Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Psoriatic Arthritis
Treatment: Formulary exception for Xeljanz, Pre-service
The insurer denied the Formulary exception for Xeljanz, Pre-service.
The denial is overturned. 

The patient is a female with psoriatic arthritis diagnosed five years ago.  She failed treatment with NSAIDs (nonsteroidal anti-inflammatory drugs), Otezla, Humira, Simponi and Stelara.  She has not tried or failed the Plan-preferred alternatives Enbrel or Cosentyx.  The provider indicates that Cosentyx is contraindicated due to this patient's history of colitis.  The appeal is for Xeljanz for the treatment of psoriatic arthritis.

Yes, the health plan should cover the Formulary exception for Xeljanz.

This patient with psoriatic arthritis failed treatment with NSAIDs (nonsteroidal anti-inflammatory drugs), Otezla, Humira, Simponi and Stelara. She has not tried or failed the Plan-preferred alternatives Enbrel or Cosentyx. Since this patient has already failed treatment with two TNF (tumor necrosis factor) inhibitors (i.e., Humira and Simponi), treatment with an alternate mechanism of action would be preferred over a trial of a third TNF (tumor necrosis factor) inhibitor, such as Enbrel. Although Cosentyx works via an alternate mechanism of action (IL-17 [interleukin 17] inhibition), the provider correctly asserts that Cosentyx is contraindicated due to this patient's history of colitis.

Xeljanz is FDA (Food and Drug Administration)-approved for the treatment of psoriatic arthritis, and thus would be a clinically appropriate and medically necessary treatment for psoriatic arthritis in this patient who has failed the aforementioned therapies. Therefore, the health plan should cover the formulary exception for Xeljanz for the treatment of psoriatic arthritis.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Diabetes.
Treatment: Humalog.
The insurer denied Humalog. 
The health plan's determination is overturned. 

This is a female diagnosed with T1DM (type I diabetes mellitus). As per the provider; the patient must be able to bolus insulin in half unit increments. She is on Lantus 24-25 units daily; Novolog with ICR (Insulin to Carb Ratio) was 1:10; ISF (Insulin sensitivity factor) was 1:40 target of 120. The plan formulary drugs are Fiasp and Novalog. The provider is requesting Humalog Jr (insulin lispro).

The formulary drug would not be as effective as the non-formulary drug as the formulary drug is not available in half unit increments. The physician reports that the patient must bolus in half unit increments which are only available using the pen device in the nonformulary drug.
There are no studies demonstrating superiority of one rapid acting insulin analog over another. The patient needs half unit increments. This is only available in the pen device that is being requested. It is not available in the formulary alternatives. The request is consistent with generally accepted standards of medical practice.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, Coronary Artery Disease, Urinary incontinence and CVA with residual hemiplegia
Treatment: Personal Care Aide (PCA) 12 Hours per Day - 7 Day(s) per Week- a Total of 84 Hours per Week
The insurer denied the Personal Care Aide (PCA) 12 Hours per Day - 7 Day(s) per Week- a Total of 84 Hours per Week.
The denial is overturned. 

The patient is a male with a history of Alzheimer's disease, Coronary Artery Disease, Urinary incontinence and CVA (cerebrovascular accident) with residual hemiplegia. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the Personal Care Aide (PCA) 12 Hours Per Day - 7 Day(s) Per Week- A Total of 84 Hours Per Week is medically necessary.

This is a male with a history of Coronary Artery Disease, Chronic Kidney Disease, Dementia and Stroke. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent correspondence from the patient's medical provider indicates that due to worsening functionality, generalized weakness and gait ataxia, the patient requires more assistance for completion of all of his ADLs (activities of daily living). For these reasons, the health plan's currently approved regimen of 56 hours per week is not sufficient to meet the patient's needs. Therefore, the proposed treatment 84 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain and Acute cholecystitis. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is overturned. 

