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

Diagnosis: Muscle weakness, Abnormality of gait
Treatment: Personal Care Aide 7 days x 24 hour split shifts

The insurer denied coverage for Personal Care Aide 7 days x 24 hour split shifts.
The denial is overturned. 

This is a female with a past medical history of chronic pancreatitis, pancreatic cancer, congestive heart failure, diabetes mellitus, depression, anxiety, bipolar disorder, gastroesophageal reflux disease, angina, hypertension, hyperlipidemia, ventricular tachycardia, muscle weakness, and abnormality of gait.  Per Uniform Assessment System (UAS) documentation, the patient lives alone. The patient's apartment building has a functioning elevator and access for people with disabilities. The patient is totally dependent on meal preparation and ordinary housework. The patient requires extensive assistance with managing finances, managing medications, using the phone, using stairs, transportation, dressing her upper body, walking, and locomotion, toilet transfer, using the toilet, bed mobility and eating. The patient needs maximum assistance with shopping, bathing and dressing her lower body. She needs limited assistance with personal hygiene.  At the time of this UAS, the patient was status post hospitalization for chronic pain exacerbation. The patient's right hand was swollen due to a suspected infection status post an intravenous placement. Personal care aide 7 days x 24 hour split shifts is being requested. Of note, the patient was recently hospitalized due to acute pancreatitis. 

On what appears to be the final assessment by Physical Therapy (PT) and Occupational Therapy (OT) at a Skilled Nursing Facility (SNF), it is indicated that the patient needs maximum assistance for bed, transfers, and toilet. The patient appears to have plateaued. Due to this patient's limited mobility and condition, the patient needs to be turned and positioned every 2 hours due to risk of skin breakdown. There is adequate documentation that this patient's needs have increased since past assessments (level of need for assistance higher).  

This patient's needs have increased and are at a level that supports 24-hour care. An aide cannot be assured 5 hours of uninterrupted sleep. The insurer's assessment of this patient was made without the most recent information. 

Based on the review of the medical record and literature, the request for Personal Care Aide 7 days x 24 hour split shifts, is medically necessary for this patient.

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

The carrier's denial of coverage for the requested Personal Care Aide 7 days x 24 hour split shifts should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tachycardia, Hypertension
Treatment: Full hospital admission
The insurer denied coverage for the full hospital admission.
The denial is upheld. 

This is a female patient with a past medical history of mitral valve prolapse, premature atrial contractions (PACs), premature ventricular contractions (PVCs), prolactinoma, a hiatal hernia, and hyperlipidemia. The patient presented to the Emergency Department (ED) due to weakness and lightheadedness.  She had the symptoms for 1 week.  She noted palpitations, fatigue, and feeling unsteady. She had seen her Cardiologist who ordered an echocardiogram.  The patient denied nausea, vomiting, or headaches.  The patient's blood pressure was 167/101 and her pulse rate was 135. Physical examination revealed the patient was not in acute distress and was not diaphoretic. She had tachycardia. She was alert, oriented to person, place, and time. There were no focal deficits. Her motor function and sensation were intact. Her coordination was intact. Her mood was anxious. The patient's electrocardiogram (EKG) revealed sinus rhythm at a rate of 99 with right atrial enlargement and possible right ventricular hypertrophy (RVH).  Her troponin was negative. All other laboratory findings were reassuring. The patient's chest X-ray was negative. She was admitted for further evaluation and treatment due to weakness and lightheadedness.  The patient underwent a cardiac consultation.  Magnetic Resonance Imaging (MRI) of the cervical spine revealed degenerative spondylolisthesis.  The patient was stabilized and discharged on day 4 of admission.

The medical necessity for the full admission was not established. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

In this case, the patient developed weakness with lightheadedness.  Her neurological examination was non-focal.  She was found to have elevated blood pressure and tachycardia. She was found anxious. There was no neurological condition identified by the time of discharge.  From a neurological standpoint, there was no evidence to support a full inpatient admission.

The carrier's denial of coverage for the full hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Skin Disorders. 
Treatment:  Pharmacy/Prescription Drugs (Cimzia). 

The insurer denied Cimzia.  The denial is overturned in whole.

This is a male with a past medical history (PMH) of Type II Diabetes, Psoriasis and severe Hidradenitis Suppurativa (HS).  His HS disease involves his groin, scalp, buttocks, axillae, sacrum and trunk.  The patient is currently on methotrexate, and his dose was increased recently.  He has experienced a recent flare up of his groin and scalp.  The patient is using Hibiclens to bathe and topical Clindamycin and Protopic.

The patient has tried and failed Humira, oral antibiotics, Accutane, topical steroids and Remicade in the past.  His provider prescribed Cimzia, which was denied.  Treatment with Cimzia is under review to determine if it will be more beneficial than any standard treatment.

The health plan's determination is overturned.

