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

Diagnosis: Ulcerative Colitis
Treatment: Stelara 90 mg every 4 weeks
The insurer denied Stelara 90 mg every 4 weeks.
The determination is overturned.

The patient has ulcerative colitis and has failed mesalamine, Humira, and Entyvio. She started Stelara and she had ongoing disease symptoms. The Stelara level was low at 1.5 micrograms per milliliter [ug/mL] (and anti-Stelara antibodies were absent). A colonoscopy showed inflammation from the rectum to the sigmoid colon; biopsies were positive for active disease in the descending colon, sigmoid colon, and rectum. At issue is the medical necessity of Stelara 90 milligrams (mg) every 4 weeks for the treatment of ulcerative colitis.

The Stelara 90 mg every 4 weeks is medically necessary. 

The patient has failed multiple conventional and biologic therapies; she then had improvement on Stelara [1-3]. Stelara has shown efficacy for the treatment of ulcerative colitis in a Phase III trial, UNIFI [1,4]. This trial demonstrated that a single intravenous dose of Stelara induced clinical remission in a significantly greater proportion of patients than placebo did, as measured by both clinical response and endoscopic response; this result was attained in a patient population which was 50% biologic-refractory. Recent studies have demonstrated that Stelara 90 mg every 4 weeks is safe and well-tolerated for the treatment of inflammatory bowel disease, with recovery of effectiveness in patients with active disease [5-7]. A recent study showed that 43% of ulcerative colitis patients on Stelara required dose escalation, and over 50% of those with dose escalation achieved corticosteroid-free remission, and long-term improvement in endoscopic inflammation [8]. In this case, the patient has ulcerative colitis, and has failed multiple guideline-recommended alternatives, with active disease symptoms and objective evidence of active disease on colonoscopy with biopsies in the setting of a low Stelara level, and the use of Stelara 90 mg every 4 weeks can lead to remission. Continuation of the current dose of 90 mg every 8 weeks or a discontinuation of Stelara (even if an alternative is immediately attempted) may result in ongoing symptoms and complications such as toxic megacolon, dysplasia leading to colorectal cancer, hospitalization, or need for surgery. For all of these reasons, the request for Stelara 90 mg every 4 weeks is medically necessary for the treatment of this patient's ulcerative colitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hiatal hernia
Treatment: Inpatient stay
The insurer denied: Inpatient stay
The denial is: Overturned

The patient is a female who presented to the hospital with the diagnosis of a recurrent paraesophageal hiatal hernia. She underwent laparoscopic repair of the paraesophageal hiatal hernia with mesh, gastropexy, and intraoperative endoscopy. She was admitted to the hospital. The operation included the mobilization of the distal esophagus and crural repair with 3 individually placed sutures, mesh placement, gastropexy, and take down of the prior fundoplication. The patient reported abdominal pain consistent with the operation performed. An upper gastrointestinal (UGI) was obtained and was normal post-surgery. She did tolerate a full liquid diet. She had a decrease in oxygen saturation and was evaluated with pulmonary consultation and exercise oximetry. She remained clinically stable and was discharged from the hospital.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

An inpatient level of care was necessary and appropriate.
This patient had a paraesophageal hiatal hernia and underwent operative repair and gastropexy. The operative dictation describes the mobilization of the distal esophagus, crural repair and gastropexy in addition to upper endoscopy and mesh placement for crural repair. The patient was initially nothing by mouth (NPO) after surgery and she was monitored for dysphagia, pain, nausea. She was provided antiemetic medications and parenteral analgesia. An upper gastrointestinal (UGI) was obtained on the first post-surgical day. She manifested a drop in oxygen saturation on the second post-surgical day and was evaluated with pulmonary consultation and exercise oximetry.
An inpatient level of care is consistent with generally recognized standards of care for the condition of a paraesophageal hiatal hernia as documented to exist in this case. This patient underwent an operation that carried the reasonable expectation of hospitalization for at least 2 midnights (48-hours). The anticipated length of stay, the diagnosis of paraesophageal hiatal hernia and the intensity of service provided in this case support an inpatient designation on the dates in question.
Based on the pre-surgical diagnosis, the anticipated length of stay, and the need for post-surgical monitoring, a physician exercising prudent clinical judgment would admit this patient to an inpatient level of care. This level of care is/was in accordance with generally accepted standards of medical practice, clinically appropriate, is/was considered effective for the patient's illness, injury or disease, and is/was not primarily for the convenience of the patient, physician, or other health care provider.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose veins
Treatment: Sclerotherapy
The insurer denied: Sclerotherapy
The denial is: Overturned

