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

Diagnosis: Immunologic-Other/Sarcoidosis
Treatment: Pharmacy/Prescription Drugs - Humira 40mg Weekly
The health plan denied Humira 40mg weekly as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient is seeking approval for Humira 40 milligrams (mg) weekly. The patient has a history of sarcoidosis. She has had steroid injections into cutaneous lesions, and she had been on infliximab. She stopped using this after a year due to developing lichen planus. She then developed more facial granulomas and had more steroid injections. Her pulmonologist has been treating her throughout. She has been on Adalimumab most recently and has responded well to treatment and has not had any recurring lesions.

The requested Humira 40 mg every week is medically necessary for this patient.

According to Field et al, Patel et al, Heffernan et al, and Lahmer et al, this medication has been well described to be beneficial especially in extrapulmonary sarcoidosis. This patient is having severe and disfiguring sarcoid lesions on her skin and face. She had been on Humira previously and responded well. This is a common usage of Humira, and it is safe and effective for this reason. The physician's judgement is sound, and the patient would benefit from treatment.

Although Humira 40 mg every other week would be the preferred dosing regimen, Heffernan et al found that once weekly dosing is reasonable for the treatment of cutaneous sarcoidosis. Typically, the regimen for most conditions is every other week, but for cutaneous sarcoidosis in particular, once weekly dosing is reasonable based on current literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Arm Numbness and Weakness
Treatment: Inpatient admission

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented to the emergency ward with left arm numbness. At presentation her neurological examination showed decreased sensation in left arm, NIH SS (National Institutes of Health Stroke Scale) score was 1,  and CT (computed tomography) brain was negative for acute pathology. She was admitted for possible TIA (transient ischemic attack). Subsequent MRI (Magnetic resonance imaging) brain was negative for acute stroke.

No. The Inpatient Hospital Admission was not medically necessary.
The patient presented with complaints of vague left arm symptoms and had no other focal deficits. Initial evaluation with CT (computed tomography) brain was negative and she was otherwise medically stable. There were no features concerning for significant stroke or TIA (transient ischemic attack) (Cereda and Olivot; Mendelson and Prabhakaran). The monitoring, evaluation and treatment could have been safely and effectively provided at a lower level of care.

Yes. The health plan did act reasonably, with sound medical judgment and in the best interest of the patient
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Blood Clot.
Treatment: Pharmacy/Prescription Drugs.
The health plan denied the requested medication (Eliquis) as not medically necessary. The health plan's determination is upheld.

This is a female with a superior mesenteric vein thrombosis. The patient has a JAK2 mutation.
The patient was treated with Lovenox but was transitioned to Eliquis; this is under review.

The health plan's determination is upheld.

In this setting, systemic anticoagulation is used to minimize the extension of a thrombus. These agents have never been compared in a head-to-head trial in this clinical scenario and thus there is a paucity of data demonstrating an outcomes benefit with therapy using Eliquis over Warfarin or Xarelto. Lacking literature that demonstrates such a benefit, neither the authors of UpToDate nor guidelines specify a preferred approach. There is no evidence that the use of a formulary alternative would be less effective or less safe than Eliquis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Guillain-Barre, muscle weakness, bipolar disorder, generalized anxiety disorder, major depressive disorder, hypertension, schizoaffective disorder, and hypothyroidism
Treatment: Long Term Custodial Care
The insurer denied the Long Term Custodial Care
The denial is upheld

The patient is a female. She has multiple conditions, including Guillain-Barre, muscle weakness, bipolar disorder, generalized anxiety disorder, major depressive disorder, hypertension, schizoaffective disorder, and hypothyroidism. Denial of Long Term Custodial Care is being appealed. During this period, the patient's medical and mental status were stable. She was able to ambulate with a rolling walker. She required stand-by assistance with standing activities. She was able to independently bath, dress and toilet. She continued to see PT/OT (physical therapy/occupational therapy) for muscle weakness. She was able to tolerate a regular diet.

