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

Diagnosis: Psoriasis, Psoriasis Arthritis
 
Treatment: Taltz

The insurer denied the Taltz. The denial was reversed.  
This is a male patient with a history of psoriasis and psoriasis arthritis that involves more than 5% of his body surface area; his truck, left leg, and neck.  It was reported that the patient has been treated and has failed topical steroid medications, narrow band ultraviolet light therapy, as well as oral medication such as Stelara, Enbrel, Otezla. He is currently being treated with Cosentyx. His dermatologist is requesting Taltz.
Leonardi C1, Maari C2, Philipp S3, Goldblum O4, Zhang L4, Burkhardt N4, Ball S4, Mallbris L4, Gonzalez P5, Fernandez-Penas P6, Puig L7. (2018), "At week 156, 80.5% of patients had achieved at least a 75% improvement from baseline in their Psoriasis Area Severity Index (PASI) score, 66.0% had achived at least a 90% improvement from baseline in their PASI score, and 45.1% had achieved a 100% improvement from baseline in their PASI score with use of the modified nonresponder imputation method, and 97.2% and 86.2% of patients had achived at least a 75% improvement from baseline in their PASI score with use of the as-observed and multiple imputation methods, respectively. Similar response rates were observed in patients with baseline scalp, nail, or palmoplantar involvement. No new safety signals were identified through year 3."

Genovese, M. C., Combe, B., Kremer, J. M., Tsai, T. F., Behrens, F., Adams, D. H.,  Nash, P. (2018), "During the extension period, the overall safety profile of ixekizumab remained consistent with that observed with the double-blind period, and clinical improvements persisted up to 1 year."

Gottlieb AB. et al. (2018), "Improvements from baseline in PASI 75, PASI 90, and PASI 100 were observed in both groups with and without PsA involvement (Fig 1)."     
The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient has tried and failed biologics (Stelara, Enbrel and Cosentyx), methotrexate will be inappropriate. The patient has a diagnosis of psoriatic arthritis Tremfya, and skyrizi are inappropriate for this patient. The patient has tried and failed an anti-TNF, Cimzia and Humira are inappropriate.      

Based on the above, the medical necessity for Taltz is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder
 
Treatment: Feeding Therapy Service (92526)

The insurer denied the Feeding Therapy Service (92526). The denial was reversed.   
This is a young female patient with a history of autism, psychogenic food refusal, morbid obesity, intellectual disability, mild asthma and constipation. It was reported that the patient was minimally verbal and had significant delay in development. An evaluation was performed by a pediatric feeding disorder facility that revealed the patient required verbal prompting to chew boluses during the session, demonstrated prolonged mastication time, as well as increased pocketing of food.  The patient's pediatrician is requesting that the patient participate in the outpatient feeding program to avoid a sequelae of food disorders.  
Pediatric feeding disorders are one of the most frequent concerns in pediatric medicine.  Avoidant/restrictive intake disorder (ARFID) can contribute to impaired cognitive or emotional development, compromised immune functioning and may contribute to hospitalization.  Adequate nutrition and growth curve maintenance may also be impacted.(1)  Behavioral and sensory-based food avoidance can be a common issue in children with Autism Spectrum Disorder (ASD).  Expert consensus increasingly is recognizing intensive multidisciplinary intervention at a day hospital program as the standard of care for children with complex feeding disorders. (2,3)

Additionally, the patient has already been medically affected by her ARFID by obesity, constipation and anemia as a result of extremely limited food acceptance (initially cookies and PediaSure).  Her body mass index (BMI) has come down modestly (27 vs 29) while participating in the program 2x per week. The intensive feeding program is warranted and medically necessary for this child.  She does have neurologic disease (autism) which has demonstrated an impact on swallow function.  Pharyngeal phase dysphagia and xerostomia are certainly not the only types of dysphagia with significant health sequelae.  The patient has started to make good progress, and a more intensive feeding program has been demonstrated to be very effective in individuals such as this patient for autism spectrum/sensory-based feeding disorder.

The carrier's denial of coverage for Feeding Therapy Service (92526) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a  patient iagnosed with major depressive disorder (MDD), recurrent, moderate, generalized anxiety disorder (GAD) , Cannabis use disorder, severe and Alcohol use disorder, mild. The patient was admitted on 3/29/19 due to depression anxiety, school attendance issues, and substance use. The health plan's determination of medical necessity is upheld.

