Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Alopecia Areata (AA).
Treatment:  Xeljanz.

The insurer denied Xeljanz as experimental/investigational. The denial was upheld.

The patient is a female with severe alopecia areata (over 50% of her hair was lost on her scalp), for which topical, intralesional, and oral steroids have been tried and failed. The patient has had complete regrowth of her hair while on Xeljanz.

At issue is whether Xeljanz is likely to be more beneficial than any standard treatment or treatments.

The proposed health treatment of Xeljanz is not likely to be more beneficial than any standard treatment.

The requested medication is investigational at this time, and merits further study before being presumed acceptable for widespread clinical use. At this time, the long-term safety of this medication is not confirmed as short-term efficacy in the use of Xeljanz for this condition.

Alopecia areata is notoriously difficult and unpredictable to treat, as well as unpredictable in its response to treatment. Oral immunosuppressants, light therapy, contact allergen treatment and related therapies have all resulted in variable and unsatisfactory outcomes, and self-resolution is often the only choice a patient has (along with hairpieces) for severe cases.

However, while Xeljanz has some promising preliminary results in open-label studies (5, 6) the overall literature and reviews on alopecia areata (1-4) mention Xeljanz only as investigational. Xeljanz was denied United States Food and Drug Administration (FDA) approval for use in psoriasis, in large part for safety reasons, and is not without a significant risk of side effects that preclude an acceptable risk for use outside of the investigational setting for the condition of alopecia areata.

At this time, Xeljanz is only FDA-approved for rheumatoid arthritis patients who have failed methotrexate, polyarticular juvenile idiopathic arthritis, psoriatic arthritis, and for ulcerative colitis, and all three conditions have indications whereby the safety risks of not using treatment are significantly greater than treatment itself.

The same cannot be said for Xeljanz in the treatment of alopecia areata, where physical/functional impairment and overall health impacts are minimal to nonexistent, despite the social/psychological impacts that can occur in some patients. There are no large, randomized, controlled, prospective trials demonstrating and proving the safe and effective treatment of alopecia areata with specific dosing of Xeljanz.

Therefore, as per the evidence-based literature, Xeljanz is acceptable only within the investigational setting and not medically necessary for less-monitored outpatient clinical use.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Alopecia Areata (AA).
Treatment:  Xeljanz.

The insurer denied Xeljanz as experimental/investigational. The denial was overturned.

The patient is a female with a medical history of alopecia areata (AA), treated unsuccessfully with topical, oral and intralesional steroids. The provider is requesting continuation of Xeljanz as patient has regrown her hair on this medication.

At issue is whether the health treatment of Xeljanz is likely to be more beneficial than any standard treatment.

The proposed health service or treatment Xeljanz is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Xeljanz has proven to be substantially more beneficial than standard treatments for alopecia areata. A wide range of treatments have been used for the management of alopecia areata, most of which are not highly effective. Treatments include topical or intralesional corticosteroids, topical minoxidil (2% or 5%), topical anthralin, systemic corticosteroids, cyclosporine, and other immunosuppressants. A dependable and safe treatment for extensive disease (totalis or universalis) has yet to be found. Given the rarity of the disease, large randomized controlled trials are extremely difficult.

Alopecia areata and its variants is an extremely distressing disease. Xeljanz is currently Food and Drug Administration (FDA) approved for Rheumatoid arthritis and undergoing approval trials for psoriasis and psoriatic arthritis. It is known to be safe and effective in the conditions for which it is FDA approved. Biologic medications as a whole have many off label uses, leading to better outcomes in rare diseases for which large, randomized trials are not readily available.

Therefore, given the support in current literature and lack of effective therapies for alopecia areata, and this patient's favorable response to therapy, Xeljanz is medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Syncope.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is modified. 

This case involves a patient who presented to the Emergency Department (ED) due to syncope and loss of consciousness. The documentation indicated the patient has a history of protein C and S deficiency. The documentation also detailed the patient has a positive history that includes diabetes as well as hypertension, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and atrial fibrillation (A. fib).  The physical examination revealed the patient was alert and oriented.  The patient had 99% oxygenation on room air.  A normal sinus rhythm was noted per EKG (electrocardiogram).  The physician detailed the patient should undergo diagnostic and laboratory studies.  A computed tomography (CT) scan of the head revealed no acute findings. The physician indicated the patient was re-observed multiple times while in the ED.  It was recommended that the patient be admitted for further evaluation due to syncope.  The documentation indicated the patient was recommended to undergo consultation by cardiology as well as neurology for further treatment recommendation.  The patient continued with treatment and no further significant abnormalities.  It was recommended that this patient undergo a tilt table test as well as the possibility of an implantable loop recorder.  The patient however refused tilt table testing.  Throughout the stay the patient also refused orthostatic vital signs as well as monitoring with telemetry.  The documentation indicated the patient subsequently developed a rash where he was given intravenous (IV) diphenhydramine.  The following day the patient declined further treatment and signed out against medical advice (AMA).

