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

Diagnosis: Cellulitis
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female with a past medical history of diabetes, hypertension, atrial fibrillation, cerebrovascular accident (CVA), prior sacral wound infection, and anemia, who was admitted for redness of the 4th finger and streaking of the forearm. Review of system was negative for additional clinical findings.
The patient was afebrile, described as awake and not in acute distress. Her blood pressure was 136/94, pulse rate of 79, respiratory rate of 18, and oxygen saturation of 98% on room air. Physical examination was remarkable for left sided weakness of the leg.
Review of the laboratory results revealed the following notable findings: white blood cell (WBC) elevated at 11.7, C-reactive protein (CRP) elevated at 11.20. The patient was admitted for right ring finger cellulitis and fluid collection of the distal fingertip. 

The inpatient hospital admission was medically necessary. The care could not have been safely rendered at a lower level of care.
The patient was admitted for cellulitis and fluid collection of the 4th digit fingertip. This was in the setting of leukocytosis and multiple comorbid conditions including prior infections and diabetes. Inpatient level of care was warranted for drainage of fluid collection, management of diabetes and monitoring for complications and treatment failure.
The infection was at a location where there was increased risk of deep fascial space infection and ischemia at the distal fingertip. In the absence of prompt and aggressive treatment, the patient was at risk for ischemia and digit loss. In addition, hand involvement has been identified as a risk factor for increased likelihood of inpatient admission for treatment of cellulitis. Inpatient admission for management of progressive hand cellulitis was appropriate in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Immunologic Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Xeljanz for medical necessity. 
The denial was overturned. 

This patient is a male with alopecia areata, progressing to involve entire body, treated with topical steroids and systemic steroids. His provider is recommending Xeljanz.
At issue is the medical necessity of Xeljanz 5 milligrams (mg).

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

The requested health service/treatment of Xeljanz 5mg is medically necessary for this patient.
Treatment studies for any form of alopecia areata are difficult to perform because the disease has an unpredictable course, and much investigation is still needed. A wide range of treatments have been used for the management of alopecia areata, most of which are not highly effective. A dependable and safe treatment for extensive disease (totalis or universalis) has yet to be found. Given the rarity of the disease, large randomized controlled trials are extremely difficult.
Xeljanz first demonstrated efficacy in alopecia areata (AA) in a patient with concomitant psoriasis and AA was treated with the medication and serendipitously his alopecia areata reversed. 
Xeljanz is currently United States Food and Drug Administration (FDA) approved for Rheumatoid arthritis and undergoing approval trials for psoriasis and psoriatic arthritis. It is known to be safe and effective in the conditions for which it is FDA approved. Biologic medications as a whole have many off label uses, leading to better outcomes in rare diseases for which large, randomized trials are not readily available.
Therefore, given the support in current literature and lack of effective therapies for alopecia areata, and this patient's favorable response to therapy, Xeljanz is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia.
Treatment: Xeljanz.
The insurer denied Xeljanz. 
The health plan's determination is overturned. 

The patient is a female who has severe alopecia areata universalis, for which the patient has tried and failed topical, intralesional, and oral steroids. The patient has been noted to have severe chronic eye irritation and inflammation which makes most of the patient's daily activities of life impossible. Coverage of Xeljanz is under review for medical necessity.

Xeljanz is medically necessary for this patient. The patient's ocular symptoms and inflammation from loss of her eyebrows and eyelashes can lead to a significant conjunctivitis and pain that can be debilitating (such as with this patient), and therefore Xeljanz is medically necessary for this particular patient at this time.
Although off-label for use of Xeljanz, alopecia areata to date has been responsive only to JAK (Janus kinase) inhibitors (such as Xeljanz) at this time. No other treatment save Xeljanz reliably and effectively treats this condition, which is usually a non-functionally impairing disease of the skin and hair. However, this particular patient has a form of alopecia areata universalis that affects not only the hair of the scalp but on the eyelids and eyebrows. A significant risk of chronic conjunctivitis and ocular pain, and even ocular damage with consideration to a lack protection of the eyes from wind, dust, and the elements does exist. This otherwise non-functionally impairing disease is for this particular patient medically necessary for use of Xeljanz, which to date has no significant safety impacts or adverse events for alopecia areata patients (unlike those which are much more numerous in rheumatoid arthritis patients).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System-Asthma
Treatment: Inpatient Hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has a history of asthma. She presented with increasing shortness of breath (SOB). She was also using an inhaler and a nebulizer for an increased number of times. She had no fever, or chills. No increasing cough or sputum production. She was tachycardiac to 124 in the emergency room (ER). She had wheezing on examination and no accessory muscle use. She was not hypoxic. Her labs did not show any acute abnormality. Her power of hydrogen (pH) was 7.42. She had no hypoxemia. She was placed on bi-level positive airway pressure (BiPAP). She was given albuterol nebulizers and was admitted to the hospital. She was feeling better on admission and was taken off BiPAP quickly. She was also started on intravenous (IV) solumedrol and was switched to by mouth (PO) prednisone after 2 days. She had a normal chest x-ray and was discharged on antibiotics.