The patient was working on coping skills and relapse prevention skills for cannabis. The patient's family was supportive. The patient was noted to be medically stable. Going forward, the patient was generally cooperative. There were no safety concerns and no acute medical concerns. The patient was actively participating in treatment. The patient was in the pre-contemplative stage of change in terms of substance use. The patient had adequate sleep, appetite and ADLs. There was no indication for 24 hour a day support.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Allergy
Treatment: Inpatient admission
The inpatient admission was medically necessary. 
The management is according to clinical standards of care.  This patient is older and has a history of hypertension (HTN) in addition to other cardiac risk factors.  She came in with facial swelling and complaints of swelling in her throat.  The patient was noted to not respond to treatment with had continued sensation of irritation at the back of the throat.  Biphasic reactions can occur and should be monitored for and the patient required a second dose of epinephrine which is a worrisome sign.
This patient has a history of asthma, previous allergic reactions and CVA.  The patient complained of hives and swelling of the throat which required two rounds of epinephrine to resolve.  The patient then complained of chest pain - requiring cardiac workup.  The patient should have been admitted - this patient was at risk of rebound anaphylaxis.
The patient did have an indication for admission- the patient did not respond to therapy and should have been admitted for continued monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain, acute coronary syndrome
 
Treatment:  Inpatient admission, diagnostic testing, monitoring

The insurer denied the inpatient admission. The denial was upheld.

This patient had no prior medical history.  She presented to the Emergency Room (ER) with complaints of chest pain for the prior two days, but had become constant by the time of her presentation to the ER.  It seemed to worsen with movement and was worse with lying supine.  She was given aspirin, nitroglycerin, and a gastrointestinal (GI) cocktail.  Her troponins were borderline at 0.04 and 0.05, with an electrocardiogram EKG showing non-diagnostic ST-T segment abnormalities.  Chest radiography noted pulmonary venous congestion.  She was admitted for acute coronary syndrome.  CT angiogram of the heart showed no aortic dissection. The patient signed out against medical advice. 

The patient presented with chest pain. The initial evaluation in the ER was unremarkable, including borderline but not positive cardiac troponin and a non-diagnostic EKG.  Inpatient admission was not medically necessary for this patient.  In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing prior to discharge.  Further evaluation was warranted, however inpatient admission criteria was not met.  Although the patient had new onset symptoms, medical criteria was not met for any other additional extenuating circumstances.  There were no other high-risk co-morbidities.   

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

Diagnosis: Three-day history of passing black stools and one episode of vomiting blood

Treatment: Inpatient Hospital Admission

Summary:
Given this clinical scenario, the acute level of care for the management of this patient's condition was not medically necessary.  Since his EGD did not show any evidence of active bleeding from the ulcer (high risk endoscopic features such as arterial bleeding, adherent blood clot, nonbleeding visible vessel, or evidence of variceal bleeding, and subsequently over the next 24-48 hrs), he had no clinical evidence of ongoing, active, GI bleeding (hematemesis), or drop in his Hb/HCT requiring additional blood transfusion, and hemodynamic instability, he could have been safely managed at the lower level of care after his EGD and then safely discharged home with outpatient evaluation of the his gastric malignancy with endoscopic ultrasound.  The hospital stay was not warranted in the acute inpatient level of care for the management of his condition.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with concerns for a learning disability. A hearing test was normal. An ear exam was normal. There was concern for a central auditory processing disorder. Evaluation for a central auditory processing disorder was carried out and an auditory processing disorder was ruled out. The issue under review is the medical necessity of the requested hearing test.

The health plan's determination of medical necessity is overturned. Although this child had normal hearing there were documented concerns for learning and attention issues. Evaluation of a central auditory processing disorder (CAPD) was needed to determine if the child had a diagnosis of CAPD and if certain treatment regimens could be implemented in order to help the child progress in school.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the emergency department with seizures. The patient was well until the day of admission when his mother noticed that he was 'zoning out' and turning his head to the right with his mouth open. He was admitted for continuous electroencephalogram (EEG) monitoring for probable partial complex seizures.