This is a male patient with a past medical history of asthma and laparoscopic appendectomy who was brought by ambulance to the Emergency Department (ED) with subjective complaints of severe, constant abdominal pain rated 8 out 10, in severity.  The patient's pain was present for 2 hours.  In the ED, the patient's blood pressure was 156/87 and his heart rate was 98.  The patient had moderate right upper quadrant and epigastric tenderness to palpation.  The patient's abdomen was soft and non-distended.  The patient's diagnostic ultrasound revealed mild gallbladder wall thickening.  The patient's laboratory tests revealed elevated liver function tests.  The patient was admitted to the surgical unit for the management of abdominal pain and acute cholecystitis.  The patient was treated with intravenous (IV) fluids, IV antibiotics, and oxycodone.  After the fluids, antibiotics, and oxycodone, the patient noted that he felt better and wanted to leave.  The patient left Against Medical Advice (AMA). 

Based on the review of the medical record and literature, inpatient hospital admission was medically necessary for this patient.  The patient presented to the ED via ambulance with acute abdominal pain.  The patient was mildly febrile with leukocytosis and lactic acidosis.  The patient's labs showed elevated transaminases and imaging showing probable cholecystitis.  The patient required admission for acute cholecystitis for antibiotics and possible cholecystectomy.  The patient left against medical advice (AMA) the next day, but this has no bearing on this patient's clinical need for admission on the day of hospital presentation. 

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

The medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left supracondylar fracture.
Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient admission.
The denial is upheld. 

This female child is a patient with no significant past medical history. The patient presented to the Emergency Room (ER) from another hospital with a left supracondylar fracture after falling off her scooter. The patient's x-ray of the left humerus revealed a Type 3 supracondylar humerus fracture. The patient remained non-weight bearing (NWB) on the left upper extremity (LUE). The patient was admitted to the Pediatrics unit and was kept on nothing-by-mouth (NPO). Intravenous (IV) fluids were given. The patient was taken to the operating room (OR) for a left elbow supracondylar humerus fracture closed reduction and percutaneous pin fixation and long arm casting. The patient's American Society of Anesthesiologists (ASA) risk class was 1E. After surgery, the patient was transferred to the post anesthesia care unit (PACU). The patient's heart rate was elevated. The patient was given IV fluids and pain medication. The patient's diet was advanced as tolerated and she was discharged after a period of medical stability.

Based on the review of the medical record, inpatient admission was not medically necessary for this patient. The patient sustained an elbow fracture. This was a low energy type of injury. There were no open wounds. The patient's neurovascular status was satisfactory. There were no issues with tolerating oral pain medication. There were no other injuries. The patient did not require additional imaging or medical consultations. This service would be at an observation level of care. Splinting to the extremity with monitoring of circulatory status would be appropriate prior to surgery. The services provided can also be performed at an ambulatory surgery unit (ASU) or a surgical center. As per literature review, inpatient criteria have not been met for this patient.

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

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

Diagnosis:  Systemic lupus erythematosus.
Treatment:  Acthar gel (repository corticotropin injection) for the treatment of systemic lupus.

The insurer denied coverage for Acthar gel (repository corticotropin injection) for the treatment of systemic lupus.  The denial is overturned. 

This is a female patient with a medical history of systemic lupus erythematosus (SLE). The patient's symptoms include painful flares throughout all of her joints. The patient has been treated with plaquenil, prednisone, leflunomide, duexis, meloxicam, and diclofenac sodium tablets.  The patient's current treatment includes benlysta infusions, Acthar gel and plaquenil.  The patient started Acthar gel as an adjunctive therapy, and she has had positive results. The patient's SLE is at a moderate level of severity. Office visit notes indicate that the patient benefits from Acthar. 
 
The insurer has denied coverage for Acthar gel for the treatment of lupus as not medically necessary. 

Acthar Gel is indicated in "selected" cases of SLE. There is no further definition in the labeling of what "selected" means. The benefit of Acthar is not clear, and a study is being done to assess this. (1) Small studies have suggested benefit. (2-3) 

In this particular case there is documentation that prednisone did not reliably help. Acthar has steroid-related properties and side effects, but other mechanisms of action as well. The patient has tolerated it and it has helped. There has not been any apparent toxicity. Withdrawal of treatment and substitution of other immunosuppressive therapy would expose her to unknown benefit and risk. 

