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

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Home Health Care 
The insurer denied additional 10 hours of consumer directed personal assistance services. 
The determination is overturned.

The patient is a female with past medical history of knee osteoarthritis, right sciatica, and morbid obesity who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 15 hours/week. There was a request to increase CDPAP services with letter from orthopedist stating the patient required 25 hours of CDPAP services per week. The patient underwent assessment tool which was not included for review. The insurer sent initial adverse determination notice denying request to increase CDPAP services by 10 additional hours per week.

The denial is overturned.

The requested service is medically necessary. The patient's orthopedic provider and primary care physician (PCP) requested an increase in Personal Care Aide (PCA) hours. The patient had an anticipated event (knee surgery) which would render her in need of an increase in CDPAP services. The requested increase in CDPAP services could not be met with adaptive equipment and medical supplies alone. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested CDPAP hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical Chest Pain
Treatment: Inpatient hospital stay
The insurer denied coverage for inpatient hospital stay.
The denial is upheld.

The patient is a female with a past medical history of hypertension who presented to the hospital with chest pain after running out of anti-hypertensive medications.  She noted mid sternal chest pain radiating to her left jaw, left arm and left leg while preparing food.  On arrival to the hospital, vital signs were stable (BP [blood pressure] 148/89 mmHg [millimeters of mercury], Pulse 87 bpm [beats per minute]).  Physical examination revealed no major abnormality.  12 lead ECG [electrocardiogram] revealed sinus rhythm with no evidence of ischemic ST [interval on ECG] or T [interval on ECG] wave abnormalities.  Serum troponin levels were not elevated [< (less than) 0.01 ng/ml (nanogram per milliliter)] and CT (computed tomography) chest revealed no evidence of pulmonary embolism or aortic dissection.  Echocardiogram demonstrated a normal left ventricular ejection fraction (LVEF) with no evidence of valvular abnormalities.  The patient was treated with antihypertensive medication and discharged with cardiology follow up.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.  This patient presented with atypical chest pain and a past medical history of hypertension.  Her pretest probability of coronary artery disease was low (Reference 1).  Utilizing the HEART [history, ECG, age, risk factors, and Troponin] score, she was considered low risk (Reference 2).  Utilizing the risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3).  Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati, et al (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation.  Using the TIMI (thrombolysis in myocardial infarction) risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this patient could have been treated at a lower level of care.

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

The insurer's denial of coverage for the inpatient hospital stay is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient presented to the emergency room with a three-day history of a left-sided facial droop and slurred speech. The patient also endorsed dizziness. In the emergency room, the patient was hypertensive. A computed tomography (CT) scan showed a chronic lacunar infarct. The patient was admitted to the hospital for evaluation of a stroke. The admission history and physical indicates that the patient has dysarthria but no facial droop or other focal neurologic deficits. The patient underwent  magnetic resonance imaging (MRI) of the brain that showed an acute lacunar stroke in the right basal ganglia. A carotid ultrasound and echocardiogram were unremarkable. Neurology was consulted and recommended secondary risk factor prevention and treatment with dual antiplatelet therapy and a statin.
At issue is the medical necessity of an inpatient stay.

An inpatient hospital stay is not medically necessary for this patient.
The patient presented to the hospital with a three-day history of stroke like symptoms. On presentation to the hospital, the only neurologic deficits were a slight facial droop and slurred speech. The patient did not have any significant weakness in the arms or legs that impaired activities of daily living or instrumental activities of daily living. The patient underwent a standard evaluation for stroke/transient ischemic attack including an MRI of the brain, carotid ultrasound, and echocardiogram. The MRI of the brain showed a small lacunar stroke. The patient was treated with dual antiplatelet therapy and a statin. Other risk factors, such as hypertension, were treated.
An acute inpatient stay is not medically necessary as the patient did not have a significant neurologic deficit. The patient did not require physical or occupational therapy. The patient did not require disposition to a skilled rehabilitation. She was not treated with tissue plasminogen activator or parental anticoagulation. The patient did not have an abnormal cardiac rhythm. The patient did not require a procedure such as a carotid endarterectomy. The imaging could have been performed, interpreted, and acted upon in a 24 to 48 hour period and could have been done at a lower level of care. Therefore, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of bipolar disorder with (w/) inpatient hospitalizations who was admitted with multiple complaints, including right lower quadrant (RLQ) abdominal pain. The patient was intoxicated on admission and received sedating medication for agitation. Vital signs were significant for hypertension (HTN). The physical exam was unremarkable, the abdomen was soft/nontender (NT)/not distended. Lab work was unremarkable. A computed tomography (CT) scan of the abdomen/pelvis (A/P) showed colitis. The patient was diagnosed with colitis and treated with intravenous (IV) ciprofloxacin and Flagyl. Psychiatry evaluated the patient and determined there was no need for an inpatient psychiatry admission. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with complaints of (c/o) abdominal pain. The patient did not have associated high-risk features, such as renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability. The patient did not have a bowel obstruction, diabetic ketoacidosis, or appendicitis. He was hemodynamically stable, did not meet sepsis criteria, he did not have acute kidney injury, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression.
While the patient exhibited some psychiatric symptoms, psychiatry deemed the patient not appropriate for inpatient psychiatric treatment. The patient presented with acute colitis, was treated and responded to IV antibiotics, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a history of hypertension, hyperlipidemia, myocardial infarction, ischemic cardiomyopathy with left ventricular ejection fraction (LVEF) 25% (percent),  coronary artery disease (CAD), percutaneous interventions, and an automatic implantable cardioverter defibrillator (AICD). There was a residual stenosis of the right coronary artery and left circumflex artery after a percutaneous intervention of the left anterior descending (LAD). He presented for elective percutaneous intervention of the right coronary artery (RCA). Vital signs and the oxygen saturation were essentially normal. The creatinine was 0.8. He underwent successful and uncomplicated percutaneous intervention, remained stable, and was discharged.

