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

Diagnosis: Digestive System/Gastrointestinal
Treatment: Pharmacy/Prescription Drugs
The health plan denied the increase in Stelara to Q4 weeks as not medically necessary. The reviewer has upheld in whole in health plan determination.

The patient has Crohn's Disease and was diagnosed 14 years ago and underwent an ileocolic resection in 2012. The patient did not respond/experienced infectious complications on anti-tumor necrosis factor therapy. The patient was not able to tolerate a thiopurine medication due to nausea. The patient had multiple studies performed including a magnetic resonance enterography that documented improved disease in the ileum and at the ileocecal (IC) valve. The patient had improved inflammatory markers. A Colonoscopy showed inflammation at the ileocolic anastomosis, Rutgeert's i2A histology with chronic active enteritis.  Recent serology suggested a low ustekinumab (Stelara) level without the presence of antibodies on 90 milligrams every (Q) 8weeks.
The patient's provider has recommended Stelara to be given every 4 weeks. The Food and Drug Administration (FDA) approved dose is Q 8 weeks.
The requested service/treatment of Stelara dosed every 4 weeks is not medically necessary for this patient. After a comprehensive literature search, there is no high quality literature which supports dose escalation of ustekinumab to Q 4 weeks. A high quality study would be prospective with a properly defined control arm. Doubling the dose doubles the cost, and it no doubt increases the risk of infection. Without high quality literature and data it is impossible to determine whether these negatives are offset by a clinically meaningful benefit. The manuscript/supporting documentation included by the provider was reviewed and noted. This would not be considered by this reviewer to be high-quality and compelling evidence. The alternative biologic, vedolizumab, would be a reasonable alternative for this patient given that there is no robust literature on the use of ustekinumab Q 4 weeks.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial numbness, droopiness, and leg heaviness
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a history of right facial hemispasm. She presented to
the emergency ward after awakening with right facial numbness, drooping and right
leg heaviness. Examination at presentation showed that the patient had full strength and mild drooping of the right face. CT (computed tomography) scan at presentation showed a right cavernous sinus soft tissue mass, which was not new. MRI (magnetic resonance imaging) after admission re-demonstrated the CT (computed tomography) scan findings, and no acute infarct was identified.

No, the Inpatient admission was not medically necessary.

At presentation, the patient had minimal deficits and stable neuro-imaging. The
identified right cavernous sinus mass was known to the patient from previous
imaging and followed in the outpatient setting. Risk stratification guidelines for TIA
(transient ischemic attack) do not support acute inpatient admission here. The
diagnostic studies, monitoring and treatment could have been safely and effectively
provided at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypersomnia.
Treatment: Formulary exception for Sunosi tablets (solriamfetol).
The insurer denied the Formulary exception for Sunosi tablets.
The denial is upheld.

The patient is a female with a diagnosis of idiopathic hypersomnia.  She has tried modafinil and armodafinil.  Due to the non-tolerance and side effects of the medication, she cannot tolerate either one of them.  The current request is for solriamfetol.  Based on the clinical information provided, the patient has not had the diagnosis of narcolepsy.  The requested services are not FDA (Food and Drug Administration) approved for the clinical condition for which it is requested.

The patient does not have a diagnosis of obstructive sleep apnea or narcolepsy. The patient does not have an FDA approved indication of the requested services.  In addition, formulary alternatives were not tried, which include the amphetamine derivatives.  According to the American Academy of sleep medicine, the following CNS (central nervous system) stimulants can be tried as an option, these include:

1) Modafinil 2) Armodafinil 3) Amphetamine 4) Dextroamphetamine 5) Methamphetamine 6) Methylphenidate

At this point, there is no recommendation from the American Academy of sleep medicine for the use of this particular medication for the management of idiopathic hypersomnia. Therefore, the patient does not meet the medical necessity criteria for the requested services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Musculoskeletal injuries.
Treatment:  Additional physical therapy visits (procedure code 97110).

The insurer denied coverage for additional physical therapy visits (procedure code 97110).  The denial is upheld.

This is a female patient, who was in a motor vehicle accident (MVA), in which she sustained multiple musculoskeletal injuries.  The patient required bilateral femur external fixation and inpatient rehabilitation.  The patient subsequently participated in outpatient physical therapy.  She more recently resumed physical therapy to improve lower extremity range of motion, strength, stability and gait.  The insurer has denied coverage for additional physical therapy visits (procedure code 97110).	