This was a young otherwise healthy female with a history of asthma. She presented with increasing shortness of breath (SOB). The patient had a moderate asthma exacerbation. She was tachycardiac with diffuse wheezing on exam. Although per emergency department (ED) notes the patient had tachypnea, on review of her vitals, her respiratory rate was 20, and is not really a tachypnea. Some degree of tachypnea is expected in an asthma exacerbation.  At the time of admission to the medicine team, her respiratory rate was again 20. She was saturating well on room air. She did have diffuse wheezing and initially had some difficulty to complete sentences, but that was resolved soon after. Her BiPAP was removed very quickly. She was admitted to the medicine service  and her BiPAP was removed around 2 hours later.  She was given antibiotics on discharge. She does not meet medical necessity for inpatient level of care. She was suitable for a lower level of care.  The only concerning finding was slight tachycardia without impending respiratory failure, there was an absence of hypoxia, and no respiratory acidosis or alkalosis that will make her a candidate for inpatient management [1,2]. Based on Milliman Care Guidelines (MCG) health Inpatient & Surgical Care Edition 25th edition: Asthma the inpatient admission is indicated for ventilatory support, peak respiratory flow rate < 25% predicted, peak expiratory flow rate between 40% and 60% predicted and associated hypoxemia, partial pressure of carbon dioxide (PaCo2) elevation, dyspnea, accessory muscle use, hemodynamic instability, or altered mental status [3]. Although the patient was briefly on BiPAP in the emergency department, it was very brief. Based on this the inpatient admission was not indicated and the patient was suitable for a lower level of care. There was a lack of impending respiratory failure, acidosis, hypoxemia, hemodynamic instability, or other associated condition that would require inpatient management as mentioned above [1,2].
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis
Treatment: Orencia SQ 125mg
The insurer denied the Orencia SQ 125mg.
The denial is overturned.

This patient is a female with history of rheumatoid arthritis.  The patient has previously tried and failed conventional disease modifying antirheumatic drugs (DMARDs) methotrexate and sulfasalazine.  The patient has untreated latent tuberculosis, with negative chest x-ray.  The patient has recently been started on rifampin earlier this year.

Yes, the proposed treatment is medically necessary.

The patient has seropositive rheumatoid arthritis.  She has tried and failed two conventional disease modifying antirheumatic drugs (DMARDs).  She continues to have synovitis and significantly elevated inflammatory markers.  She is in need of advanced therapy.  The requested drug Orencia is Food and Drug Administration (FDA) approved for treatment of rheumatoid arthritis.  The American College of Rheumatology does not favor one biologic therapy over another in the treatment of rheumatoid arthritis.  Therefore, it is medically necessary that this patient be allowed an advanced therapy such as Orencia.

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

The patient has significantly active disease and is in need of advanced therapy.  Given the lack of a policy describing alternative advanced therapy options, the health plan did not act reasonably, with sound medical judgement, or in the best interest of the patient because the patient needs to be allowed to have an advanced therapy at this time and Orencia is an FDA approved advanced therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rule out seizure
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a boy who presented after an episode of syncope. He was well until the day of presentation when he was playing on a scooter and fell to the ground. He did not remember what had happened, but his brother noted that he seemed to be 'playing dead'. He felt dizzy afterward with headache and flushing. His mother gave him a cool bath, but he continued to appear dazed, was stuttering, and was described as having difficulty finding words. He was therefore brought to the emergency department for care. He vomited 4 times prior to being evaluated.
His past history is significant for a similar incident back in March when he was admitted for evaluation after having episodes of jerking movements. He was evaluated for seizures at that time and the workup was negative.
In the emergency department, he was noted to have a headache that was 8/10 in intensity. He was alert with normal vital signs. His examination revealed tenderness on the parietal scalp. Laboratory values were obtained as well as a head computed tomography (CT) scan. He was treated with Zofran and was observed with repeat evaluation. Due to his history of a questionable seizure disorder and the occurrence of a repeat unexplained event with delayed full resolution of symptoms, he was admitted for further care.