No, the requested Long Term Custodial Care is not medically necessary.
Custodial care is care primarily for the purpose of assisting a patient in ADLs (activities of daily living) or in meeting personal rather than medical needs, and which is not specific treatment for an illness or injury. It is care that cannot be expected to substantially improve a medical condition and has minimal therapeutic value. Such care includes assistance with walking, bathing or dressing; transfer or positioning in bed; normally self-administered medicine; meal preparation; feeding by utensil, tube or gastrostomy; oral hygiene; ordinary skin and nail care; catheter care; suctioning; using the toilet; enemas; or preparation of special diets and supervision over medical equipment or exercises or over self-administration of oral medicine. During the period in question, the patient did not require care to assist with ADLs (activities of daily living) as noted above. The patient was able to independently perform most ADLs (activities of daily living). She did not have special dietary needs or require supervision with medications. The requested Long Term Custodial Care is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Groin Pain
Treatment:  Peripheral Nerve Stimulator (PNS)
The insurer denied the  Peripheral Nerve Stimulator (PNS)
The denial is upheld

The patient is a male with right groin and testicle pain for several years after hernia surgery. He has tried acupuncture, chiropractor, physical therapy, cupping, epidurals at L1 (first lumbar spine vertebra), L2 (second lumbar spine vertebra), L3 (third lumbar spine vertebra), L4 (fourth lumbar spine vertebra) and S2-3 (second sacral vertebra  third sacral vertebra) without benefit. He has also tried cymbalta, naprosyn, robaxin, and prednisone without benefit or side effect.

As of the most recent visit the patient's pain medications include: Xtampaza, oxycodone, and tizanidine. MRI (magnetic resonance imaging) of the lumbar spine from approximately three years ago is significant for a sacralized L5 (fifth lumbar spine vertebra) vertebrae, spinal stenosis, facet arthropathy, mild SIJ (sacroiliac joint) arthrosis, and enlarged prostate. Assessment includes ilioinguinal neuralgia of the right side.

Sprint PNS (peripheral nerve stimulation) was recommended. Provider is also considering T12/L1 (twelfth thoracic spine vertebra/first lumbar spine vertebra) DRG (dorsal root ganglion) if patient fails PNS (peripheral nerve stimulation). The request for peripheral nerve stimulator for groin pain was denied as not proven effective and as such not medically necessary. The denial is being appealed.

No, the requested peripheral nerve stimulation is not medically necessary.
Peripheral nerve stimulation (PNS) has been increasingly used to manage acute and chronic pain. However, the level of clinical evidence to support its use is not clear. There is insufficient or inconclusive evidence published in peer-reviewed medical literature to evaluate the therapeutic value. There are no well-designed and well-conducted studies. There is inconclusive evidence published in peer-reviewed medical literature that the service improves net health outcomes. The services' beneficial effects on health outcomes does not outweigh any harmful effects on health outcomes. The service under consideration is not as beneficial as any established alternatives. Small published case studies do demonstrate the significance of peripheral stimulation as an innovative approach to treat chronic pain, however, more studies are needed to substantiate its effectiveness and safety. As such the requested service is considered unproven and not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient considering the current literature regarding this treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid Obesity. 
Treatment: Saxenda 3 MG/0.5ML PEN INJCTR. 

The insurer denied the Saxenda 3 MG/0.5ML PEN INJCTR. 
The denial is upheld. 

The patient is a female. She is appealing denial of Saxenda for obesity. The patient has failed to lose weight through lifestyle modification. There are no clinical records.  A letter notes the patient has tried and failed Fastin, Belviq, and Contrave. Liraglutide was effective as follows:  Provider states Liraglutide at 1.8 mg (milligrams) became ineffective, resulting in weight gain of 50 pounds.  Liraglutide to titrate to max dose of 4.5 mg (milligrams) is being requested. 

No, the requested Saxenda is not medically necessary. 

Saxenda is FDA (United States Food and Drug Administration) approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index or 30 or greater or BMI (body mass index) 27 in the presence of at least one weight-related comorbid condition. After initial approval, continuation coverage is indicated if the patient has lost at least 4% of their initial body weight after 16 weeks of starting Saxenda. This patient has been treated with Saxenda previously. Most recently, the medication was started earlier in the year. However, re-evaluation approximately 4 months later showed the patient gained weight. The requested Saxenda is not medically necessary, because it is not consistent with accepted medical standards for this patient who failed to lose more than 4% of body weight after approximately 20 weeks of Saxenda. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis of the knees. 
Treatment: Increase Home Care / Personal Care Level II From 35 Hours To 56 Hours Per Week. 

The insurer denied the Increase Home Care / Personal Care Level II From 35 Hours To 56 Hours Per Week. 

The denial is upheld. 

