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

Diagnosis: Chronic Diarrhea. 

Treatment: Polymerase Chain Reaction (PCR) testing - code 87507. 

The insurer denied coverage for Polymerase Chain Reaction (PCR) testing - code 87507. 

The denial is upheld. 

The patient had required a previous colectomy and ileal rectal anastomosis. An anastomotic ulcer with perforation occurred and a loop ileostomy was needed. There was then reversal of the ileostomy but subsequently the patient developed diarrhea. She was also having pelvic pains and weight loss. A workup for chronic diarrhea was ordered. 

Up To Date article titled "Approach to the adult with chronic diarrhea in resource-rich settings" notes, stool testing is a recommended part of this workup. Testing for Giardia, clostridium difficile, fecal leukocytes, and fecal calprotectin are advised. The topic of PCR stool testing is addressed under the topic approach to the adult with acute diarrhea in resource-rich settings. The article states that a high degree of clinical correlation is necessary when interpreting results of molecular testing since these assays detect genetic material, which does not always indicate infection with a viable organism. Any specimen that tests positive on a multiplex molecular panel should be submitted for a confirmatory culture. 

This patient has chronic diarrhea and stool testing is part of the workup. However, the PCR testing is not a standard part of the workup for chronic diarrhea. In addition, even for acute diarrhea, it has limitations as compared to doing specific stool testing for bacteria and parasites. Therefore, the health care plan acted reasonably and with sound medical judgement. PCR testing is not medically necessary. 

The denial is upheld. 

The insurer's denial of coverage for Polymerase Chain Reaction (PCR) testing - code 87507, is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 Braces
The insurer denied the D8080 Braces
The denial is overturned.

The patient is a female with a Class I malocclusion. The request is for braces. She has a deep bite and an impacted #11 (upper left canine).

Yes, the braces are medically necessary.
The patient has an impacted upper left permanent canine (tooth #11). When there is an impacted permanent tooth with extraction not indicated, this is an automatic qualifier according to the handicapping index scale. This case has medical necessity for orthodontic treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Lower Extremity Pain and Numbness
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient, a male, underwent a left lower extremity angiogram. He had undergone complex surgery for acute ischemia and now had worsening left heel gangrene and pain. His angiogram showed no treatable disease and was therefore only diagnostic. The patient was admitted as an inpatient following the procedure. He was seen by a Podiatry consultant, who recommended hyperbaric oxygen therapy. The patient was discharged the next day.

Coverage for the inpatient stay was denied on the basis that the patient did not meet any of the Milliman Care Guideline (MCG) criteria for inpatient hospital stay.

No, the proposed inpatient admission was not medically necessary.
The patient presented for angiography, which was performed uneventfully. The procedure was purely diagnostic, meaning that no intervention was performed. He did not have any complication from the procedure such as bleeding, contrast reaction, or hemodynamic compromise. 
An angiogram, especially one where no intervention is done, is a very low risk procedure that is not expected to cause any functional impairment beyond the first few hours after the procedure. For this reason, patients are managed as outpatients in almost every instance. There are rare reasons for inpatient admission, including procedural complications  (e.g. bleeding, vascular injury, and embolization) or development of a serious medical condition (e.g. myocardial infarction, stroke). This patient did not have any such event. He continued to have the same symptoms and signs which were present before the procedure, namely left heel gangrene and pain.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Mellitus
Treatment: Humalog KwikPen 100unit/ml SC SOPN, Brand, Pre-service
The insurer denied the Humalog KwikPen 100unit/ml SC SOPN, Brand, Pre-service.
The denial is upheld.

This is a male patient with type II diabetes. He has tried and failed Admelog. His glycated hemoglobin (A1C) is 7.3%. 

The request for Humalog KwikPen is under review. The prior request was denied as the patient has not tried and failed generic insulin lispro marketed by Eli Lilly and Co. The attending physician is appealing this determination because the patient is currently stable on Humalog.