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 Acthar gel (repository corticotropin injection) for the treatment of systemic lupus is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis.
Treatment: Total knee replacement surgery (outpatient procedure 27447 x1).
The insurer denied coverage for the total knee replacement surgery (outpatient procedure 27447 x1).
The denial is upheld. 

This is a female patient with a medical history of primary osteoarthritis of both knees. The patient experiences right knee pain worse than the left knee, and she has had this problem for many years.  The knee pain is worse with weight-bearing activities but also present at rest.  The patient also has difficulty going up and down stairs, and she is limited with how far she can walk.  She has not had significant benefits with multiple non-steroidal anti-inflammatory drugs, physical therapy (PT) or steroid injections.  The patient takes Mobic daily and ibuprofen at bedtime.  An X-ray revealed: right knee with severe medial and moderate lateral/anterior compartment degenerative changes, left knee with moderately severe medial and moderate lateral compartment degenerative changes, and mild degenerative changes to both hips.  Her physician is an orthopedic surgeon, and the treatment plan is for total knee replacement surgery.

Surgical indications require definition of a pain generator and failure to improve with conservative treatment.  The records show a pain generator has been defined, i.e. right knee.  Conservative treatments have been provided of PT, medications and injections.  Thus, based on these findings, the patient is a candidate for total knee arthroplasty (TKA).  Her body mass index (BMI) is greater than 42.  This is a relative contraindication to surgery as increased weight results in higher forces across the joint.  There is an associated increased rate of complication (medical and mechanical). The scientific literature recommends a trial or attempt of weight reduction prior to surgical intervention. 

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

The medical necessity for the total knee replacement surgery (outpatient procedure 27447 x1) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a pre-diabetic obese female. She presented to the Emergency Department with a history of increasing rectal pain and swelling of several weeks duration. Past history notes a prior failed attempt at a thrombectomy under local anesthesia. She had been seen earlier that day in the Surgical Clinic with complaints of increasing anal pain, and was referred from there to the ED (emergency department) for admission to the hospital.

In the ED, (emergency department), the patient was documented to be afebrile with stable vital signs within normal parameters. A CBC (complete blood count) showed a Hgb (hemoglobin) of 13.3 and a WBC (white blood count) of 5.8. Her Blood Glucose was elevated at 307mg (milligrams).

The patient was admitted to acute in-patient status and was taken to surgery on the following day. A chronic posterior anal fissure with an associated superficial fistula was found. The fistulous tract was opened, and the skin tag at the lower pole of the fissure was excised. Botox was then injected into the internal sphincter.

The patient's post-operative course was uneventful, and she was discharged from the hospital to be followed in the clinic.

No, the Inpatient admission was not medically necessary.

The patient experienced anal pain and swelling secondary to a chronic anal fissure with a superficial fistula arising within the fissure. She underwent a fissurectomy/fistulotomy with injection of Botox into the internal sphincter. The care rendered is appropriate for an observational and/or ambulatory setting. The severity of the patient's illness and the intensity of services rendered do not rise to the level required for acute in-patient care.

The needed care could have been delivered safely and appropriately at an observational or ambulatory level of care. The records to not document that the patient's illness required the services of acute in-patient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVID-19, Multiple fractures
Treatment: CDPAP: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week.
The insurer denied the CDPAP: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week.
The denial is overturned. 

The patient is a male with a history of COVID-19 infection, multiple right sided rib fractures, bilateral lower extremity weakness and urinary incontinence. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review requested for potential approval of 168 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 168 hours/week Personal Assistance Services is deemed medically necessary.