 The submitted documentation indicated the patient presented with multiple complaints with a history of a-fib with hypertension, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD).  The documentation indicated the patient was admitted due to the need for close monitoring and further observation.  The initial hospital day was medically indicated, however the patient did not have any further adverse events and remained stable the remainder of the time.  Therefore, the remainder of the admission was not medically necessary. The health plan acted reasonably in part.

The insurer's denial of coverage for the emergent hospital admission is modified.  Medical Necessity is substantiated for first inpatient day, but is not substantiated for the remainder of the inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Endocrine/Metabolic/Nutritional/Diabetes/Diabetic Ketoacidosis
Treatment: Inpatient Hospital
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a history of Type 1 (T1) diabetes mellitus (DM) who presented with epigastric and back pain x 2 days. She reported recent noncompliance with insulin usage. On admission her vitals were a blood pressure of 125/77 millimeters of mercury (mmHg), a heart rate of 99 beats per minute (bpm), respirations of 18/minute and she was afebrile. Labs were notable for sodium of 127, a glucose of 860, an anion gap of 15, a normal potential hydrogen (pH), a bicarbonate (HCO3) of 25, and positive urine ketones. She was admitted for hyperglycemia/mild diabetic ketoacidosis (DKA) and was started on insulin, fluids and supportive care for her abdominal pain. The anion gap quickly normalized, and she was transitioned to Levemir. She was seen by endocrinology who made adjustments to her insulin regimen and felt she was appropriate for discharge. She was discharged the following day. The medical necessity for an inpatient admission was denied, this is a review of the appeal.

The health plan's determination of medical necessity is upheld, in whole.

No. Inpatient admission was not medically necessary, as the appropriate level of care could have been provided in observation. The patient is a female with T1DM who presented with hyperglycemia in the setting of insulin noncompliance. She had a mildly elevated anion gap, elevated glucose and positive urine ketones. In patients who present with hyperglycemia/DKA, the American Diabetes Association recommends inpatient admission if the serum glucose is > 250 in addition to an arterial pH < 7.3, bicarbonate < 15 and a moderate or large amount of urine ketones[1]. She was not acidotic and had a normal venous pH and bicarbonate level. In patients who present with mild DKA with normal neurologic exam and who are able to tolerate oral fluids, observation admission for fluids/insulin and monitoring the subsequent discharge is appropriate[2]. Given her presenting signs/symptoms, observation admission would have been medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-bilateral heel pain.
Treatment: Orthotics. 
The insurer denied custom shoe inserts. 
The denial is upheld.

The patient is a female who presented to her podiatrist for treatment of her bilateral heel pain, right greater than (>) left for the past 7 months or so. The patient reported continued pain in her right heel. She had previous cortisone injections but had a reaction to them. She has tried non-steroidal anti-inflammatory drugs (NSAIDs) but did not tolerate them due to gastrointestinal (GI) symptoms. She had her foot strapped which did not help. The patient has also been using prefabricated inserts, but they are not helping. She has also been stretching. Her provider is recommending custom molded orthotics. The issue is the medical necessity of the custom molded orthotics.

No, Based on all of the records that were submitted it appears that the patient has tried some tier 1 conservative measures. The patient had not tried a course of reasonable conservative measures before custom molded orthotics are recommended. Custom Molded orthotics are not considered a first line treatment options. Based on the submitted information, the custom molded orthotics were recommended as a first line treatment at the podiatrist initial treatment visit with the patient.
The patient has tried over-the-counter (OTC) prefabricated inserts, stretching, and previous cortisone injections which she had a bad reaction. However, it does not appear that the patient has tried the first line treatments according to the standard of care, such as physical therapy, home cryotherapy, shoe modification, or activity modification. The use of custom molded orthotics in this patient is not considered medically necessary at this time. The patient has not exhausted all conservative measures before custom molded orthotics should be tried.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated Prostate Specific Antigen

Treatment: Oncotype DX Prostate cancer Assay

The insurer denied coverage for Oncotype DX Prostate cancer Assay

The denial is upheld

The patient is a male, who had a prostate specific antigen (PSA) of 8.6.  The patient had prostate biopsy which revealed Gleason 3+4 adenocarcinoma in 2/12 cores.  His urologist then ordered an Oncotype Dx prostate cancer assay (PCA) test for further evaluation.  His genomic prostate score (GPS) was 61 which resulted in a high predicted individual risk.  