No, the proposed Humalog KwikPen is not medically necessary.
This request is for Humalog KwikPen. The prior request was denied as the patient has not tried and failed generic insulin lispro marketed by Eli Lilly and Co. The authorized generic is the exact same insulin as the branded product and is expected to be equally safe and effective. The American Diabetes Association clinical guidelines do not recommend the use of branded Humalog over the authorized generic. Therefore, the proposed Humalog KwikPen is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: severe dementia, worsening gait ataxia and chronic urinary incontinence.
Treatment: Increase Personal Care Service 24 Hours A Day (split shift) 7 Days A Week For a Total of 168 Hours.
The insurer denied the Increase Personal Care Service 24 Hours A Day (split shift) 7 Days A Week For a Total of 168 Hours.
The denial is overturned. 

The patient is a female with a history of severe dementia, worsening gait ataxia and chronic urinary incontinence. 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/week Personal Assistance Services to offer increased ADL activities of daily living) support.

Yes, the requested 168 hours/week (split shift) Personal Care Services is deemed medically necessary.
This is a female with a history of severe dementia, worsening gait ataxia and chronic urinary incontinence. Due to impairments related to these conditions, she requires assistance for completion of the majority of his activities of daily living (ADLs).

Although an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and noted that the currently approved plan of 84 hours/week Personal Care Services is sufficient to meet the patient's current needs, the patient's physician that relates this reduced schedule leaves the home alone, completely unassisted for numerous hours/day. This is problematic, as she now requires 24 hour assistance, is unable to perform any activities of daily living by herself, including toileting, bathing, dressing, and she requires overnight assistance due to increased risk of falls.

Hence, provision of 168 hours/week (split shift) Personal Care Services can reasonably be expected to be beneficial for the patient and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 168 hours/week Personal Care Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine

Treatment Emgality 120mg/ml [milligram per milliliter]

The insurer denied coverage for Emgality 120mg/ml.

The denial is overturned.

This case involves a female who has complained of migraines since an early age. The documentation indicated she has tried multiple medications however her migraines remain refractory. The documentation indicated the patient was only able to remember topiramate which was the last medication she utilized. She was then placed on sumatriptan which did help; however, she could not utilize this medication frequently. The physician indicated she was then recommended to utilize Emgality which decreased her headaches by 80% (percent).

According to current literature this medication is a calcitonin gene related peptide antagonist indicated for preventative treatment for migraines in adults. The submitted documentation indicated this patient has suffered from migraines at an early age. She has utilized prior preventative medications without success. The documentation indicated the patient was prescribed this medication for migraine preventative treatment which is consistent with current standard of care. Furthermore, in a randomized trial by Mulleners et al, they found that "Galcanezumab was superior to placebo in the preventive treatment of migraine and was safe and well tolerated in patients for whom multiple previous standard-of-care preventive treatments had failed." As such, Emgality is medically necessary.

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

The insurer's denial of coverage for Emgality 120mg/ml is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis.
Treatment: Actemra.
The insurer denied the Actemra.
The denial is overturned.

The patient is a male with seronegative rheumatoid arthritis (RA) and interstitial lung disease (ILD).  He failed treatment with sulfasalazine, Xeljanz and steroids.  Earlier this year, he presented with a flare of his disease following COVID(Coronavirus Disease) vaccination, along with a high titer anti-ribonucleoproteins (RNP) antibody, consistent with mixed connective tissue disease (MCTD). The patient was noted to have bilateral wrist synovitis, as well as cough, hoarseness and bronchospasm.  

The attending physician (AP) wishes to treat with Actemra, for both rheumatoid arthritis (RA) and scleroderma-associated interstitial lung disease (ILD), as interstitial ling disease (ILD) findings in scleroderma and mixed connective tissue disease (MCTD) may be similar.  The patient has not tried or failed the Plan-preferred agents Rinvoq or Kevzara.  Although Kevzara is an interleukin-six (IL-6) inhibitor similar to the requested Actemra, Kevzara is not similarly Food and Drug Administration (FDA)-approved for the treatment of scleroderma-associated interstitial lung disease (ILD).  The appeal is for Actemra for the treatment of seronegative rheumatoid arthritis (RA) and mixed connect tissue disease (MCTD)/scleroderma-associated interstitial lung disease (ILD).