The physical therapy treatment notes provide insufficient objective clinical evidence to support the medical necessity of continuing a structured outpatient physical therapy treatment program.  Based on the clinical records reviewed, the expectation does not exist that the therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time.  A recent physical therapy note documents a plateau in progress; particularly with lower extremity motor strength and range of motion.  The patient's lower extremity strength via manual muscle testing had not significantly changed from the prior week, and bilateral hip range of motion was also much the same.  The patient is functionally independent and fully ambulatory.  Based on the review of the medical record and literature, continued improvement can be accomplished by adhering to a home exercise program.

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

The carrier's denial of coverage for additional physical therapy visits (procedure code 97110) should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/circulatory
Inpatient hospital

Diagnosis: coronary artery disease
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This  man presented to the hospital for scheduled right and left heart catheterization for evaluation of atypical chest pain, orthopnea and paroxysmal nocturnal dyspnea. His medical history was remarkable for coronary artery disease, ischemic cardiomyopathy, heart failure with reduced ejection fraction (20%), diabetes, hypertension, hyperlipidemia and prior cocaine abuse. His blood pressure was 133/56 mmHg with a heart rate of 95 beats/minute. His room air oxygen saturation was 97%. His cardiac exam was unremarkable. An electrocardiogram showed sinus tachycardia at 105 beats/minute with incomplete right bundle branch block and evidence of an old anteroseptal infarction. There were no acute changes. Cardiac catheterization showed a mean pulmonary capillary wedge pressure of 20 mmHg. There was a 90% obtuse marginal artery stenosis that was treated with two drug-eluting stents. A Cardiomems device was implanted. The procedure was uncomplicated. 

The inpatient hospital admission was not medically necessary.
While some period of observation immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient met none of these criteria. His procedure was uncomplicated and he was discharged several hours post-procedure. An inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Nurtec ODT 75 mg tablets. 
The denial is upheld in whole. 

This is a male with a history of headaches who was seen by his treating neurology provider. He had a history of a heroin overdose the previously with concern about anoxic encephalopathy because of memory loss, that had improved. He had a history of depression, anxiety and drug abuse. Medications at that time were buprenorphine, gabapentin, quetiapine and sertraline. Medical history was significant for carpal tunnel syndrome, and herniorrhaphy. There is no documentation of actual coronary artery disease. His neurological examination was normal. The provider prescribed duloxetine to treat his headaches. 

The patient was seen by a nurse practitioner. He was on duloxetine that was helping but was continuing to have 2-4 headaches per week associated with photophobia or phonophobia. Pertinent medications were duloxetine, gabapentin, buprenorphine, quetiapine and sertraline. His neurological examination remained normal. Montreal cognitive assessment was 24/30 with points missed mostly related to delayed recall. He was provided with Nurtec samples. A repeat Montreal cognitive assessment the next examination was planned. Duloxetine was continued. 

The subject under review is the medical necessity for the Nurtec in this case. 

The health plan's determination is upheld in whole. 

Nurtec is not medically necessary. The patient has not had a trial of any plan preferred formulary medication. The treating nurse practitioner indicated that the patient had a cardiac arrest. However, the patient has no evidence of coronary artery disease, which is a contraindication. The cardiac arrest appears to be from a heroin overdose. Triptans are contraindicated in severe hepatic impairment. There is no evidence that the patient has severe hepatic impairment based on the documentation provided. There is no documented contraindication to a Triptan. There is no evidence the peer-reviewed medical literature that Nurtec or other medications in its class is superior in efficacy as a migraine abortive agent compared with all triptans. The patient has no contraindication to triptans. As there is no evidence of any coronary artery, cardiovascular, cerebrovascular or peripheral vascular disease, or severe hepatic impairment there is no specific indication for Nurtec.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia and Depression.
Treatment: Home Care/Personal Care home health care - Level 2 Personal Care Services, per 15 minutes increase to 49 hour(s) per week.
The insurer denied the Home Care/Personal Care home health care - Level 2 Personal Care Services, per 15 minutes increase to 49 hour(s) per week. The denial is overturned. 

The patient is a male with a history of Alzheimer's dementia and Depression. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADL's). Appeal review requested for potential approval of 49 hours/week Personal Assistance Services to offer increased ADL support.

Yes, the proposed treatment of 49 hours/week Personal Assistance Services is deemed medically necessary. 