The health plan's determination is overturned. The inpatient stay was medically necessary. The decision making at the time of admission for this patient was consistent with his young age, the presence of new onset afebrile seizures and a prolonged postictal phase, and the need for prompt evaluation and initiation of treatment with further intervention as needed for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ruptured anterior cruciate ligament
Treatment: Physical therapy (PT) (97140)
The proposed treatment, PT, was medically necessary.
A review of the physical therapy notes shows that the manual therapy (CPT code 97140) was documented on each date of service for fifteen-minute intervals.  The documentation indicates that the manual therapy was focused on mobilization of the patella tendon and quadriceps tendon and for retrograde massage of the quadriceps muscles.  The patient was documented as presenting with both injuries to the anterior cruciate ligament (ACL) and lateral meniscus with post-operative right knee edema.  The medical literature (see references below) recommend the use of manual therapy to prevent patella contracture (i.e. infrapatella contracture syndrome) and restrictions in the mobility of the quadriceps tendon following knee surgery that would limit knee range of motion and quadriceps muscle activation.  This treatment requires the skill and one-to-one treatment of a licensed physical therapist who is familiar with the necessary techniques.  The recovery of range of motion, strength, and control of joint swelling can take longer with both ACL and meniscal injuries compared to just ACL injuries alone.  Any loss of knee mobility following ACL surgery can result in long-term loss of function for the patient.  
This treatment was:
- clinically appropriate in terms of type, frequency, extent, site, and duration and considered effective for this particular injury;
- required for the direct care and treatment or management of this patient's condition;
- provided in accordance with generally-accepted standards of medical practice;
- not primarily for the convenience of the patient, his family or the Provider;
The patient's condition could have been adversely affected without this treatment.
The manual therapy (97140) billed for the dates of service under review was medically necessary based on the available documentation.
Appeal type: Medical necessity
Decision: Overturned

The patient has a previous history of depression, chronic pain (face and neck), alcohol use disorder in remission, and possible cannabis use disorder who was voluntarily admitted to the hospital. The patient drove to the emergency room complaining of suicidal ideation, depression, and "I am hearing voices." The patient was prescribed escitalopram and trazodone from a psychiatrist but was not taking them for 2 or 3 weeks. The patient reported recent deaths in the family. 

The patient has chronic pain in the neck and face from a past car accident. The patient reported using medical marijuana for pain. Other substance use was denied, including alcohol, from which the patient reported seven years sober. On the initial psychiatric evaluation, the patient reported command auditory hallucinations to commit suicide. The patient also reported a plan and intent but further details such as means, availability or means, etc. were not recorded. The patient was admitted with diagnoses of major depressive disorder (MDD) with psychosis and cannabis dependence. 

The health plan's determination is overturned.

The inpatient stay is medically necessary. This patient has a history of previous suicide attempt, previous admission, was psychotic at the time of admission, was homeless at the time of admission and was admitted for suicidal ideations with reported plan and intent. The patient's age, homeless status, previous admissions and current diagnoses are all pre-admission variables that place the patient at increased risk of readmission. Numerous articles looking at predictors of readmission have found that shorter lengths of stay are also associated with increased risk of readmission. The submitted records included daily notes from an attending psychiatrist which demonstrated a clear treatment arc of the patient's depressive symptoms and signs improving over admission. The patient reported a reemergence of hallucinations during the admission which was addressed with a change in medications. The notes indicate the start of small but significant improvements. However, each note indicates the ongoing symptoms that are still the focus of treatment. In other words, the notes indicate that the patient is better, but not well, and each note indicates a rationale for continued hospitalization. Even on discharge the patient is noted to have ongoing deficits in interpersonal interactions, but that improvement was made, and the patient demonstrated appropriate interaction with select staff. The notes document that the team kept the patient until treatment goals were reached but understood that the patient still will have challenges to work on in the outpatient arena. The care provide was active and evidence-based. If discharged prior to the date of discharge there would have been an unnecessary, significant risk of rapid decompensation and readmission.
Appeal type: Medical necessity
Decision: Overturned

This is a male patient with a chief complaint of overjet and discomfort. He is treatment planned for orthodontics to correct his malocclusion.