The insurer has denied coverage for the Oncotype Dx PCA as not medically necessary.  They stated there is a lack of any significant randomized trials in the medical literature showing a significant benefit or difference in outcome for patients with prostate carcinoma, and molecular profiling with multigene cancer panels are not considered safe or effective.    

While current National Comprehensive Cancer Network (NCCN) guidelines states that men with low risk or favorable intermediate risk prostate cancer and at least a 10-15 year life expectancy may consider the usage of Oncotype Dx PCA and/or similar type tests, they also note the absence of randomized prospective trials which could show a clinical benefit by usage of this test.  American Urological Association (AUA) guidelines are more negative regarding the utility of this test stating that "tissue based genomic biomarkers have not shown a clear role in Active Surveillance for localized prostate cancer, and are not necessary for follow-up."  There is currently no level I evidence supporting use of genomic biomarkers in clinically localized prostate cancer.  The most common result of a genomic biomarker test is no change in the clinical risk profile.  The impact of tissue based gene expression tests, such as Oncotype Dx PCA, on clinical practice and long term patient outcomes remains to be empirically demonstrated.  Prospective studies of these tests yielding a true clinical benefit when implemented in clinical practice are still lacking.

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

The Oncotype Dx PCA test (code 0047U) is not considered medically necessary for this patient.

The insurer's denial of coverage for Oncotype DX genetic testing of prostate tissue (Oncotype DX Prostate cancer Assay, code 0047U) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Common Variable Immunodeficiency (CVID

Treatment: Gamunex

The insurer denied coverage for Gamunex

The denial is upheld

The patient is a female who has with a medical history of allergic rhinitis, allergic urticaria, allergy to penicillin and other unspecified drug/meds/biologic substances and foods, chronic sinusitis, regional ileocolitis, mixed hypercholesterolemia, hypertriglyceridemia, irritable bowel syndrome with diarrhea, endometriosis and recurrent sinusitis. The patient had multiple visits (at least 7) with her doctor where no sinus tenderness or purulence was noted. The patient had pneumococcal titer performed showing 20 out of 23 serotypes with levels greater than 1.5 mcg/ml. Titers assessed a prior showed all serotypes with greater than 1.5.mcg/ml (one titer not measured due to technical reasons). The patient is said to have had multiple ear and sinus infections. IgG, IgA, IgM and IgG subclass levels were normal.

There is thus inadequate evidence for antibody deficiency from the records provided. There is no evidence to support medical necessity for gamma globulin treatment.

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

The insurer's denial of coverage for Gamunex is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 

The insurer denied Crown and buildup for medical necessity. 
The denial was overturned. 
 
The patient is a female who presented to the office of her provider, for evaluation and treatment of tooth #19. She presented with discomfort on her lower left jaw and a fracture on her root canal treated tooth. Treatment included a new porcelain crown restoration and buildup for tooth #19, and peri-apical radiographic images. Previous denial has been on the basis that the tooth has a guarded periodontal prognosis due to the presence of external resorption evidenced by the radiographic appearance of the distal root. 

At issue is the medical necessity of Crown and buildup on tooth 19. 

The health plan's determination of medical necessity is overturned in whole. 
The requested health service/treatment of Crown and buildup on tooth 19 was medically necessary for this patient. 
From the radiographic image provided, although the distal root of #19 does show the presence of periapical periodontitis, this is typical for an endodontic lesion where a cyst has formed. Although the distal root is shorter than the mesial root, there is no evidence of a loss of the periodontal ligament to indicate external root resorption nor is there any abnormal appearance of the internal root structure. The tooth has no external root resorption, and the tooth required buildup and crown due to the amount of missing coronal tooth structure after removal of decay and root canal access. Considering the amount of coronal tooth structure lost, the tooth could not be restored without a buildup and crown. 

Hence, the treatment of crown and buildup for tooth #19 was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: pneumonia