This female who has medical conditions including osteoarthritis of the knees.  She is appealing denial of increase in personal care assistance (PCA) from 35 to 56 hours per week.  Appeal statement notes that she needs full time assistance due to osteoarthritis of knees.  The request is denied based on nursing assessments performed.  The recent assessment shows that the patient's function has declined and she needs more assistance with toilet transfer and use.  She needs assistance to walk up steps.  She has not fallen in past 90 days.  A letter from the patient's daughter notes that patient falls when left alone.  

A clinical note by the provider notes the patient has physical and cognitive decline.  She has difficulty ambulating and needs a wheelchair and requires more assistance with activities of daily living (ADLs).  She needs more assistance with urinary incontinence.  She has falls and has shortness of breath when ambulating.  The clinical note recommends 24 hour care. 

A letter from another provider recommends care 12 hours per day. 

No, the proposed treatment is not medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient has osteoarthritis of knees.  She is appealing denial of increase in personal care assistance (PCA) from 35 to 56 hours per week.  

Nursing assessment performed shows the patient's function has declined and she needs more assistance with toilet transfer and use when compared to the assessment performed previously.  She needs assistance with stairs.  The patient's daughter notes the patient falls when left alone.  Clinical notes show the patient has decline in cognitive and physical functioning.  It notes the patient is at risk for falling and needs assistant with transfers as already accounted for in the nursing assessment.  The patient has not fallen in the past 90 days.  Personal care assistance is not indicated when no tasks are being performed or for safety supervision.  The documentation does not support the medical necessity for an increase in personal care assistance hours.   The approved personal care assistance 35 hours per week is appropriate.  The proposed increase in personal care services to total 56 per week is not medically necessary.  

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

The patient has a past medical history (PMH) of gastroesophageal reflux disease (GERD), osteoarthritis (OA), and a recent knee replacement who was admitted with complaints of (c/o) fatigue, a fever, and dysuria associated with pus draining from the penis. Vital signs were notable for a pulse of 101. The physical exam was notable for no apparent distress (NAD), non-toxic appearing, positive (+) suprapubic tenderness. Lab work was notable for a white blood cell count (WBC) of 13.95. A bladder scan showed 1 liter (L) of urine. The patient was diagnosed with a urinary tract infection (UTI) and treated with Zosyn and an infectious disease (ID) consultation. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was medically necessary at an inpatient level of care.
This patient with a history of recent knee replacement presented to the Emergency Department with a fever, leukocytosis, and tachycardia with evidence of a urinary tract infection. He was provided with intravenous antibiotics and hydration, to which the patient responded well. This patient met sepsis criteria with tachycardia, leukocytosis and a fever, increasing the clinical risk of monitoring this patient at a lower level of care than inpatient, especially given the patient's concomitant urinary retention. In addition, after evaluation by ID, the recommendation was to begin the patient on intravenous (IV) antibiotics, rather than oral antibiotics. He required close monitoring, intravenous antibiotics, and cultures to ensure that his sepsis was adequately controlled, his vital signs were improving, and that he did not become more hemodynamically unstable. Overall, this patient required an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient stay

The insurer denied the inpatient stay. 
The health plan's determination is upheld.

The case involves a female who presented for inpatient treatment to address substance use disorder with a stimulant (crack cocaine) class substance. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. She had a history of substance use disorder with escalating use of crack cocaine with up to $150 worth on a daily basis; she had no prior substance use disorder treatment. She was referred for treatment by her counselor with the goal of stopping the cycle of use which was triggered by comorbid psychiatric conditions (anxiety and depression), as well as physical and mental abuse by her boyfriend.

Inpatient Admission is not medically necessary for this patient.
The patient presented with substance use disorder with use of crack cocaine, referred for treatment by her mental health counselor. She readily engaged in treatment with reasonable motivation. During the time interval under review, the patient was noted to be in no apparent distress with improved functioning and active participation in treatment including positive interactions with staff and peers. There were no biomedical, emotional/psychiatric or other clinical features that would have required inpatient level monitoring or structure. The application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria did indicate that the patient was clinically appropriate for treatment with lower-level care in a less restrictive treatment setting. Thus, medical necessity for the admission is not met in this case scenario and is consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowding
Treatment:  D8080 Braces and D8670 Monthly Visit (x12)

The insurer denied the  D8080 Braces and D8670 Monthly Visit (x12).
The denial is overturned.

The patient is a male. The request is for orthodontic treatment (Braces) and monthly visits.

Per the Provider's dental consultation, the patient presents with class I skeletal relationship, class II canines, moderate maxillary crowding, severe mandibular crowding, deep bite, moderately excessive overjet, anterior cross bite with gingival attachment loss (Mandibular left Canine).

