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

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

The patient is a female. She has no significant past medical history but has a family
history of CAD (coronary artery disease). The patient was referred to the ER
(emergency room) for evaluation of chest pain and abnormal ECG
(electrocardiogram) at an urgent care center. The patient was hemodynamically stable. The ECG (electrocardiogram) revealed diffuse ST elevations with depression in aVR (Augmented Vector Right) and lead III. Troponin was negative. The patient was admitted to rule out ACS (acute coronary syndrome).Repeat troponin was negative as well. No cardiac catheterization or CCTA (cardiac computed tomography angiography) was planned. A 2D (two dimensional) echo
was obtained, revealing EF (ejection fraction) of 50% with no wall motion
abnormalities. The patient's symptoms resolved and she signed out.

No, the proposed inpatient admission is not "medically necessary".

This patient presented for evaluation of atypical chest pain. The diagnosis of an
acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were
negative. ECG (electrocardiogram) changes were present and suggestive of
pericarditis vs. ischemia. There was no evidence of acute myocardial infarction,
ACS (acute coronary syndrome), decompensated CHF (congestive heart failure),
malignant arrhythmia or hemodynamic instability. There was no pericardial effusion
or wall motion abnormality on the echocardiogram. The clinical information provided
in the record submitted for review does not support medical necessity for this
admission and the care required could have been provided at a lower level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Severe persistent asthma. 
Treatment: Fasenra. 

The insurer denied the Fasenra. 
The denial is overturned. 

The patient is a female with a history of severe persistent eosinophilic asthma.  The request is for approval of Fasenra. 

Yes, the health plan should cover the proposed Fasenra. 

Benralizumab is a cytotoxic monoclonal antibody directed against IL-5 receptor alpha that is approved by the Food and Drug Administration (FDA) as add-on therapy in patients (greater than or equal to [>=] 12 years) with severe asthma and an eosinophilic phenotype. The submitted documentations indicate that the patient has severe persistent eosinophilic asthma with several courses of oral steroids for uncontrolled asthma symptoms. The patient has elevated blood eosinophil count and has documented contraindication for the formulary alternative Nucala which is associated with the risk of herpes zoster. The requested medication is medically necessary and clinically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: History of breast cancer, diabetes mellitus and generalized weakness
Treatment: Increase of Consumer Directed Personal Aide hours to 24-hour split-shift
The insurer denied the Increase of Consumer Directed Personal Aide hours to 24-hour split-shift.
The denial is upheld. 

The patient is a female with a history of breast cancer, diabetes mellitus and generalized weakness. Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs). 

Appeal review requested for potential approval of 24 hour split shift Personal Assistance Services to offer increased ADL support.

No, the proposed treatment of 24 hour split shift Personal Assistance Services is not deemed medically necessary. 

This is a female with a history of breast cancer, diabetes mellitus and generalized weakness. Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs). However, an in-home assessment of the patient's functionality and ability to perform activities daily living (ADLs) was completed and revealed that the currently approved plan of 38 hours per week Personal Assistance Services is sufficient to meet the patient's current needs. Although the appeal letter indicates that the patient lives alone, has overnight needs, is a fall risk and should not be left alone, there is no additional documentation which demonstrates objective findings to support that the patient has sustained further functional loss since the date of the last assessment. For these reasons, the proposed treatment of 24 hour split shift Personal Assistance Services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal Heart Rhythms
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a past medical history significant for HTN (hypertension), paroxysmal SVT (supraventricular tachycardia). She was admitted for an elective SVT (supraventricular tachycardia) ablation. 

The patient underwent the scheduled ablation of AVNRT (atrioventricular nodal reentrant tachycardia). She was admitted for monitoring overnight. There were no reported complications, bleeding, arrhythmia, heart block, MI (myocardial infarction), etc (et cetera). The patient was discharged home the next morning with a plan for outpatient follow-up.

No, the Inpatient admission was not medically necessary.

This patient was admitted for an elective EP (electrophysiology) study, and an uncomplicated RF (radiofrequency) ablation was performed. There were no peri-procedural complications. The standard of care for patients presenting for an elective EPS (electrophysiology study) is ambulatory care with post-procedure observation. Usually no acute inpatient admission is required, unless there is evidence of access site bleeding or other complications, such as periprocedural MI (myocardial infarction), tamponade, AV (atrioventricular) block, need for pacemaker placement, hemodynamic or electric instability. None of these complications were documented for this patient, and she was discharged home in the morning. Thus, the medical record does not support medical necessity for acute inpatient care, and care during this admission could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal stenosis, gait ataxia and frequent falls
Treatment: Increase Personal Care Services 24 Hours A Day, 7 Days A Week (live-in) For A Total Of 91 Hours Per Week
The insurer denied the Increase Personal Care Services 24 Hours A Day, 7 Days A Week (live-in) For A Total Of 91 Hours Per Week. 
The denial is upheld. 