The patient is a male with symptomatic lower extremity varicose veins who was seen for 3 month follow up by his healthcare provider.
The patient complained of bilateral lower extremity varicose vein pain, fatigue, heaviness, and skin discoloration.
He had been wearing daily 20-30 millimeters of mercury (mmHg) knee high compression stockings daily.
He was noted to have large ropy varicosities of the bilateral lower extremities with venous stasis changes.
A venous duplex ultrasound of the bilateral lower extremities demonstrated deep venous reflux and bilateral greater saphenous vein reflux.
The patient offered greater saphenous vein (GSV) laser ablation with bilateral lower extremity phlebectomy.
The patient underwent left lower extremity endovascular laser treatment varicose vein initial and phlebectomy single extremity.
The patient was seen for follow up, where he complained of painful medial ankle varicose veins.
He was noted to have large ropy varicosities left (L) greater than (>) right (R) and venous stasis changes in gaiter distribution, left lower extremity (LLE).
A venous duplex ultrasound of the left lower extremity performed demonstrated occlusion of the left great saphenous vein and no deep vein thrombosis (DVT) in the left lower extremity.
A computed tomography venography (CTV) of the abdomen and pelvic performed demonstrated moderate compression of the left iliac vein by the left iliac artery.
The patient was offered phlebectomy and sclerotherapy of the left medial ankle varicose veins followed by left iliac venous stent placement for treatment of the May Thurner Syndrome.
The patient underwent sclerotherapy of the left lower extremity.
The issue at hand is whether or not the sclerotherapy was medically necessary.

The health plan's determination is overturned.

The treatment of sclerotherapy was medically necessary for this patient. The patient has symptomatic lower extremity varicose veins, requiring sclerotherapy. Sclerotherapy is the standard of care for the treatment of symptomatic varicose veins. The treatment is medically necessary. The patient will benefit from the treatment.
Appeal type: Medical necessity
Decision: Upheld

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

The patient ha a past medical history (PMH) of hypertension (HTN), hyperlipidemia (HLD), and diabetes mellitus type 2 (DM2) who was admitted to the hospital with complaints of (c/o) a headache and intermittent chest pain (CP). His vital signs were notable for a blood pressure (BP) of 212/128. The physical exam was notable for occipital tenderness to palpation (TTP), normal neurological examination. Lab work was notable for chronic kidney disease (CKD) and hyperglycemia, negative troponin. Imaging studies, a transthoracic echocardiogram (TTE) showed diastolic dysfunction, a computed tomography (CT) scan of the head showed no acute pathology, a chest x-ray (CXR) showed no acute disease. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) with (w/) left ventricular hypertrophy (LVH). The patient was diagnosed with hypertensive urgency and was treated with hydralazine, with a reduction in the blood pressure (BP). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

The admission was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o a headache and intermittent CP and was found to have a significant blood pressure elevation. He did not have any evidence of end-organ damage as there was no alteration of consciousness, neurologic deficits, encephalopathy, cerebrovascular accident (CVA), intracerebral hemorrhage (ICH), retinal hemorrhage/papilledema, acute coronary syndrome (ACS), aortic dissection, acute heart failure, or acute kidney injury. The patient was treated in the ED with anti-hypertensives, and responded appropriately to the medication with a reduction in BP. The patient did have chest pain, but was documented to have atypical chest pain with a low HEART [History, EKG, Age, Risk factors], score of 3. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hepatic failure; limited range of motion. 
Treatment: Increase Personal Care Aide (PCA) Services For a Total of 84 Hours per Week.
The insurer denied the Increase Personal Care Aide (PCA) Services For a Total of 84 Hours per Week. 
The denial is overturned. 

The patient is a female. Her conditions including hepatic failure, and limited range of motion. Denial of increase personal care aide (PCA) services for a total of 84 hours per week is being appealed. The plan approved 59.5 hours per week.

Uniform Assessment Systems (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances, bathing dressing, walking, locomotion, and toileting; extensive assistance with managing finances, personal hygiene, and bed mobility; limited assistance with phone use; and independent with eating. The patient has occasional bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in personal hygiene, upper body dressing, and eating.

Yes, the requested Increase Personal Care Aide (PCA) Services For a Total of 84 Hours per Week is medically necessary. 
Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase personal care aide (PCA) services for a total of 84 hours per week is being appealed. The plan approved 59.5 hours per week. 