Yes, the proposed Actemra is medically necessary.
The requested Actemra is Food and Drug Administration (FDA)-approved for the treatment of rheumatoid arthritis (RA), as well as scleroderma-associated interstitial lung disease (ILD).  This patient has both RA and mixed connective tissue disease (MCTD)-associated interstitial lung disease (ILD) (similar to scleroderma-associated interstitial lung disease [ILD]), and has failed treatment with steroids and Xeljanz.  He has experienced a recent flare of both joint and pulmonary symptoms.  Thus, treatment with Actemra at this juncture would be clinically appropriate and in accordance with standard of care in the medical community.  Although the Plan-preferred agent Kevzara is an interleukin-six (IL-6) inhibitor similar to Kevzara, Kevzara is not indicated for the treatment of  scleroderma-associated interstitial lung disease (ILD).  Therefore, the proposed Actemra for the treatment of both rheumatoid arthritis and mixed connective tissue disease/scleroderma-associated interstitial lung disease (ILD) is medically necessary for this specific patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia as well as urinary incontinence, coronary artery disease, hypertension, depression, anxiety.

Treatment: Personal care services Level 2 of 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week

The insurer denied coverage for personal care services Level 2 of 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The denial is overturned.

This case involves a female with a history of Alzheimer's dementia as well as urinary incontinence, coronary artery disease, hypertension, depression, anxiety, ataxia, osteoarthritis, low back pain, gastritis, multiple falls. The documentation indicated the patient is totally dependent for meal preparation as well as housework and activities of daily living such as shopping. She needs extensive assistance with managing medications as well as transportation, bathing, personal hygiene, dressing, toilet transfer and toilet use. She is bladder incontinent; however, has complete bowel control. She needs limited assistance with ambulation as well as locomotion. It was recommended she increase personal care services to 24 hours a day 7 days a week. The documentation indicated she has been receiving services prior to this request.

This patient with severe dementia requires help with activities of daily living and is dependent on another person for meal preparation and ambulation among other things. She requires supervision 24/7 due to cognitive impairment related to her dementia. She is also at high risk for falls with potentially severe sequela if left unsupervised. Due to her cognitive impairment, she will not be able to ask for help or notify emergency services in the appropriate settings. 

She is an appropriate candidate to receive personal care services 24 hours seven days a week due to all the above reasons.

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

The insurer's denial of coverage for the requested Personal Care Services Level 2 of 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain, Lumbar Radiculopathy. 
Treatment: Rehab treatment (treatment in an acute rehabilitation facility) after back surgery. 

The insurer denied coverage for rehab treatment (treatment in an acute rehabilitation facility) after back surgery. 

The denial is upheld. 

This is a patient with chronic medical problems including cardiomyopathy, rheumatoid arthritis, hypertension, asthma and fibromyalgia.  She underwent revision lumbar decompression laminectomy, from lumbar (L) 3 - sacrum (S) 1, exploration of fusion and extension of fusion L2-3.  Under review is the medical necessity of treatment in an acute rehabilitation facility. 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the clinical records do not support the medical necessity of acute inpatient rehabilitation.  According to the occupational therapy note, the patient was already at the supervision to contact guard level of activities of daily living.  The occupational therapist only recommended "3-5 days/week while in hospital."  Approximately 1 week ago the patient was ambulating approximately 40 feet (rolling walker) with contact guard assistance.  In addition, she has 5/5 strength in the bilateral lower extremities and is ambulating with physical therapy with some imbalance issues. She will be high functional for inpatient rehab, and may be not able to meet criteria for 3 skilled needs for inpatient acute rehab. She is also otherwise medically stable and does not have any specific complicated nursing needs to support acute physician or skilled nursing care (respectively) in an acute rehabilitation setting.  The patient can be safely transferred to a lower level of care, e.g., short term subacute skilled nursing facility or home with home physical/occupational therapy. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient in this particular case.  Considerations include the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations. All decisions are evidence-based. 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, inpatient acute rehabilitation admission is not medically necessary. 

The insurer's denial of coverage for rehab treatment (treatment in an acute rehabilitation facility) after back surgery is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult with type 2 diabetes on insulin therapy and coronary artery disease who presented after a syncopal episode.  He was found unconscious with a glucose of 33 mg/dL (milligrams per deciliter).  He was given dextrose and brought to the emergency department.

The patient had an echocardiogram, which showed new cardiomyopathy with a mildly reduced left ventricular ejection fraction.  The second echocardiogram was read as similar to the previous study.  Chest x-ray showed mild vascular congestion, but cannot exclude atypical pneumonia/pneumonitis.  The patient had COVID-19 two months prior.  He had worsening memory and gait for months. Inpatient stay is under review.