The health plan's determination is overturned. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma.3 Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the morbidity of repairing these teeth. Therefore, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This patient was diagnosed with recurrent glioblastoma multiforme. The patient had a magnetic resonance imaging scan of the brain in 2018 which revealed a mass in the left frontal region of the brain. The tumor was resected and pathology confirmed glioblastoma. The patient began chemoradiation and finished treatments in 2018. Temozolomide had to be stopped early on due to thrombocytopenia. Follow-up magnetic resonance imaging scan demonstrated that the patient was without recurrence and in stable condition. Therefore, Optune was recommended. Magnetic resonance imaging scan of the brain in 2019 demonstrated improvement of the edema and mass in the left hemisphere and intervertebral prominence of the ventricular system and sulci which could be attributed to steroid administration. The enhancement around the surgical cavity medial aspect of the left frontal operculum had decreased, although there was interval nodular increased enhancement seen anterior and inferior to the surgical site. 
The insurer has denied coverage for Electric Stim Cancer Treatment (Tumor Treatment Field Therapy). The decision was reversed.
Per the National Comprehensive Cancer Network guidelines, preferred adjuvant treatment regimens for glioblastoma include a standard brain radiation therapy and concurrent temozolomide and adjuvant temozolomide with or without alternating electric field therapy. According to current peer-reviewed medical literature, a portable medical device applied to the scalp that generates Tumor Treatment Fields first became available in 2011 for treatment of recurrent glioblastoma, and results of a subsequent open-label randomized trial suggest that the device improves both progression-free and overall survival when used along with monthly temozolomide in patients with newly diagnosed glioblastoma in the post-radiation setting. Use of the device is encouraged in interested patients. The patient is being treated for glioblastoma and she is status post-surgical resection and radiation therapy. Therefore, the requested electric Stim Cancer Treatment (Tumor Treatment Field Therapy) used in combination with temozolomide is consistent with standard of care and is considered medically necessary for the patient's clinical condition.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was prescribed Suboxone (brand) 8MG-2MG Film for the diagnosis of opioid dependence. According to the appeal, the provider stated that the generic product affects his ADLs (activities of daily living) and makes him want to use more medication. 

The Suboxone (brand) 8MG-2MG Film is not medically necessary for this patient. Although it was reported that the patient notices a significant difference on generic formulation and feels the need to use more of the films, the active and inactive ingredient in the generic is identical to the active and inactive ingredient in the branded medication. The health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient  presented with a cough and fever. The cough began 2 months ago but had worsened over the past 5 days.  The patient was seen by the primary medical doctor (PMD) and was referred to the emergency room for increased work of breathing. The health plan's determination of medical necessity is upheld in whole.  The admission exam did not document hypoxia or respiratory distress. Although she had mild tachypnea with a respiratory rate (RR) in the 30s recorded at times; there was no mention of respiratory distress after admission. She responded well to treatments and progressed as expected. She did not require any supplemental oxygen or increased intensity of services while admitted.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: bile leak
Treatment: inpatient admission
The proposed treatment as inpatient was not medically necessary.
ERCP is usually performed on an outpatient basis, especially for diagnostic purposes. In this particular case, the patient had a contained leak (fistula) with a drain, and was in stable condition preoperatively. The procedure was uneventful and the patient remained stable both intraoperatively and in the postoperative state. This patient could have been monitored at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fevers, Chest Pain
Issue under review: Inpatient admission

Determination:
The inpatient admission was medically necessary.

This little boy could not have been safely managed at a lower level of care and required acute inpatient admission.

Sickle cell anemia is a common genetic disease in which hemoglobin in red blood cells is replaced by an abnormal form, hemoglobin S. This causes red blood cells to form sickling shapes that block small blood vessels. In addition, these red blood cells do not survive as long, causing anemia. As a result, multiple complications can occur, including chronic anemia, acute chest syndrome, vaso-occlusive crisis, splenic sequestration, dactylitis, stroke, altered immune function with increased risk of bacterial sepsis, pulmonary hypertension, and renal disease. 

Fever in patients with sickle cell disease must be taken seriously. These patients are immunocompromised due to abnormal immune function and functional asplenia. Infection with encapsulated bacteria (e.g., S. pneumoniae, S. aureus, E. coli, Salmonella) can be particularly dangerous. In fact, infection is the leading cause of death in children with sickle cell disease. While pneumococcal vaccination and penicillin prophylaxis have reduced the risk of mortality, they have not eliminated it, and any history of fever must be taken very seriously. If no obvious source of fever is present, minimum evaluation should include laboratory studies and cultures, with chest x-ray for younger patients. Broad-spectrum parenteral antibiotics should be given pending culture results. Some consideration should also be given to other potential causes of fever in this population, including acute splenic sequestration, aplastic crisis, and early acute chest syndrome in young children.

This little boy with sickle cell anemia status post splenectomy and history of multiple admissions for fevers, acute chest syndrome, and vaso-occlusive crisis presented with fevers and chest pain suggestive of acute infection complicated by vaso-occlusive crisis. His examination was unrevealing and his chest x-ray was negative, making acute chest syndrome less likely. He had failed outpatient management with anti-pyretics and could not have been safely managed at a lower level of care. Given his age, clinical history, symptoms, and need for close monitoring with multiple interventions per the standard of care, acute inpatient admission was medically necessary and appropriate.