Recent documentation from the patient's provider indicates that the patient has unfortunately demonstrated progressive decline in his overall functionality, ability to perform ADL's and has been demonstrating more frequent wandering behavior putting him at high risk for becoming lost.  For these reasons, the currently approved plan of 28 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. Hence, the proposed treatment of 49 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infertility; CMT (Charcot-Marie-Tooth).
Treatment: Genetic Testing (for IVF - in vitro fertilization).
The insurer denied the Genetic Testing (for IVF - in vitro fertilization). The denial is overturned. 

The patient is a female with infertility, personal history of mild Charcot-Marie-Tooth (CMT) Disease, two unaffected offspring with a reported family history (mother, unspecified grandmother) of severe CMT per appeal letter. The patient had a prior pregnancy that was affected by CMT and was terminated.  

The patient is requesting coverage IVF (in vitro fertilization) with preimplantation genetic diagnostic testing for embryo deselection at IVF for CMT  diagnosis. 

Yes, the Genetic testing as part of infertility treatment is medically necessary.

CMT disease is the most common inherited neuromuscular disorder. It is characterized by inherited neuropathies without known metabolic derangements. For a woman considering a pregnancy, preimplantation genetic diagnosis (PGD) is available if someone does not want to have a child affected with CMT.

This patient was tested for CMT. She is a carrier. She has already had a child affected by this condition necessitating termination of pregnancy. IVF with PGD  is medically necessary and standard of care. This patient has been counselled extensively about a condition she is familiar with, as her mother is affected.  The procedure was denied is indicated and medically necessary.

CMT is an X-linked dominant condition. PGD, when used to deselect embryos with genetic mutations, is considered medically necessary in this case because one partner is a known carrier of a single gene X-linked disorder, a specific mutation, or set of mutations, has been identified, that specifically identifies the
genetic disorder with a high degree of reliability, the genetic disorder is associated with severe disability or has a lethal natural history, and genetic counseling has been performed.

This patient meets medical necessity for PGD. In order to perform PGD, IVF is medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain And Swelling In The Groin
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He was admitted through the ER (emergency room)  with right groin swelling two weeks after penile prosthesis replacement.  CT (computerized tomography) imaging demonstrated a possible infection of the penile prosthesis.  

The patient's WBC (white blood cell) count was 10,100.  IV (intravenous) antibiotics were started.

The patient had an inguinal exploration with removal of the old prosthesis reservoir.

The patient's WBC (white blood cell) count was 12,020.  Invanz was continued.

The patient was discharged home

No, the Inpatient Admission was not medically necessary.

The patient was hemodynamically stable and afebrile.  He was post-operative and the source of the infection had been removed.  Use of IV (intravenous) antibiotics can be provided in a lesser level of care than acute inpatient.  He was medically stable, ambulatory and tolerating a diet.  The Inpatient Admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis
Treatment: Dupixent 300MG/2ML SC SOSY
The insurer denied the Dupixent 300MG/2ML SC SOSY. 
The denial is overturned. 

The patient is a male with atopic dermatitis (AD) for whom Dupixent is requested. He has severe atopic dermatitis that has been well-controlled with Dupixent for the past two years.

Yes, the treatment with Dupixent is medically necessary.

The patient has severe atopic dermatitis which has been well controlled with Dupixent for the past two years.  Because he is doing well on Dupixent and has been using it for a long time, this is continuation of therapy and is medically necessary to prevent a severe flare and setback of his disease.

Dupilumab is an interleukin (IL)-4 and IL-13 receptor-alpha antagonist that was approved by the US Food and Drug Administration in 03/2019 for the treatment of adolescents aged 12 years and older with moderate to severe atopic dermatitis not adequately controlled with topical prescription therapies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung nodules 
Treatment: CPT G0297 - Low Dose Computerized Tomography (LDCT)
The insurer denied coverage for CPT G0297 - Low Dose Computerized Tomography (LDCT).
The denial is upheld.

This is a female patient with a past medical history of nasal congestion, and obstructive sleep apnea (OSA) who is currently being managed with bi-level positive airway pressure (BIPAP) and nasal steroids (fluticasone) and Zyrtec. The patient has a history of smoking for 18 years, 1/2-pack per day or 9-pack years. The patient has had prior low dose computed tomography (LDCT) scans. The patient's last computed tomography (CT) scan revealed stable scarring right upper lobe (RUL); stable nodules were up to 3 millimeters; and resolution of previous bibasilar airspace disease. There was no mass or cavity on the image.