The health plan denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index Report, the score necessary for the approval of orthodontic treatment (Braces).

The provider appealed the case based on the diagnoses, particularly the anterior crossbite with gingival attachment loss--an automatic qualifier for orthodontic treatment per the HLD (Handicapping Labio-Lingual Deviation) Index Report.

Yes, the Braces and monthly visits are medically necessary.
As supported by the photos and X-rays and as stated in the Provider's dental clinical summary, the patient presents with severe mandibular and moderate maxillary crowding. He also has anterior crossbite with gingival attachment loss on mandibular left Canine.

The crowding and crossbite (mal alignment) can affect the patient's ability to chew food properly. It also affects proper speech and the ability to maintain proper hygiene and can lead to gingivitis/inflammation and gum disease.

Therefore, given the above, the braces and monthly visits are medically necessary.

No, the Health plan did not act reasonably, with sound medical judgement and in the best interest of the patient.
If the patient's conditions are left untreated, the complications of decreased proper function as it relates to chewing, speech and compromised oral hygiene can only lead to more dental problems in the future.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission

The insurer denied the inpatient admission.
The denial is upheld.

This is a male. He was hospitalized due to worsening fever and abdominal pain. The reason for prior denial was that the admission and acute hospital care did not meet criteria.

Brief summary of hospital stays:
Day one: (ED notes) history of autism and seizures; had fever, irritability and abdominal pain for one day and was seen in ED (emergency department);
Physical exam showed dehydration and irritability;
Received intravenous (IV) fluids and fleet enema.

Day two: (admission note) admitted early in the morning for running nose, abdominal pain and constipation; no cough, wheezing or respiratory distress. Had poor appetite and dehydration.
Plans: continue maintenance IV fluids; gastroenterology (GI) consult.
Gastroenterology consult: follow up in outpatient clinic in a month.

Day three: (discharge summary) no abdominal pain or distension; clinically stable and back on his regular diet; discharged home.

No, the proposed treatment was not medically necessary.
As documented in the attached medical records, this patient had fever, irritability and abdominal pain. The patient was seen in ED (emergency department). The patient received IV (intravenous) fluids. The admission note documented that the patient did not have respiratory distress, cough or wheezing. When the patient was admitted in the early morning, he did not have any more fever. Abdominal pain also stopped. The patient was back on his regular diet soon after admission. GI (gastroenterology) was consulted with no recommendation for any acute intervention. The patient was discharged home on the 2nd day after admission. The patient likely had acute gastroenteritis.

From admission until discharge, this patient was clinically stable, with no fever, vomiting, diarrhea, respiratory distress, hemodynamic instability, or toxic appearance. Thus, the proposed inpatient acute care is not medically necessary (1-2).

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

The patient did not have any acute symptoms that required acute inpatient stay including hemodynamic instability, high fever, altered mental status, specific infections (pneumonia, meningitis) and others.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure Disorder
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

Patient is a man with history of seizures, non-compliant on anti-epileptic medications. He was admitted after having four episodes of seizures with postictal state.

The patient was given IV (intravenous) antiepileptics. He was made NPO (nothing by mouth), and put on alcohol withdrawal watch. He was noted to have tachycardia and hypertension. He was borderline tachypneic. He was admitted for further evaluation including possible EEG (electroencephalogram)/epilepsy consultation as well as brain MRI (magnetic resonance imaging). He left against medical advice.

This admission was previously denied by the health plan, as it was determined not to be medically necessary.

Yes, the Inpatient admission was medically necessary.
Admission to manage and workup a seizure, particularly to rule out non-convulsive status epilepticus is warranted, as discharging a patient with non-convulsive status epilepticus is dangerous and can negatively affect the patient. A patient who has multiple seizures without a return to baseline is considered to be in status epilepticus, which was evidenced to be the case in this patient. MCG (Milliman care guidelines) guidelines state that admission is warranted in status epilepticus. This would warrant a continuous EEG (electroencephalogram) as well as making sure that he did not have any additional seizures. Furthermore he also had abnormal vital signs, which needed to be monitored, as well as concern for potential alcohol withdrawal, and therefore needed to be on the CIWA (clinical institute withdrawal assessment) protocol.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient was considered to be in status epilepticus and warranted hospital admission for the above stated reasons. Failure to control and rule out non convulsive status epilepticus can have profound consequences.