The Inpatient Hospital Admission was medically necessary for this patient.
 
This is a young boy who presented with an unexplained syncopal event. He had a prior event that was thought to possibly be a seizure, and had symptoms of headache, dizziness, and difficulty with word finding following the event. He also vomited 4 times. He required prompt evaluation and consultation by neurology. Video EEG monitoring was recommended to help identify a seizure disorder and direct appropriate treatment. He also required intravenous fluids and seizure precautions with close monitoring.
The decision making at the time of admission for this patient was consistent with his young age, the presence of an unexplained syncopal event with residual symptoms, and the need for prompt evaluation while receiving intravenous fluids, prolonged video EEG monitoring in an attempt to catch any epileptiform events, and close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: OTEZLA 30mg (milligrams) TABLET, Pre-service.

The insurer denied the OTEZLA 30mg (milligrams) TABLET, Pre-service.  The denial is overturned.

The patient is a male with psoriasis affecting 20% BSA (body surface area) for whom Otezla is requested. He has failed multiple topical steroids, including clobetasol and fluocinonide, as well as dapsone and hydroxyzine. He started Otezla and has had a positive response.

Yes, the treatment with Otezla is medically necessary.

The patient is not a candidate for conventional systemic medications due to kidney disease and for phototherapy due to the location of affected areas on sensitive areas.

Otezla, an inhibitor of phosphodiesterase four (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy (Celgene).  Otezla is an oral small molecule inhibitor of phosphodiesterase four (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA) as well as the treatment of patients with moderate to severe plaque psoriasis (Celgene).

The patient has severe psoriasis for which therapy with Otezla is appropriate and medically necessary.

Conventional systemic therapies are not an optimal choice for a patient with kidney disease. Phototherapy is not appropriate when psoriasis affects sensitive areas, including the face and neck, as they are exposed to daily UV (ultraviolet) light and predict non-responsiveness to phototherapy. The patient has already started taking Otezla and has had a positive response to it. Stopping the treatment risks the patient flaring and might interfere with his health outcomes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer/Prostate Cancer
Treatment: Radiology Services/Positron Emission Tomography (PET) 
The health plan denied the PET scan as not medically necessary. 
The health plan's determination is upheld.

This patient has Gleason grade Group 1 prostate cancer. His clinical stage is T1c. He has National Comprehensive Cancer Network (NCCN) very low risk prostate cancer; he is managed with active surveillance. The has had a bone scan which was negative. His follow up prostate-specific antigen (PSA) is lower than his initial pre-biopsy value (4.6 vs 5.1). positron emission tomography (PET) / computed tomography (CT) is ordered. This is the topic of this review.

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

No. Current guidelines of NCCN do not endorse PET scans for patients on active surveillance for Gleason Grade Group 1 prostate cancer. Patients with Gleason grade Group 1 disease under active surveillance do not require this test as part of their follow up.
NCCN guidelines note that patients with very low- and low-grade disease are preferably managed with active surveillance. This protocol includes periodic PSA testing and repeat biopsy. A PET scan is not part of the recommended follow up protocol.
This test is not medically necessary based on standard of care. Current guidelines of the American Urological Association (AUA) do not endorse the use of this test as part of the active surveillance program. Current literature notes that the value of PET scanning is best applied for detection of recurrent or persistent disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Myeloma. 
Treatment: Carfilzomib. 

The insurer denied Carfilzomib. The health plan's determination is overturned. 

The patient is a female with newly diagnosed immunoglobulin G (IgG) kappa Multiple Myeloma with 90% of bone marrow involvement with kappa restricted plasma cells and M protein of 3.6 grams without renal insufficiency, hypercalcemia and anemia. Kappa/Lambda ratio was 7.29. Lactate dehydrogenase (LDH) and B2-Microglobulin levels were not elevated. Cytogenetic/ FISH (Fluorescence in situ hybridization) analysis showed copy number gain of 11q, deletion 17p and copy gain of 15q. Plan of treatment with upfront induction chemotherapy followed by stem cell collection and autologous stem cell transplantation was recommended by treating hematologist for high-risk myeloma based on the above cytogenetics. Under review is the medical necessity of Carfilzomib 1 mg Injection. 