The patient is a female with a history of spinal stenosis, gait ataxia and frequent falls. Due to impairments related to these conditions, she requires assistance for completion of many her activities of daily living (ADLs). An appeal review requested for potential approval of 24 hours a day, 7 days a week (live in) Personal Assistance Services to offer increased ADL (activities of daily living) support.

No, the proposed treatment increase to 24 hours a day, 7 days a week (live in) Personal Assistance Services is not deemed medically necessary. 

This is a female with a history of spinal stenosis, gait ataxia and frequent falls. Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs).

The beneficiary statement which was submitted with this appeal review states that the patient requires increased assistance with dressing, hygiene, meals and overnight toileting. However, an in-home assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and revealed that the currently approved plan of 42 hours/week Personal Assistance Services is sufficient to meet the patient's current needs. There is no additional objective documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment 24 hours a day, 7 days a week (live in) Personal Assistance Services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine fibroids, Abnormal uterine bleeding.
Treatment: Transcervical uterine fibroid ablation procedure.
The insurer denied coverage for the transcervical uterine fibroid ablation procedure.
The denial is overturned.

This is a female patient with a history of uterine fibroids, abnormal uterine bleeding, and a breast lesion discovered on mammography. She is requesting coverage for the Sonata procedure. The patient declined a hysterectomy. The patient was not interested in preserving fertility.

The Sonata System combines intrauterine ultrasound (IUUS) with radiofrequency (RF) ablation in a single handpiece. Sonata is suitable in an inpatient or outpatient setting, and is intended for diagnostic intrauterine imaging and transcervical treatment of symptomatic uterine fibroids, including those associated with heavy menstrual bleeding. The Sonata system is Food and Drug Administration (FDA) approved for the management of fibroids. There are multiple studies documenting the safety and efficacy of this procedure in controlling symptoms due to fibroids. Studies have shown symptomatic improvement is observed within the first three months after this procedure, and this clinical improvement has been maintained at least through 24 to 36 months of follow-up. In this case, this patient is not planning on conceiving and her fibroids are less than 5 centimeters in size. This patient's clinical case meets the criteria for the Sonata procedure. 

Thus, the Sonata procedure, which is a transcervical uterine fibroid ablation procedure, is considered medically necessary for this patient.

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

Based on the above, the medical necessity for the transcervical uterine fibroid ablation procedure is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures.
Treatment: Inpatient admission.
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This is a male patient with a history of autism spectrum disorder as well as mild cognitive delay, pseudoseizures and seizures on multiple medications who was admitted to the hospital to undergo a video electroencephalogram (vEEG) for 24 hours given the concern for recent breakthrough seizures. The patient completed the study and the preliminary results showed no areas of focal slowing, persistent asymmetries for epileptiform discharges. There were no seizures during the hospital admission, and the patient was discharged the following day.

According to the guidelines provided by the InterQual 2019, the acuity of this case is considered to have required observation as the patient with a transient neurologic of unknown cause although pseudoseizures are suspected. Upon arrival to the hospital, the patient was not considered to be in status epilepticus. No events concerning for seizures were noted during the hospital stay. Precautionary testing with computed tomography (CT) scan and electroencephalogram (EEG) were performed without abnormality. No other interventions were medically necessary. 

The current literature indicates that a patient may be admitted to the hospital when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. The submitted documentation does not detail that the patient had a trial and failure of care at a lower level such as observation. The documentation detailed that the patient was back at his baseline and was discharged after 24 hours. The requested inpatient admission would not be the most appropriate level of care and therefore, 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 medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyshidrotic eczema

Treatment: Dupixent

The insurer denied coverage for Dupixent.

The denial is upheld.

This is a female patient with a diagnosis of dyshidrotic eczema. She was treated with Dupixent, which worked but was never covered by her insurance; the patient received treatment via samples. The patient failed oral and topical steroids. The insurer asks for preferred agent usage of oral cyclosporine, azathioprine, and methotrexate (MTX) or phototherapy (UV). 