Yes.  HS is a severely painful, chronic, recalcitrant, disabling condition.  There are very few drugs that are Food and Drug Administration (FDA) -approved for this disease.  The patient has exhausted mostly all of the medications used to try to control and treat his condition.  He is currently already on Methotrexate as the first line treatment.  He has tried and failed the only FDA-approved treatment for HS, which is Humira.  He could not tolerate Remicade Infusions and failed by mouth (PO) Accutane.  There are off label anecdotal reports in the literature, and limited data currently in the literature for the use of Cimzia in HS; however, in this case there are a paucity of treatment(s) left to treat this patient; it is, therefore, recommended to try Cimzia for this complex and painfully debilitating HS.  Cimzia is likely in this case to be more beneficial than other treatments to treat his disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Skin Disorders. 
Treatment:  Pharmacy/Prescription Drugs (Cimzia). 

The insurer denied Cimzia.  The denial is upheld in whole.

The patient is a male with hidradenitis suppurativa (HS).  The patient has previously failed Humira, isotretinoin, Remicade, clindamycin, methotrexate.  The provider is requesting treatment with Cimzia.  The subject of this review is whether the requested treatment with Cimzia will likely be of greater benefit to this patient than any standard treatments for his HS.

The health plan's determination is upheld.

No, there is not sufficient evidence in the literature that treatment with Cimzia is likely to be more beneficial than any standard treatment.  The patient has only failed two different tumor necrosis factor (TNF) drugs, Remicade and Humira.  It is not clear how Cimzia would be safe and effective long-term in this case, particularly when the patient has failed other drugs in a similar class.  As stated by Savage et al., "There is a report of certolizumab utilized in a pregnant HS patient as an alternative to adalimumab."  With only one mention in the literature, no assessment of certolizumab's efficacy in the treatment of HS can be ascertained.  There is a lack of support in the literature that treatment with Cimzia will be more beneficial in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Skin Disorders. 
Treatment:  Pharmacy/Prescription Drugs (Cimzia). 

The insurer denied Cimzia.  The denial is upheld in whole.

The patient is a male with severe hidradenitis suppurativa of the genitalia and legs.  The patient has tried and failed oral Methotrexate, Isotretinoin, and Clindamycin, as well as the biologic agents Humira and Remicade (discontinued due to side effects of wheezing and vomiting), as well as incision/drainage and excisional procedures.  The subject under review is whether the use of Cimzia is likely to be more beneficial for this patient than any standard treatment for his condition.

The health plan's determination is upheld in whole.

No, Cimzia is not likely to be more beneficial than any standard treatment.

The patient has severe hidradenitis suppurativa that is both symptomatic and treatment-resistant to all appropriate topical, oral, and biologic therapies (often in combination), and requires treatment.  There are no apparent alternative therapies that have been overlooked and not exhausted.  The ideal option of Remicade used concurrently with Methotrexate was not tolerated and had significant and threatening symptoms.  Although all available literature reviews support use of tumor necrosis factors for hidradenitis suppurativa, the options of Humira and Remicade have been most studied, and the option of Cimzia is poorly-defined with respect to efficacy and dosage. [8]

However, if all available options are outside the standard of care for this patient, the question of whether or not there is a viable alternative treatment must be considered.  According to literature, there are interleukin-17 inhibitors which would be the most defined of all the alternative biologic options [5,6,] in the treatment of moderate to severe hidradenitis and are, therefore, the appropriate considerations when all Food and Drug Administration (FDA)-approved and mainstream treatments have either been failed or exhausted.  Cimzia is both unproven and not documented to be reliably effective at standard doses for hidradenitis suppurativa, unlike interleukin-17 options (despite those agents not being tumor necrosis factor inhibitors).

Accordingly, Cimzia is not likely to be more beneficial than any standard second- or third-line treatments, and it is not likely to be more beneficial than any fourth-line, less studied and documented alternative treatments.  As supported by the literature, consideration of alternative biologic therapies would be recommended for this challenging clinical scenario at this time.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female.  At the time of admission to the hospital she presented with no significant past medical history.  She presented with complaints of left sided chest pain, intermittent, non-exertional, fluctuating between dull and sharp, present for about a week. The patient also had an episode of dizziness and lightheadedness. 

The patient was hemodynamically stable. The electrocardiogram (ECG) revealed no acute ischemic changes. Cardiac troponins were negative. Brain natriuretic peptide (BNP) was normal. Chest x-ray revealed cardiomegaly with no lung infiltrates or acute pulmonary disease. The patient was admitted to rule out acute coronary syndrome (ACS). Repeat troponin was negative. An echocardiogram revealed normal left ventricular (LV) function. The blood pressure (BP) was elevated and the patient was diagnosed with hypertension (HTN) and started on Nifedipine. She was also found to have diabetes based on glycated hemoglobin (HgA1c) of 6.7% and was advised to treat it with diet. No stress test or catheterization was planned. The patient was discharged home with a plan for outpatient follow-up.