Carfilzomib 1 mg Injection is medically necessary for this patient. 

Carfilzomib, Lenalidomide and Dexamethasone (KRD) is one of the preferred regimens for patient with newly diagnosed multiple myeloma who are transplant candidate. Carfilzomib is a next-generation proteasome inhibitor shown to improve both progression-free and overall survival in relapsed and refractory multiple myeloma in combination with lenalidomide and dexamethasone (KRd). Given the favorable response rates seen in phase II trials treating newly diagnosed myeloma, this combination is listed as a viable option for upfront treatment. The regimen of Carfilzomib (KRD) is recommended by NCCN guidelines in front line setting for transplant eligible patients.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Pharmacy/Prescription Drugs 
The insurer denied Emgality. 
The denial is upheld. 

The patient is a female who has been under the care of her neurologist for migraine headaches. The patient is noted to have a history of daily headaches, with severe headaches 3-4 times per week. According to a letter from the patient's treating pediatric neurologist, the patient did a trial of amitriptyline. The patient has also taken fluoxetine, nortriptyline, and Venlafaxine. She has now been recommended for Emgality by her provider. This was previously denied by the health plan for not meeting the pharmacy requirements for coverage.

At issue is the medical necessity of Emgality 120 milligrams (mg)/milliliters (ml) pen injector.

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

The requested health service/treatment of Emgality 120mg/ml pen injector is not medically necessary for this patient.

To date, there is only high-quality evidence published on the use of the calcitonin gene-related peptide (CGRP) drugs in the adult population. The requested drug remains under active study [in the form of an ongoing phase 3 trial] for use in the pediatric and adolescent population at this time (ClinicalTrials.gov). The article and citation provided by the treating provider are largely retrospective case and cohort reports, often involving a heterogenous patient population. The evidentiary value of such publications is otherwise limited and does not permit conclusions on the efficacy of the drug at this time in the pediatric population. 

In addition, the patient is noted to have only trialed two antidepressant agents to date for migraine (a prior trial of amitriptyline and a more recent trial of venlafaxine). However, there was not a clear indication within the documentation provided as to why the patient would otherwise be unable to trial another prophylactic medication class. There are other medications that are generally regarded as being effective and safe for use in pediatric migraine (Oskoui, et al). It cannot be concluded that there is a sufficient body of literature to support the use of Emgality in this patient's case.

Therefore, the requested health service/treatment of Emgality 120mg/ml pen injector is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal- Other-Necrotizing enterocolitis. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Epogen. 
The denial was overturned.

The patient is a female, former preemie who developed a short bowel syndrome as a result of necrotizing enterocolitis (NEC) who was total parenteral nutrition (TPN) dependent with intestinal failure associated liver disease. She received a multi-visceral organ transplant of pancreas, stomach, intestine, colon, and liver. She has had some gastrointestinal (GI) bleeding following endoscopies requiring packed red blood cells (PRBC) transfusions. She received intravenous (IV) iron. She reportedly was started on Epogen. There are no results of reticulocyte counts nor erythropoietic levels. Her immunosuppression has been tacrolimus and rapamycin. The treating physician is requesting Epogen to maintain her hemoglobin levels in the normal range and to prevent or minimize PRBC transfusions and to prevent anemia which might affect rejection of her transplanted organs.
At issue is the medical necessity of Epogen 2000/milliliters (ML) injectable (INJ).

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

The requested health service/treatment of Epogen 2000/ML INJ is medically necessary for this patient.
The patient should receive Epogen to increase her hemoglobin and maintain it in a normal range. The patient's hemoglobin levels have slowly and mostly consistently increased. There has been some fluctuation in the hemoglobin levels, but the levels have maintained greater than 9 and greater than 10. The treating physician states that it is important to maintain the patients hemoglobin in the normal range for the patient's age to prevent severe anemia and to minimize rejection of her organ transplants. The patient's hemoglobin (Hb) levels are lower than normal for a girl. The normal Hb range for patients age is 11.4 - 15.0.  This patient will benefit and will require support for her ongoing chronic anemia. Epogen is generally considered a safe and effective treatment for chronic anemia status post (s/p) organ transplant.
Therefore, the requested health service/treatment of Epogen 2000/ML INJ is medically necessary.