At a recent office visit, the patient presented with non-specific dermatitis that was isolated only to her hands. While the requested medication, Dupixent (dupilumab) is useful in the treatment of atopic dermatitis, literature supports that the insurer's list of preferred alternatives are also effective in the treatment of atopic dermatitis. Gooderham et al. (2017)'s review of systematic treatment options for adult atopic dermatitis states that "cyclosporine is recommended as first-line treatment for short-term use, azathioprine is second line, and methotrexate third-line." Roekevisch et al. (2019) further supports the use of disease-modifying antirheumatic drugs (DMARDs) for the treatment of atopic dermatitis. Roekevisch et al. (2019)'s study "demonstrates that [methotrexate (MTX)] and [azathioprine (AZA)] seem to be appropriate and safe options for the treatment of adult patients with severe [atopic dermatitis (AD)]."  

Based on the review of the medical record, the patient does not have any documentation of medical contraindication for treatment with DMARDs, such as MTX and AZA. The insurer's provided alternative medications are considered appropriate treatment options for this patient. Therefore, Dupixent 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.      

Based on the above, the medical necessity for Dupixent is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Gynecological. 
Treatment: Infertility Treatment. 
The plan denied hormone treatment and IVF cycle. 
The determination is overturned in part.

The patient is a female who had undergone previous in vitro fertilization (IVF) cycles for infertility which had been unsuccessful. At the recommendation of her treating provider she underwent in-vitro fertilization (IVF) cycle, the result of which was 3 fertilized eggs being transferred. This cycle was successful, and the patient is pregnant.
The subject under review is the medical necessity for the high dose gonadotropins (greater than [>] 450 international units [IU] daily) and the IVF cycle.

The subject under review is the gonadotropins and IVF cycle.

The health plan's determination is overturned in part. 

The gonadotropin dose beyond 450 IU daily was not medically necessary. Published evidence does not support gonadotropin dosages beyond 450 IU daily. However, the IVF cycle was medically necessary.
This patient had infertility.  Based on the American Society of Reproductive Medicine (ASRM) definition that includes "numerous assisted reproductive technologies (ART) cycles without adequate...embryo development," the IVF cycle was medically necessary for this patient.
In a Cochrane review, that included 27 randomized controlled trials (RCTs) (4031 couples or women) it reported failure to transfer any embryos was higher in the blastocyst transfer group (OR 2.50, 95% confidence interval [CI] 1.76 to 3.55; 17 RCTs, 2577 women, I(2) = 36%, moderate quality evidence). This suggests that if 1% of women have no embryos transferred in (planned) fresh cleavage stage transfer, between 2% and 4% will have no embryos transferred in (planned) fresh blastocyst stage transfer.
This data in combination with American Society of Reproductive Medicine (ASRM) guidelines regarding poor prognosis cycles which states that when changing a major aspect of the protocol (such as the day of transfer), the prognosis can change despite a history of failed cycles. Thus, as this cycle was doing something decidedly different, doing the embryo transfer at the multicell stage as opposed to the blastocyst stage, a subsequent cycle was reasonable and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Endocrine/metabolic/nutritional
Growth Hormone

Diagnosis: short stature
Treatment: Nutropin AQ
The insurer denied Nutropin AQ. The health plan's determination is overturned. 

The patient is a female who is seeking growth hormone (GH) treatment. Her reported mid parental height is 67 inches. Her height at the age of 9 year 1 months was 125.7 cm (9.92 percentile: -1.29 standard deviation (SD)); however, she grew 13 cm in a little less than 3 years and her height dropped to the 5th percentile at the age of 12 years. Her height was 138.7 cm (5.12 percentile: -1.65 SD). Her weight points during that time frame are not available. Her bone age was read as 11 years at chronological age 12 years.
Her evaluation for short stature showed IGF-1 (insulin like growth factor one) 114 ng/ml (-2.6 SD); however, other evaluation including complete blood count (CBC), comprehensive metabolic panel (CMP), TFT's (thyroid function tests), insulin-like growth factor binding protein-3 (IGFBP-3) and celiac screen was unremarkable. She underwent growth hormone (GH) stimulation testing and her peak GH response was 4.1 ng/ml after Arginine and 13 ng/ml after clonidine. An magnetic resonance imaging (MRI) of the pituitary gland showed 8 mm region of non-enhancement in the pars intermedia, and solitary small hyperintense focus along the left frontal periventricular white matter of doubtful clinical significance.