The inpatient hospital admission was not medically necessary. This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged in-hospital intravenous medications or oxygen support. There was no need for urgent repeat intervention, or introduction of high-risk medications requiring prolonged in-hospital monitoring. In this setting an inpatient level hospitalization has not been established as standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

This is a gentleman that presented to the hospital complaining of chest pain. Past medical history was significant for ischemic systolic cardiomyopathy within left ventricular ejection fraction (LVEF) of 35-40% (percent), hypertension, systemic lupus erythematosus (SLE), and active drug use. Upon arrival to the hospital, vital signs were stable [blood pressure (BP) 126/79 mmHg (millimeters of mercury), pulse 79 beats per minute (bpm)]. Physical exam was without abnormality. 12 lead electrocardiogram (EKG) revealed old inferior and anterior wall myocardial infarction without ischemic ST (interval on EKG) or T (interval of EKG) wave abnormalities. Serum blood testing was significant for a creatinine of 1.47 mg/dl (milligrams per deciliter) and serum troponin of 0.027 ng/ml (nanograms per milliliter). The patient was admitted to the hospital for further work up. Serial troponin levels were not elevated. Echocardiogram revealed an LVEF of 45-50%. He was ultimately discharged on medical therapy.

The patient's pretest probability of coronary artery disease is intermediate. (1) Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score he was considered intermediate risk. (2) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati, et al. (3) Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement and echocardiography prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. (4,5) They found no significant difference in outcome at 30 days between the two groups. Fernanda Bellolio, et al noted that patients presenting with chest pain, that were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital. (5) Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been managed at a lower level of care.

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

Full hospital admission was not medically necessary for this patient that presented with chest pain.  

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia areata

Treatment: Xeljanz

The insurer denied coverage for Xeljanz

The denial is overturned.

The patient has a diagnosis of alopecia areata.  She has failed therapy with topical, intralesional, and oral steroids.  The patient has been successfully treated with Xeljanz for years.  The patient has noted complete hair regrowth without any documented side effects.  The requested medication is continuation of Xeljanz.  

The patient is currently stable with her current regimen.  It would be medically inappropriate to deny coverage for a therapy shown in studies to improve the patient's condition following successful therapy having failed numerous reasonable alternatives.  As a result, the denial is overturned and the use of Xeljanz is medically necessary for use in the treatment of the patient's condition at the discretion of the prescribing physician's medical judgment. 

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

The insurer's denial of coverage for the medication Xeljanz is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arthropathic Psoriasis
Treatment: Otezla 30mg, Pre -service
The insurer denied the Otezla 30mg, Pre -service.
The denial is upheld.

The patient is a male with a history of psoriasis, psoriatic arthritis, hypogammaglobulinemia and difficult-to-control asthma (on Fasenra). Per attached progress notes, he has been treated with Otezla 30 mg (milligrams) twice daily, methotrexate 15-20 mg (milligrams) weekly, sulfasalazine 3500 mg (milligrams) daily and prednisone 10 mg (milligrams) daily. Cosentyx was added and the patient noticed improvement in joint symptoms. Per attached documentation, it is not evidenced that Otezla was ever discontinued upon starting treatment with Cosentyx. Continuation of Otezla was denied for this patient because it was being prescribed in combination with Cosentyx, and the provider provided a published case series supporting the safety of Otezla used in combination with biologic therapy. Appeal is for continuation of Otezla in combination with Cosentyx for the treatment of psoriasis and psoriatic arthritis.