The patient has several chronic conditions. Uniform Assessment Systems (UAS) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living), except eating. She has occasional bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in personal hygiene, upper body dressing, and eating. This patient has significant physical impairments that have progressed between UAS (Uniform Assessment System) evaluations. The approved PCA (personal care aide) 59.5 hours per week is inadequate to meet the patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living). The requested increase in PCA (personal care aide) to a total 84 per week is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 
The requested increase in personal care aide service hours is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a female. The patient presented to the emergency room (ED) with the complaint of sharp abdominal pain in the area of her incisions.  She had undergone laparoscopic appendectomy that was performed the day before.  She had been discharged from the hospital following surgery.  

The patient was alert and oriented at the time of presentation.  Her vital signs at the time of presentation were normal.  Examination revealed some abdominal tenderness between the three abdominal incisions. The white blood cell (WBC) count was normal at 4.9 thousand (K).  Her hemoglobin was normal at 12.5.  The metabolic panel was normal.  The patient was admitted to the hospital.  

The patient was provided a diet and monitored overnight.  The records indicate that the patient had normal vital signs and was considered to be stable for discharge home.  

No, the proposed treatment was not medically necessary.  

In this case, inpatient care was not medically necessary.  The care and treatment provided during this time could have been rendered with a lower level of care and did not require an inpatient designation.  This lower level of care would have provided for surgical assessment, intravenous fluid as provided, follow up, labs, and overnight monitoring.  

This patient presented with abdominal pain having undergone appendectomy and having been discharged from the hospital following surgery.  The evaluation with examination and lab data identified abdominal incisional tenderness but no obvious indication for acute surgical intervention.  The patient was monitored overnight, and remained clinically stable during the period of monitoring.  

This patient's clinical needs could have been satisfied with a lower level of care.  This lower level of care would have provided for clinical assessment and monitoring including overnight observation as was performed.  The patient was clinically stable at the time of presentation and remained so during the period of monitoring.  

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

The health plan acted reasonably and with sound medical judgment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unsteady gait, history of falls with pelvic fracture, and dementia. 
Treatment: Personal Care Aide (24 Hours per Day, 7 Days per Week (2 Shifts of 12 Hours)). 
The insurer denied: Personal Care Aide (24 Hours per Day, 7 Days per Week (2 Shifts of 12 Hours)). 
The denial is overturned. 

The patient is an elderly female who reportedly has unsteady gait, history of falls with pelvic fracture, and dementia. The patient also has blindness in one eye and decreased vision in the other eye. The patient lives alone and needs 24/7 assistance. She is currently residing in a skilled care facility for rehab after hip fractures. The patient is not safe to live by herself at home.  The patient is requesting personal care aide (24 hours per day, seven days per week [two shifts of 12 hours]). 

The proposed treatment is medically necessary. 

The patient has dementia and a history of falls; she is at risk of recurrent falls. She is blind in one eye with decreased vision in her second eye. She cannot walk by herself and cannot use a walker. She needs help with all her activities of daily living (ADLs) including making food, eating, walking, toileting and transfers. The plan approved 20 hours per day however it is not enough as the patient needs help with getting to the toilet and transfers all the time, both during the day and the night. Therefore, the proposed increase in personal care aide is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea/Vomiting
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female with medical history of cannabis abuse with cannabinoid hyperemesis syndrome, hyperemesis gravidarum, gastroesophageal reflux disease (GERD), hypothyroidism, ovarian torsion status post right oophorectomy, hemorrhoids complicated by bleeding, anxiety disorder, and alcohol use.

She presented to the emergency department with severe acute epigastric pain, nausea, and vomiting since that morning, and rectal bleeding from hemorrhoids for which she was seen five days prior. She was brought to the emergency department due to agitation. Physical examination was notable for agitation, dry mucous membranes and generalized abdominal tenderness. Labs showed unremarkable complete blood count, unremarkable basic metabolic panel, and elevated aspartate aminotransferase of 54 units per liter (U/L). Urine toxicology screen was positive for opiates and cannabinoids. Computed tomography scan of the abdomen and pelvis showed a large left adnexal cystic-appearing structure measuring 4.6 x 4.2 centimeter (cm) with unilocular appearance (compared with bilobed appearance on prior scan); ovarian torsion could not be excluded. She was treated with intravenous fluids, morphine, and Haldol. Labs showed elevated aspartate aminotransferase of 38 U/L. Transvaginal ultrasound showed left corpus luteum cyst with no evidence of torsion. Gynecology consultation concluded that she had an ovarian cyst without torsion and recommended no gynecologic intervention. She signed out from the hospital against medical advice, with a recommendation for Primary Care follow-up. At issue is medical necessity for the inpatient hospital admission.