The patient is a male with a history of COVID-19 infection, multiple right sided rib fractures, bilateral lower extremity weakness and urinary incontinence. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent correspondence from the patient's medical provider indicates that due to progressively worsening gait ataxia, generalized weakness and more frequent falls, the patient has become bed-bound and now almost completely dependent on others for assistance with ADLs (activities of daily living). Hence, the currently approved plan of 77 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of 168 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She was sent to the emergency department by her primary physician for severe anemia with a hemoglobin of 6g/dl (grams per deciliter). She had some intermittent dizziness and headache but no other symptoms.  She was noted to have recently had a hemoglobin in the 7-8g/dl (grams per deciliter) range prior to being found to have a hemoglobin of 6g/dl (grams per deciliter).

The patient was admitted.  She was treated with one unit packed red cell transfusion. She was also treated with intravenous iron (Venofer) as she was found to have iron deficiency anemia.  Pelvic ultrasound was done and revealed polycystic ovaries.  Abdominal ultrasound was done and revealed mildly prominent spleen.  She was discharged.

No, the Inpatient admission was not medically necessary.

This patient was found to have worsening anemia with a hemoglobin of 6g/dl (grams per deciliter). However, she did not have active bleeding and also had no hemodynamic instability. She was treated with single unit transfusion and also treated with intravenous iron. She was discharged after a two-day hospital stay, and during her hospital stay there were no other active medical issues documented. At the time of admission she had mild symptoms related to her anemia and no evidence of hemodynamic instability. She did not require acute care inpatient admission for treatment of her anemia and could have been safely managed in the outpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congenital absence of the hand and fingers
Treatment: Durable Medical Equipment (custom made artificial arm and hand prosthesis) L7499 x 1
The insurer denied the Durable Medical Equipment (custom made artificial arm and hand prosthesis) L7499 x 1.
The denial is overturned. 

The patient is a female with history of congenital absence of the hand and fingers. The child has been seen by the skilled and certified prosthetist following physician prescription for a passive aesthetic upper extremity prosthesis. Based on the review of clinical records, the proposed prosthesis, "has the most realistic appearance, can assist child to perform non-grasping activities such as pushing, stabilizing, balancing... This type of device has the lightest weight."

Yes, the Durable Medical Equipment (custom made artificial arm and hand prosthesis) L7499 x 1 is medically necessary.

In this specific case, the below-elbow prosthetic passive left upper-extremity has been appropriately prescribed by the healthcare provider.  In this case, the patient is a child with congenital absence of the left upper extremity, which is a rare condition to begin with. Secondly, the passive prosthetic upper extremity device cannot be prefabricated and should be custom designed for the child with upper limb loss, regardless of etiology.

In this specific case, the patient is a female with congenital absence of the left hand. In this age group, and with her specific medical condition, it is important and medically necessary to have use of a left upper-extremity prosthetic device that will enable the closest approximation to the natural appearance of the contralateral intact hand and provide important functional tool for basic bimanual skills, as well as positive impact on the psychological well-being of this teenager. In this circumstance, passive hand and below elbow prosthesis cannot and should not be prefabricated, and should always be custom-made.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thoracic aorta dissection, respiratory failure,
urinary retention, muscle weakness, gait ataxia
and pulmonary edema
Treatment: Increase Personal Care Services; Increase to 24 Hours per Day, 7 Days per Week (Split-Shift); Total 168 Hours per Week
The insurer denied the Increase Personal Care Services; Increase to 24 Hours per Day, 7 Days per Week (Split-Shift); Total 168 Hours per Week.
The denial is overturned. 

The patient is a female with a history of thoracic aorta dissection, respiratory failure, urinary retention, muscle weakness, gait ataxia and pulmonary edema. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 168 hours per week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 168 hours per week Personal Assistance Services is deemed medically necessary.

This is a female with a history of thoracic aorta dissection, respiratory failure, urinary retention, muscle weakness, gait ataxia and pulmonary edema. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).

Recent correspondence from the patient's physician indicates that due to progressively worsening functional decline, the patient now requires maximum assistance for completion of all of her ADLs (activities of daily living), including frequent bed repositioning every two hours, manual wheelchair mobility and safety monitoring. Hence, the currently approved plan of 49 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 168 hours/week Personal Assistance Services is deemed medically necessary.