No, the proposed continuation of Otezla is not "medically necessary".
This patient with psoriasis, psoriatic arthritis, hypogammaglobulinemia and difficult-to-control asthma (on Fasenra) has been treated with Otezla 30 mg (milligrams) twice daily, methotrexate 15-20 mg (milligrams) weekly, sulfasalazine 3500 mg (milligrams) daily and prednisone 10 mg (milligrams) daily. Cosentyx was added and the patient noticed improvement in joint symptoms. Cosentyx is FDA (United States Food and Drug Administration)-approved for the treatment of both psoriasis and psoriatic arthritis. Per attached documentation, it is not evidenced that Otezla was ever discontinued upon starting treatment with Cosentyx, which would have been standard of care in the rheumatology community. Although a small retrospective study suggests that the combination of Otezla with other biologic therapies may be safe, there is no documentation for this patient that the combination of Cosentyx with his two other DMARDs (disease modifying antirheumatic drugs), methotrexate and sulfasalazine, and prednisone would have been ineffective, warranting the continuation of Otezla in this setting. Furthermore, the addition of Otezla to biologic therapy is not supported in the published American College of Rheumatology guidelines for the treatment of psoriatic arthritis. Therefore, continuation of Otezla in combination with other DMARDs (disease modifying antirheumatic drugs), prednisone and the biologic Cosentyx is not clinically appropriate or in accordance with standard of care in the rheumatology community, and thus not medically necessary for this patient.

Yes, as discussed in question #2, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spondylosis.
Treatment: Humira 40mg, Pre-service.
The insurer denied the Humira 40mg, Pre-service.
The denial is upheld.

The patient is a female with spondyloarthropathy, associated with low back pain and morning stiffness for 20 to 30 minutes. She has failed treatment with sulfasalazine and various NSAIDs (nonsteroidal anti-inflammatory drugs), naproxen, ibuprofen, and meloxicam. Per the attached progress note, the patient is felt to have moderate disease activity. Inflammatory markers are normal. There is documentation in the assessment of a positive quantiferon test, but no documentation of additional workup and treatment of latent tuberculosis infection (LTBI). The provider now wishes to prescribe Humira. Humira was denied for this patient because there is no documentation of failure of at least one additional NSAID (nonsteroidal anti-inflammatory drug). The appeal is for Humira for the treatment of spondyloarthropathy.

No, the requested Humira is not medically necessary.
This patient with spondyloarthropathy has failed treatment with sulfasalazine and three different NSAIDs (nonsteroidal anti-inflammatory drugs), naproxen, ibuprofen, and meloxicam.  Per a recent UpToDate review and in accordance with American College of Rheumatology guidelines, "in patients with symptoms due to active axial spondyloarthritis (SpA) and an inadequate response to initial therapy with two different NSAIDs [nonsteroidal anti-inflammatory drugs] used consecutively in an adequate dose for at least two to four weeks each, we recommend a tumor necrosis factor (TNF)-alpha inhibitor rather than continuing treatment with NSAIDs [nonsteroidal anti-inflammatory drugs] alone".  Thus, a TNF (tumor necrosis factor) inhibitor such as Humira is clinically appropriate for this patient after failure of sulfasalazine and three NSAIDs (nonsteroidal anti-inflammatory drugs).  However, this patient was also noted to have a positive quantiferon test, but no documentation of additional workup and treatment of latent tuberculosis infection (LTBI).  TNF inhibitors such as Humira carry a black box warning for increased risk of reactivation of LTBI (latent tuberculosis infection), and thus evaluation for active tuberculosis (i.e, a chest X-ray), followed by initiation of treatment for LTBI (latent tuberculosis infection) would be required prior to treatment with Humira.  Therefore, the proposed treatment with Humira for spondyloarthropathy is not clinically appropriate or in accordance with standard of care, and thus not medically necessary for this patient in the absence of additional workup and treatment of LTBI (latent tuberculosis infection).

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

Diagnosis: Crohn's Disease
Treatment: Humira 80mg, Pre-service
The insurer denied the Humira 80mg, Pre-service.
The denial is overturned.

The patient is a male with newly diagnosed moderate Crohn's disease, with active disease on colonoscopy, and MRE (magnetic resonance elastography) with significant luminal narrowing. His provider is requesting treatment with Humira.

Yes, the requested Humira is medically necessary.
The patient has active small bowel Crohn's disease. Ungaro et al showed that early biologic treatment is associated with improved clinical outcomes in adult Crohn's patients, not only in prospective clinical trials but also in real-world settings.

Berg et al showed that recent studies suggest that the use of biologic agents, specifically those targeting tumor necrosis factor alpha, earlier in the treatment course improves patient outcomes and can prevent progression to irreversible bowel damage.

Mesalamines are not effective in patients with Crohn's. Steroids have not been shown to be effective long term in the treatment of Crohn's. While immunosuppressive agents have been shown to have efficacy, they have a slow onset of action and do not have a good safety profile. Therefore, as medical literature supports early biologics as being safe and effective for the treatment of small bowel Crohn's, likely altering the long term prognosis of the disease, the requested Humira is clinically appropriate, accepted standard of medical care and is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
As per question 2, as Humira is medically necessary, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient by denying it.