Nutropin AQ is medically necessary for this patient.
Although this patient underwent GH stimulation testing and her response was normal, it does not necessarily rule out abnormality of the GH/IGF axis (especially hypothalamic dysfunction, bioinactive GH and subtle GH resistance). In the GH Research Society Consensus guidelines for the diagnosis and treatment of growth hormone, it is mentioned that some patients with auxologic GHD may have IGF-I and/or IGFBP-3 levels below the normal range, but GH responses in provocation tests above the cut-off level.
Values below a cut-off -2 SD for IGF-I and/or IGFBP-3 strongly suggest an abnormality in the GH axis if other causes of low IGF have been excluded. These children are not classically GH deficient, but may have an abnormality of the GH/IGF axis and after the exclusion of other causes could be considered for GH treatment. This patient's growth velocity is 4.7 cm per year which is more than 2 SD below the mean for bone age despite progression of puberty. Nutropin AQ is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dementia/Cerebral vascular disease.
Treatment:  Environmental Modification (Bathroom Renovation).

The insurer denied Environmental Modification (Bathroom Renovation).  The health plan's determination is upheld. 

The patient is a female with a past medical history significant for dementia, cerebrovascular disease, aortic stenosis, coronary artery disease, osteoarthritis, hypertension, hyperlipidemia and history of right breast cancer.  This review is for the medical necessity of environmental modification (Bathroom Renovation).  The patient requests that the bathroom be remodeled in order to better suit her needs. 

The Environmental Modification (Bathroom Renovation) is not medically necessary for this patient.  The patient has a past medical history significant for dementia, cerebrovascular disease, aortic stenosis, coronary artery disease, osteoarthritis, hypertension, hyperlipidemia and history of right breast cancer.  No skin ulcers are noted.  There are no issues with incontinence of bowel or bladder. 

There was no documentation of a recent physical therapy evaluation with detailed assessment of the patient's abilities to perform activities of daily living.  There was no documentation of environmental assessment of the home with a diagram that shows location dimensions of all existing bathrooms.  There was a letter from physical therapy stating that she needed the renovation; however, there is not an actual physical therapy report documenting her current status.

Therefore, the Environmental Modification (Bathroom Renovation) is not medically necessary.

In addition, according to information provided (the mortgage statement), the patient does not own the property, it is owned by another individual.  The patient's name is not listed on this mortgage statement.  Therefore, it appears that she is living there for free or paying rent.  Either way, according to New York law, as listed in the references for her location of residence, it is up to the property owners to make reasonable changes according to ADA (Americans with Disabilities Act).
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Migraine Headaches.
Treatment:  Emgality.

The insurer denied Emgality.  The determination is overturned.

The patient was diagnosed with chronic migraines.  Treatment with Emgality is requested.  The patient has previously tried and failed Depakote extended release (ER), nortriptyline, and topiramate.  At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug or would have adverse effects.

Yes, the formulary alternatives will be or have been ineffective for treatment of the member's condition.  The patient has previously tried and failed 2 of the 3 formulary alternatives including topiramate and divalproex.  The patient has also tried and failed nortriptyline.  Tricyclic antidepressants, in addition to anticonvulsants and beta-blockers, are considered first-line therapy for prevention of migraine.  Given that the patient has already tried and failed 3 first line agents (topiramate, divalproex, and nortriptyline), it is unlikely that propranolol will be as effective as Emgality for this member.  The patient has been stabilized on Emgality for the condition requested.

The health plan's determination is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mutiple Myeloma
Treatment: Hydrocodone-acetaminophen 5-300
The insurer denied Hydrocodone-acetaminophen 5-300
The determination is upheld.


The patient has multiple myeloma in complete response (CR). He has required surgical intervention and radiation. The patient has been functional and exercises but has required Vicodin for pain after failure of Neurontin, Cymbalta, Tylenol # 3, and Percocet. At issue is the medical necessity of hydrocodone-acetaminophen 5-300.
Although the health plan denied hydrocodone-acetaminophen 5-300, they did approve hydrocodone-acetaminophen 5-325. Studies demonstrating that the approved formulary alternative is inferior are not available. The difference of 25 milligrams (mg) of acetaminophen would generally be considered inconsequential from an analgesic perspective. Neither the National Comprehensive Cancer Network (NCCN) nor the authors of UpToDate nor the peer-reviewed literature recommend the use of the prescribed drug as being superior to the plan alternative.
For these reasons, medical necessity for this service cannot be established.