The patient was seen in the medical doctor's office for a follow up visit. The patient was afebrile and hemodynamically stable. The patient's oxygen saturation was 97%. The patient was in no acute distress. The patient's lungs were clear and her cardiovascular exam was unremarkable. The patient's medical doctor ordered another LDCT for her lung cancer screening. As per the National Comprehensive Cancer Network (NCCN) and the United States Preventive Services (USPS) Task Force recommendations for Lung Cancer Screening, low dose computed tomography (LDCT) scans are recommended for high-risk adults with at least 30 pack-year smoking history. 

In this case, the patient only had a 9 pack-year smoking history. The UpToDate article on "Screening for Lung Cancer" indicates potential harms of screening, such as radiation exposure and patient distress that makes lung cancer screening not medically necessary and appropriate for low-risk adults. In this case, the patient had a stable lung nodule and a smoking history that does not put the patient at high risk for lung cancer. The patient does not meet the clinical screening criteria for lung cancer screening. Thus, the requested service, low dose computed tomography (LDCT) is not considered medically necessary for this patient.

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

The carrier's denial of coverage for CPT G0297 - Low Dose Computerized Tomography (LDCT) should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/Kidney Disorder
Treatment: Pharmacy/Prescription Drugs

Diagnosis: Genitourinary/Kidney Disorder-Endometriosis
Treatment: Pharmacy/Prescription Drugs-Orlissa
The health plan denied Orlissa as not medically necessary. The reviewer has overturned in whole the health plan determination.

The patient has a history of endometriosis. She also has a past history of a cancerous tumor removed surgically from the ovary. The patient is also a BRCA carrier. She was prescribed Orlissa, as ibuprofen does not adequately treat her endometriosis related pain symptoms. She has not tried other hormonal medications such as oral contraceptive pills that contain estrogen or progesterone for symptom control.

Orlissa is medically necessary for this patient. The patient's endometriosis related pain is not adequately controlled by nonsteroidal anti-inflammatory drugs (NSAIDS). Hormonal measures that contain estrogen or progesterone should not be used for this patient due to her breast cancer antigen (BRCA) carrier status.
The patient is a BRCA carrier and has already had one ovary surgically removed for a cancerous tumor. Hormonal contraception such as oral contraceptives can increase the likelihood of breast malignancies in BRCA carriers. Orlissa offers another option for endometriosis-related symptom control. For these reasons, Orlissa is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Surgical Services. 
The insurer denied: weight loss surgery and associated hospital admission. 
The health plan's determination is overturned in whole.

This patient is a female under consideration for bariatric surgery. She is 68 inches tall and weighed 239.8 lbs. This corresponds to a body mass index (BMI) of 36.5 kilograms per square meter (kg/m2). She has comorbid health conditions of hypertension for which medication has been prescribed. She also has conditions of joint pain, gastroesophageal reflux disease (GERD), and peripheral edema. The patient has attempted weight loss with conventional weight loss programs as detailed in the surgical assessment. Unfortunately, she has not been successful with significant sustained weight loss.
The subject under review is the medical necessity for weight loss surgery and associated hospital admission.
The health plan's determination is overturned in whole.

Given this patient's diagnosis, her current health condition and generally accepted guidelines for patient selection, the proposed weight loss surgery (sleeve gastrectomy procedure) and associated hospital admission is medically necessary for this patient.  She has a BMI in excess of 35 kg/m2 with weight related comorbid health conditions that include hypertension, GERD, joint pain and edema. These are weight-related health conditions that will respond favorably to the sustained weight loss associated with sleeve gastrectomy. She has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint. She has participated in a supervised weight loss program on with follow up.
Laparoscopic sleeve gastrectomy (LSG) is medically necessary for this patient per widely accepted guidelines as her BMI is in excess of 35 kg/m2 in association with weight related illness of hypertension. There is serial documentation of active participation in a nonsurgical weight reduction regimen. The patient has undergone evaluation by a multidisciplinary bariatric program. The patient has been cleared for the proposed surgery from a mental health standpoint per the enclosed psychological consultation and clearance. The patient has undergone a preoperative medical consultation and is felt to be an acceptable candidate. Finally, the treatment plan includes pre and post op dietary / nutritional counseling.
From the available data it can be expected that laparoscopic sleeve gastrectomy would be health beneficial for her and that she meets generally accepted National Institutes of Health (NIH) and American Society for Metabolic and Bariatric Surgery (ASMBS) criteria for the proposed bariatric operation.
Accepted guidelines do not mandate that a patient have comorbid illness of a certain arbitrary severity or be uncontrolled despite medical therapy.
The proposed weight loss surgery is medically necessary in this case per accepted guidelines for the care of medically complicated obesity.