The inpatient hospital admission is not supported in this case, and the care provided could have been provided at a lower level of care status. Although the patient presented with nausea and vomiting, she did not have persistent hypotension, organ failure, or other stigmata of severe volume depletion. The presenting gastrointestinal symptoms of epigastric pain, nausea, and vomiting were consistent with inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease), cannabinoid hyperemesis syndrome, gastroparesis, or gastroenteritis [1-6]. However, the patient did not have evidence of bowel obstruction, peritonitis, abscess, fistula, sepsis, ongoing gastrointestinal bleeding, or other complications warranting inpatient level of care [7,8]. She was treated with conservative therapy, consistent with the standard of care [3-8]. Gynecology evaluation did not recommend any further workup for corpus luteum cyst [9]. All of the measures that were undertaken, including monitoring, labs, and antiemetic therapy, imaging, and Gynecology consultation, could have been performed without the inpatient level of care, at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cutaneous warts
Treatment: Cidofovir Dihydrate Compound 
The insurer denied Cidofovir Dihydrate Compound.
The health plan's determination is upheld. 

The patient is a female with treatment-refractory cutaneous warts. For several months, these warts have been extremely resistant to first- and second-line treatments, such as numerous sessions of cryotherapy with liquid nitrogen, topical therapy with imiquimod and 5-fluorouracil, and also intralesional therapy with Candida antigen. These treatments have been painful but have not been successful.

The Cidofovir Dihydrate Compound is not medically necessary for this patient.
An extensive review of overall treatments for cutaneous warts with topical and intralesional therapies note that virtually all treatments have their limitations, and that ultimately the problem may lie in the host response for which a lack thereof will prevent any therapy from being reliably treated. Virtually any treatment requires multiple sessions to achieve a desired effect of reduction or elimination of warts.
The patient has tried and failed antimetabolites (5-fluorouracil and imiquimod) and Candida antigen which demonstrates that this patient has no greater a likelihood of resolution of her warts with the requested topical cidofovir than with other therapies. Other therapies include topical cantharone/podophyllin/salicylic acid, topical and intralesional Vitamin D analogues, intralesional bleomycin, and laser therapy. Intralesional cidofovir may or may not be more effective than the requested topical compounded cidofovir. Even a more conservative/traditional approach of electrodessication/curettage under local anesthesia is a viable opportunity for this patient to achieve clearance.
Accordingly, with other treatment options available for this patient to utilize for her warts, the requested topical compounded cidofovir is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid Arthritis
Treatment: Actemra ACTPen 162mg/0.9ml SC (subcutaneous) SOAJ (solution auto-injector)
The insurer denied the Actemra ACTPen 162mg/0.9ml SC SOAJ.
The determination is upheld.

The patient has seropositive rheumatoid arthritis (RA) and lupus overlap as well as mixed connective tissue disease (MCTD). The patient is currently on by mouth (PO) methotrexate (MTX) 20 milligrams (mg) weekly, Prednisone 10 mg daily and Plaquenil 200 mg twice daily (BID). The issue in this case is the medical necessity of subcutaneous (SQ) Actemra 162 mg every other week. The patient has not tried and failed the formulary drugs, including Rinvoq, Xeljanz and Xeljanz extended release (XR).

SQ Actemra is not medically necessary for this patient. There is no medical reason the patient cannot try Rinvoq, Xeljanz, Xeljanz XR, all of which are indicated for the treatment of RA. These drugs are equally in efficacy to SQ Actemra and all of these drugs have potential side effects, such as infection, lab abnormality, allergic reaction, etc. The provider states that the formulary drugs also have an increased risk of thrombosis and malignancy, which is accurate; however, the patient does not have a personal history of thrombosis or malignancy, therefore, they are not contraindicated in this case. A paper in the New England Journal of Medicine in 2014 concluded that 'in patients who had not previously received methotrexate or therapeutic doses of methotrexate, tofacitinib (Xeljanz) monotherapy was superior to methotrexate in reducing signs and symptoms of rheumatoid arthritis and inhibiting the progression of structural joint damage. The benefits of tofacitinib need to be considered in the context of the risks of adverse events'. Most patients with RA will try methotrexate (MTX) at some point and either have a partial response, fail it entirely or have an adverse event before moving on to a biologic. The point of the trial is to show that Xeljanz is superior to MTX in a head-to-head trial. The trial does not specify whether being on MTX prior to Xeljanz is salient in terms of the patient's response to the medication. In clinical practice most patients with RA will have tried MTX at some point before graduating to a biologic. That said, there is also data proving Xeljanz in combination with a disease modifying anti-rheumatic drug (DMARD) improves disease activity in patients with active RA. A study in Ann Intern Med in 2013 found that 'tofacitinib improved disease control in patients with active RA despite treatment with nonbiologic DMARDs, primarily methotrexate'.