No, the proposed inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain and dizziness. The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative. Echocardiogram revealed preserved left ventricular (LV) function. No ischemic work-up, such as stress test, coronary computed tomography (CT) or catheterization was planned during this admission. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Therefore, 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: Experimental/Investigational
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Amitiza 8 micrograms (MCG) Capsule, 60 for 30 days
The insurer denied the Amitiza 8 micrograms (MCG) Capsule, 60 for 30 days.
The denial is upheld. 

The patient is a female with Henoch Schonlein purpura that has required corticosteroid treatment.

Pertinent to this review, the patient's provider attests to "diarrhea all day long" with stool retention, abdominal pain, and gastroesophageal reflux disease (GERD). Treatment has included Levsin for cramping, and a laxative combination of Miralax, senna, bisacodyl, and as needed (PRN) "colon clean outs."  

Motility studies have not yet been pursued, but referral to a "motility specialist" is under consideration.  The patient's provider proposes a trial of Amitiza at this time.

No, the health plan should not cover the treatment with Amitiza.

No, the treatment with Amitiza is not likely to be more beneficial.

Constipation in childhood is common, and usually responds to anticipatory guidance regarding diet, toilet training, and toileting behaviors. 

Treatment may involve education, dietary changes, behavior modification, and pharmacotherapy. The patient's records suggest there may be some accompanying stool withholding, rectal impaction, and encopresis with overflow incontinence.  

Functional constipation may be of concern here, but the patient's available record provides no objective data that addresses primary anatomic or neurologic causation, what precipitating events may be at play, nor what dietary changes and behavior modification have in this case been tried and failed.  Studies that have been done show an unremarkable gastrointestinal (GI) tract aside for fatty liver. There is neither evidence provided for advanced gastroesophageal reflux disease (GERD) nor for gastrointestinal (GI) hypomotility. 

No formal motility testing has been performed to warrant this treatment as medically necessary.  Pending objective evaluation, the standard-of-care for the patient is a maintenance regimen of laxatives if the stools is hard, large in diameter, or causes pain, as describes "chronic constipation" in her age group. Although there is literature support for the contention that lubiprostone (Amitiza) may be efficacious and well tolerated were the patient objectively found to have functional constipation, its empiric use in her case prior to appropriate evaluation is premature, off-label, and not without risk.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Amitiza 8 micrograms (MCG) Capsule, 60 for 30 days
The insurer denied the Amitiza 8 micrograms (MCG) Capsule, 60 for 30 days.
The denial is overturned. 

The patient is a female. She has had chronic constipation since shortly after birth. She has been treated with high-dose Miralax, senna and bisacodyl. She also tried lactulose and Dulcolax. Her physician requested Amitiza 8 micrograms (MCG) twice a day.

Yes, the health plan should cover the treatment with Amitiza 8MCG (microgram) Capsule 60 for 30 days.

Yes, the Amitiza 8 micrograms (MCG) Capsule, 60 for 30 days, is likely to be more beneficial.

Systemic review and meta-analysis of randomized clinical trials showed that "Lubiprostone is a safe and efficacious drug for the treatment of chronic idiopathic constipation and irritable bowel syndrome with constipation, with limited adverse effects in 3 months of follow-up". (Li et al.)

Hyman et al. recently published a study and evaluated the safety and effectiveness of lubiprostone in children and adolescents with constipation. Mean spontaneous bowel movement (SBM) frequency significantly increased compared with baseline at week #1 (3.1 versus 1.5 spontaneous bowel movement [SBM]/week, P [P-value] <0.0001). Spontaneous bowel movement (SBM) frequency was improved significantly from baseline overall (P [P-value] <0.0001) and for individual dose groups (P [P-value] Less than or equal to 0.0062) during weeks #2, #3, and #4. They concluded that "Lubiprostone was efficacious and well tolerated in children and adolescents with functional constipation." The doses of Amitiza used in this study were 12 micrograms once daily, 12 micrograms twice daily, or 24 micrograms twice daily based on age and weight.

In summary, Amitiza has been shown to effective and well tolerated in children and adolescents with functional constipation.

This patient has had chronic functional constipation. The patient has tried all available medications for chronic constipation. Based on current literature and clinical practice, the requested Amitiza is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease. The health plan should cover the proposed treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain/Cholecystitis.
Treatment:  Inpatient Hospital Stay. 

The health plan denied the inpatient hospital stay.  The health plan's determination is upheld.