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This female patient has a history of lung cancer and hypertension.  She presented to the Emergency Room (ER) with complaints of unresponsiveness, weakness, and shortness of breath (SOB.)  A chest x-ray (CXR) revealed possible interstitial infiltrates with pulmonary edema.  A computed tomography angiogram (CTA) of the chest revealed no pulmonary embolism (PE). Heart rate was 102 beats per minute.  The patient was admitted with pleural effusion in the setting of lung cancer.  The impression was pneumonitis versus infection.  The plan was to administer 40 milligrams (mg) of intravenous (IV) Solumedrol every 12 hours (Q12H), administer 500 mg of oral (PO) Azithromycin a day (QD), administer 1 gram (g) of IV Rocephin every 24 hours (Q24H), continue oxygen, and administer Duonebulizers every 6 hours (Q6H).  The patient also presented with normocytic anemia and thrombocytopenia. Hematology and oncology recommended obtaining an anemia profile, thrombocytopenic precautions, monitoring complete blood count (CBC), and deep vein thrombosis (DVT) prophylaxis.  The patient continued to have a productive cough. IV antibiotics were continued.  The patient's white blood cell count (WBC) count was elevated likely due to steroid therapy.  Steroids and IV antibiotics were discontinued.  The care plan was implemented and the patient's symptoms improved.  She was instructed to take 200 mg of PO Cefpodoxime Q12H.  The patient was discharged on with instructions to complete an additional 4 day course of PO antibiotics.

This patient did not need acute inpatient hospitalization. The patient was afebrile and hemodynamically (HD) stable.  She could have been placed in Observation status (which could be up to 48 hours) while diagnostic testing and treatment were initiated.  This patient was in no acute distress (NAD).  Oxygen (O2) saturations were at baseline.  The patient was on home O2 4 liter (L) already.  The patient had a known malignant pleural effusion and was receiving chemotherapy for it.  The patient likely had worsening of her lung cancer with lymphangitic spread.  No acute intervention was done for it nor necessary at this time.  The patient did not have any definite signs of pneumonia - no fever, chills, WBC was normal, no change in oxygenation.  The patient could have been treated in observation status with IV antibiotics and steroids if indicated and then switched to PO steroids and PO antibiotics in 24 to 48 hours and discharged home with close follow-up in an outpatient setting.
	
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 inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of Breath, Pectus excavatum deformity. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Stay. 
The determination is upheld. 

The patient is a former smoker with a past medical history (PMH) for heart palpitations (hospitalized for 60 days for severe heart palpitations) and history of (h/o) Suboxone use who presented with chest pain and shortness of breath. The patient was found to have a pectus excavatum deformity with Haller index of 2.4. A transthoracic echocardiogram (TTE) was within normal limits (WNL). He was taken to the operating room (OR) and underwent a flexible bronchoscopy, right video-assisted thoracoscopic surgery (VATS) -assisted Nuss procedure. He had an epidural in place and was on a patient controlled analgesia (PCA) pump. An electrocardiogram (EKG) showed new right bundle branch block (RBBB). Pain management was an issue during the hospitalization. The pain management team was consulted. Intravenous (IV) -PCA continued and the epidural was removed. The medications were changed to by mouth (PO) and the patient was medically cleared for discharge. At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of inpatient stay was medically necessary for this patient. Postoperative pain control remains the primary reason for inpatient stay after a minimally invasive repair of pectus excavatum. Early pain control has been shown to be better in patients managed with a thoracic epidural, while late pain control was better in patients managed with patient-controlled analgesia (PCA). 

Guidelines for Surgery and Procedures performed in the inpatient setting indicate that the following procedures are appropriate for the inpatient setting based on the InterQual Procedures Criteria: Thoracoscopy, Video Assisted (VAT). This patient underwent a right VATS-assisted Nuss procedure. The modified single-incision thoracoscopic Nuss procedure is both safe and effective for pectus excavatum correction with non-recurrence after two years. 

Postoperative pain management required an epidural, IV-PCA, and the pain management team requiring the patient to be an inpatient. This was in accordance with generally accepted standards of medical practice. 

This patient was appropriately admitted to the hospital and was discharged from the hospital once he was medically stable. The requested health service/treatment of inpatient stay was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Lower Back Pain and Blood in the Urine
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This female was admitted through the emergency room (ER) with left flank pain and gross hematuria.  She had been treated with oral antibiotics three days prior through the emergency room (ER) for a urinary tract infection (UTI).  Vitals were temperature 98.2, pulse 54, and blood pressure 119/76.  The urinalysis had large blood and white blood cells (WBCs). The serum white blood cell (WBC) count was 5500.  Computed tomography imaging demonstrated small intestinal thickening.  Intravenous (IV) antibiotics were started.

Intravenous (IV) antibiotics were administered.

The patient was discharged home.  She was afebrile and hemodynamically stable throughout the stay.

No, the proposed inpatient admission was not medically necessary.

Treatment of a urinary tract infection (UTI) without fevers with intravenous (IV) antibiotics did not require an acute inpatient level of care.   The patient did not have complicating features such as obstruction, abscess or immunosuppressed status.  Intravenous (IV) antibiotics can be administered at an observation level of care in an afebrile and hemodynamically stable patient.  There were no compelling reasons to support an acute inpatient level of care as the patient was medically stable throughout the hospital stay.