longitudinal presence and care of patients uniquely positions them to identify subtle changes in patients' health and wellness, potentially preventing disease exacerbations and hospitalizations. However, despite possessing this vital information, communication of clinical changes to medical teams is frequently difficult as most home health aides work for agencies unaffiliated with the patients' primary care providers (D'Cruz et al., 2022).

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 consumer direct personal assistance services (CDPAS) 56 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Upper gastrointestinal bleed

Treatment: hospital admission

The insurer denied coverage for hospital admission

The denial is overturned.

The patient had a history of peptic ulcer disease. The patient presented with black stools. The patient was afebrile (without fever), and the vital signs were stable. There was no abdominal rebound or guarding. An initial hemoglobin was 10 but then decreased down to 7.8. An endoscopy was performed and a clean based prepyloric ulcer was found. There was an adjacent visible vessel and an endoclip was applied. Afterwards, there was no sign of active bleeding.

Medical necessity was determined using Milliman Care Guidelines (MCG) M-180 for Upper Gastrointestinal Bleeding. A clinical indication for admission is having a peptic ulcer with a high-risk endoscopic feature. A non-bleeding visible vessel is listed as an example of a high-risk endoscopic feature. Ongoing active bleeding, as manifested by a decreasing hematocrit, is another indication for admission.

This patient was having melena (black stools) and a dropping hemoglobin. The endoscopy found an ulcer and a visible vessel that was treated with endoscopic hemostatic therapy. This has met the MCG criteria for admission under Upper Gastrointestinal Bleeding.

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

The medical necessity for the hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite/Underbite
Treatment: Dental/Orthodontic Procedure- Braces and monthly visits
The insurer denied Dental/Orthodontic Procedure- Braces and monthly visits.
The determination is overturned.

This patient has a Class II Division 1 malocclusion. They have an 8-millimeter (mm) overjet and 4-millimeter (mm) overbite. The patient has a treatment planned for orthodontics to correct their malocclusion. At issue is the requested health service/treatment of braces and monthly visits.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient. Tooth number 8 and 9 are protruding forward within the dental arch. This makes them more prone to trauma.

The requested health service/treatment of braces and monthly visits is medically necessary for this patient. This patient, like fifteen percent of the population, exhibits an Angle's Class II bite (1). Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. There is strong medical evidence that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma (2). Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with greater than 6-millimeter (mm) overjet, which this patient has (3). For these reasons orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: neck/back pain
Treatment: Consumer Directed Personal Care Services (CDPAS)
The insurer denied Consumer Directed Personal Care Services (CDPAS). The health plan's determination is upheld. 

This is a case review for a female with medical history notable for cervicalgia, low back pain, and depression. The patient was receiving Consumer Directed Personal Care Services (CDPAS). The health plan discontinued these services stating they were no longer medically necessary.

The requested Consumer Directed Personal Care Services (CDPAS) is not medically necessary for this patient.
The patient is independent in her activities of daily living (ADL). She requires some assistance with Instrumental activities of daily living (IADL) but has informal support at home from her family. There is no evidence that her personal care needs are not being met with this informal support. There is no clear demonstration of the medical necessity for her to receive personal care services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is a previously healthy adult male who presented to the emergency department (ED) during the evening with the complaint of abdominal pain of two-days duration. Examination revealed abdominal tenderness in the right lower quadrant. The 
patient's vital signs identified a normal temperature at the time of presentation. The heart rate was 66 beats per minute. The white blood cell (WBC) count was elevated at 12.5 thousand. Abdominal computed tomography (CT) scan was completed showing findings consistent with acute appendicitis. Surgical consultation was obtained, and the patient was admitted to the hospital and started on intravenous antibiotics. On Day #2, the patient underwent laparoscopic appendectomy. The operation was completed without complication. The patient was monitored following surgery and remained stable. The Day #3 progress note states that the patient was feeling much better. He had 
normal vital signs and he was converted to oral antibiotics. The patient was discharged from the hospital following the initial surgical recovery with instructions for surgical follow-up.

The health plan rationale for denial is that there is no documentation of need for an inpatient level of care and the care rendered could have been provided without full admission to the hospital.

The inpatient care was not medically necessary for this patient.

The health plan rationale for denial is that there is no documentation of need for an inpatient level of care and the care rendered could have been provided without full admission to the hospital. Vital signs were normal. There were not complications of surgery, and this operation is typically performed without need for full inpatient admission. This rationale is supported by the submitted medical records. Inpatient care for this patient was not medically necessary based on the standard of care. The care 
provided during this time could have reasonably and appropriately been provided with a lower level of care. A lower level of care would have provided for emergency department assessment, provision of intravenous fluid and antibiotics, surgical consultation, surgery to remove the appendix and monitoring. This patient was clinically stable at the time of presentation to the emergency department. He remained stable throughout the perioperative period and was able to be discharged from the hospital following an uncomplicated initial recovery on the first post-surgical day.