The patient is a male admitted to the hospital.  The patient has had reported symptoms of biliary colic for 1 month.  He was admitted for an episode of prolonged pain lasting 5 hours radiating to the chest and back associated with vomiting.  He had normal lipase and liver function tests (LFTs).  The patient has a known history of cholelithiasis.  The patient was scheduled for elective cholecystectomy.  On admission the patient underwent a repeat ultrasound, which did not demonstrate cholecystitis or choledocholithiasis.  An admission COVID-19 test was positive.  It appears he never received chest imaging.  He has no associated respiratory symptoms.  He later stated the pain was improving without further nausea or vomiting.  A diet was started.  On admission the patient appeared clinically stable.  Vital signs were within normal limits - the patient was not tachycardic or febrile.  On exam there was right upper quadrant (RUQ) tenderness without guarding or rebound.  At issue is the medical necessity of the inpatient stay.

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

The patient's symptoms were consistent with biliary pain from known cholelithiasis.  He likely lodged a small stone in the common bile duct (CBD) or cystic duct, which quickly resolved on its own.  His pain subsided over several hours, and there were no complications, such as biliary sepsis (ascending cholangitis) or biliary pancreatitis.  It was reasonable for the patient to be kept overnight in an observation setting, but acute inpatient care was not medically necessary.  The patient was found to be COVID-19 positive, but this was not acted upon other than infection control precautions with proper personal protective equipment (PPE).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Muscle Strain. 
Treatment: Pharmacy/Prescription Drugs (Lidocaine 5%). 

The health plan denied the requested prescription drug (Lidocaine 5%). The health plan's determination is overturned. 

The patient is a woman with a history of elbow strain, impingement of the right ulnar nerve, epicondylitis of the right elbow, neck pain, lower back pain, and muscular strain. According to a visit note the patient had recently injured her right elbow while she was trying to prevent an elderly woman from falling. She was seen at an outside facility and had x-rays which were negative for fracture. She was instructed to wear a sling and a magnetic resonance imaging (MRI) was ordered which demonstrated common extensor tendinopathy with a 4 mm low-grade tear at the humeral origin. Her current medications included a combination of topical gel analgesics and Gabapentin for pain management. The assessment was that she likely had cubital tunnel syndrome. She underwent an injection of Lidocaine and steroids. 

The plan states that the Lidocaine 5% patch for treatment of muscle strain or shoulder and arm pain is not approved by the US Food and Drug Administration (FDA). Instead they recommend Aspercreme with 4% Lidocaine patch and cream or icy hot patch and cream, which they state are on the preferred drug list. 

The patient's appeal request states that the patient's pain is refractory to Lidocaine 4%, other nonsteroidal anti-inflammatory drugs, homeopathic topicals, oral nonsteroidal anti-inflammatory drugs and narcotics. 
At issue is the medical necessity of the requested medication. 

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

The patient has tried multiple agents for pain management, according to the appeal report, and multiple agents are listed in the progress note that are also included in the appeal report. Because of her use of multiple agents without substantial relief, it is reasonable to treat her with a 5% Lidocaine patch. 
The reason is that the Lidocaine patches are used routinely for similar purposes such as musculoskeletal pain and in a patient who has failed other agents, it is reasonable to trial 5% Lidocaine patches. It is also possible that this may reduce the need for other medications, such as narcotics, with less favorable safety profiles.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic rhinosinusitis with nasal polyposis. 
Treatment: Dupixent. 

The insurer denied coverage for Dupixent. 
The denial is upheld. 

This is a female patient who has been recommended to utilize Dupixent. The patient has a chronic history of rhinosinusitis with nasal polyps (CRSwNP) as well as pharyngitis and Eustachian tube dysfunction. The patient's physician indicates that the patient has a longstanding history of nasal obstruction and has a treatment history of nasal steroids as well as rinses, such as Pulmicort, mometasone, and Astelin. The patient continues to suffer from intermittent plugging in the ears with no drainage, postnasal drip, nasal congestion, and facial pressure. The patient also has chronic hoarseness. The physician indicates that Dupixent has been recommended for her inadequately controlled chronic rhinosinusitis with nasal polyposis. 

As per Patel et al. "In summary, the role of emerging biologics in the treatment algorithm of CRSwNP is still being developed. Based on available data, biologic agents may be beneficial in patients with persistent polyps despite maximal medical therapy, have recurrence despite surgery, or have T2 comorbid allergic diseases including moderate to severe asthma or AERD [Aspirin Exacerbated Respiratory Disease]. Future studies and real-world evidence will determine how biologics fare in the long run. As new evidence develops regarding biologics for CRSwNP, it will continue to inform patient selection and practice management." 

Similarly, per Chen et al. "Although data on biologics from randomized controlled trials look promising, the efficacy of biologics in the real world has yet to be established." 

The patient has not undergone sinus surgery in the past two years and has not been treated with oral steroids in the past 6months. Thus, Dupixent is not considered medically necessary for the patient at this time. 

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

The carrier's denial of coverage for Dupixent as not medically necessary should be upheld. The medical necessity is not substantiated.