No, the Inpatient admission was not medically necessary.

The patient presented to the emergency room after a syncopal episode in the setting of hypoglycemia after probable accidental insulin overdose.  His hypoglycemia responded to treatment.  He was awake with mild confusion in the emergency department.  He had multiple months of memory and gait issues in the setting of prior COVID-19 infection that did not require inpatient evaluation.  He did not have acute findings on his brain and neck MRI (magnetic resonance imaging).  He was not diagnosed with an infection.  He had coronary artery disease, but no acute cardiac disease that required inpatient admission.  He was hemodynamically stable.  He did not have acute renal failure.  He was on insulin , which could have been titrated under a lower level of care.  Therefore, the requested inpatient admission level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis. 
Treatment: Otezla 10-20-30 milligram tablets (Pre-Service). 

The insurer denied the Otezla 10-20-30 milligram tablets. 
The denial is overturned. 

The patient is a male with psoriasis to the extremities and trunk, involving 10% body surface area (BSA), treated with topicals.  The provider is requesting Otezla.  The patient has hypertension and consumes three or more alcoholic beverages per day.  The health plan denied the request as the patient has not tried conventional therapy such as methotrexate. 

Yes, the proposed Otezla is medically necessary. 

Medical necessity is generally defined as: 
1) in accordance with generally accepted standards of good medical practice; 
2) clinically appropriate and considered effective; 
3) not primarily for the convenience of the patient or provider; 
4) not more costly than alternative services at least as likely to produce an equivalent therapeutic outcome. 

Otezla is an appropriate medication for this patient and is not known to be more costly.  A recent review concluded that Otezla is one of the most cost effective therapies for psoriasis.   Otezla (apremilast) is a phosphodiesterase inhibitor, and therefore its mechanism of action is different from injectable biologics.  Apremilast works intracellularly to modulate pro- and anti-inflammatory mediators. 

The ESTEEM trial (randomized, double-blind) documented favorable response to apremilast over placebo at week 16.  Side effects were generally mild and did not result in discontinuation.  A 75% reduction in Psoriasis Area and Severity Index score (PASI75) was seen in 33% of patients, and 50% reduction in Psoriasis Area and Severity Index score (PASI50) in 60%.  Efficacy has been demonstrated in psoriatic arthritis as well, and it was first Food and Drug Administration (FDA) approved for spondyloarthropathies. 

There are no studies to date comparing the efficacy of Otezla to other systemic medications for psoriasis.  It is an oral therapy and requires less medication monitoring (current data do not indicate a need for laboratory monitoring) and is not immunosuppressive.  Otezla is now among the growing number of systemic therapies for psoriasis.  Currently, there are no evidence based medical guidelines indicating which therapy is best or delineating a step-wise approach to treat psoriasis.  The guidelines of care for the management of psoriasis state that each patient requires individual tailoring and a step-wise approach is not recommended.  No evidence based literature could be found to support the use of other therapies before Otezla. 

This patient should not be treated with methotrexate due to excess alcohol consumption, and should not be placed on a high risk medication when safer alternatives are available. Otezla is a more appropriate choice in the current COVID pandemic as it does not suppress the immune system.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: atrial fibrillation.

Treatment: cardiac surgery, code 33285 Insertion, subcutaneous cardiac rhythm monitor, including programming (ILR).

The insurer is denied coverage for cardiac surgery, code 33285 Insertion, subcutaneous cardiac rhythm monitor, including programming (ILR).

The denial is upheld. 

This female patient has a history of atrial fibrillation and probable tachycardia induced cardiomyopathy.

Current literature state that electrocardiographic documentation is recommended to establish the diagnosis of atrial fibrillation. The diagnosis of atrial fibrillation should be based on the patient's clinical history and physical examination, as well as confirmed by electrocardiography, ambulatory rhythm monitoring, implanted loop recorders, pacemakers, or defibrillators. The provided documentation indicates that this patient had a diagnosis of atrial fibrillation and underwent ablation. There were no recent findings to suggest atrial fibrillation. As such, loop recorder is not supported.

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

The carrier's denial of coverage for the cardiac surgery, code 33285 Insertion, subcutaneous cardiac rhythm monitor, including programming (ILR) is upheld.  The medical necessity is not substantiated.