Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara 90mg every six weeks
The insurer denied: Stelara 90mg every six weeks
The denial is Overturned.

The patient is a male with a diagnosis of Crohn's disease (CD). The patient has ileocolonic disease diagnosed four years ago. The patient was initially treated with infliximab but eventually developed breakthrough symptoms and the patient was placed on Stelara 90 milligrams (mg) every (Q) 8 weeks. A colonoscopy 6 months after this demonstrated active right sided colitis with a cecal stricture. The patient had a magnetic resonance enterography (MRE) which demonstrated active ileocolitis and the C-reactive protein (CRP) rose. The patient also began to notice that the Stelara benefit was not lasting a full 8 weeks, perhaps only 7 weeks. He has required steroids intermittently to control disease activity.
The patient's provider has now recommended Stelara 90 mg Q 6 weeks due to active disease on Q 8 week dosing. This was denied by the plan as it is not the standard of care.

Stelara 90 mg (milligrams)/ml (milliliter) every six weeks is likely to be more beneficial than any standard treatment for the patient's condition. There are several lines of evidence which support dose intensification of Stelara for Crohn's. Inadequate drug levels are associated with active disease. The best data for the relationship between Stelara drug levels comes from Adedokun, et al. In their analysis of data from Phase 3 studies of patients with moderate to severe CD, they found serum concentrations of ustekinumab to be proportional to dose and associate with treatment efficacy. Trough concentrations of ustekinumab up to 1.4 microgram per milliliter (ug/mL) or greater were associated with maintenance of clinical remission in a higher proportion of patients than patients with lower trough concentrations. The study by Battat et al. found that a higher level of Stelara was associated with efficacy. Patients received 90 mg of ustekinumab subcutaneously at weeks 0, 1, and 2 during induction and 90 mg every 4 or 8 weeks during maintenance. The authors found that the mean trough concentration of ustekinumab at week 26 was higher in patients with an endoscopic response (4.7 ug/mL) than without (3.8 ug/mL; probability [P] = .03). An optimal ustekinumab threshold trough concentration at week 26 or later was found to be 4.5 ug/mL (area under the curve, 0.67). A greater proportion of patients with trough concentrations of ustekinumab above 4.5 ug/mL at week 26 or later had an endoscopic response (75.9%) than did patients with trough concentrations below this level (40.7%; P = .008). Patients with trough concentrations of ustekinumab above 4.5 ug/mL at week 26 or later also had a lower mean level of CRP (12.6 mg/L) than did patients with trough concentrations below this level (mean level of CRP, 23.9 mg/L; P = .04).
Based on the above data Stelara at Q 6 week dosing is likely to be more beneficial for this patient's condition due to ongoing active disease.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Osteoarthritis, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and dementia.
Treatment is an increase PCW 24 hours a day live-in, 7 days per week.
The insurer denied coverage for an increase PCW 24 hours a day live-in, 7 days per week.
The denial is modified.

This is a patient with chronic medical problems including osteoarthritis, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and dementia. She lives alone in a 1-bedroom apartment. The insurer approved PCW (personal care worker) for 8 hours/day, 7 days/weeks totaling 56 hours/week and she is requesting an increase in PCW 24 hours a day live-in, 7 days per week.

According to the Uniform Assessment System (UAS) report the patient's cognition is described as "moderately impaired;" which has declined over the prior 90 days. She requires extensive assistance for bathing, upper body dressing and toilet use. Limited assistance is required for personal hygiene, upper body dressing, ambulation (with a cane) and toilet transfers. The patient is frequently incontinent of bladder and continent of bowel. She is independent for bed mobility and eating. The combination of the patient's cognitive deficits and functional impairments support the medical necessity of increasing PCW to 12 hours/day, 7 days/week for a total of 84 hours/week. Her condition and functional needs are not at a level or unpredictable as to require the requested PCW 24 hours a day live-in, 7 days per week. This physician would agree the patient may require additional monitoring. However, safety monitoring (e.g., dementia) under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the increasing PCW to 12 hours/day, 7 days/week for a total of 84 hours/week.

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

From a physical medicine and rehabilitation perspective, the requested PCW 24 hours a day live-in, 7 days per week is not medically necessary. However, increasing PCW 12 hours/day, 7 days/week totaling 84 hours is medically necessary.

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Personal Care Worker (PCW) 24 hours a day live-in, 7 days per week services is not substantiated. However, increasing PCW to 12 hours/day, 7 days/week for a total of 84 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, thyroid disease and dementia, and decubitus ulcers.
Treatment: Personal care aide (PCA) level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week.
The insurer denied coverage for personal care aide (PCA) level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week.
The denial is overturned.

This is an elderly female with chronic medical problems including hypertension, thyroid disease, and dementia, as well as decubitus ulcers. She lives with her son in a 4-bedroom house. The insurer approved personal care aide (PCA) Level 2: 24 hours per day - live in per diem - 7 days a week. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is "severely impaired" and has declined since the prior assessment. She is dependent on activities of daily living including personal hygiene, dressing, bathing, and toilet transfer/use. She is incontinent of bowel and bladder. She is fed puree food due to the inability to chew/swallow food of regular consistency. The patient is bedbound and dependent on bed mobility. She remains at high risk for additional pressure ulcers. The patient has severe cognitive deficits with functional impairments that render her totally dependent and supports the medical necessity of PCA level 2: 12 hours/day - 7 days/week; 12 hours/day - 7 days/week (split shift) - a total of 168 hours/week. Her condition and functional needs are at a level and/or unpredictable as to require the requested continuous care split shift; 24 hours, 7 days/week; particularly as it relates to skin pressure relief, skin checks, and frequent turning. The patient's health and safety can be appropriately provided and maintained by increasing to PCA 12-hour split shift; 24 hours, 7 days/week.

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

The insurer's denial of coverage for personal care aide (PCA) Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck Pain.
Treatment: Facet Neurotomy (64633, 64634).
The insurer denied the Facet Neurotomy (64633, 64634).
The denial is overturned.

The patient is a female with history of chronic neck pain, mostly right-sided. The pain is intractable and affects her functionality. The pain started many years ago.

The patient has tried and failed conservative measures that included supervised home exercise program for approximately over 6 months, Fentanyl patch, gabapentin, Tylenol, Topamax, Tizanidine and NSAIDs (nonsteroidal anti-inflammatory drugs) for approximately over 3 months.

The patient had Bilateral C3 (third cervical spine vertebra), C4 (fourth cervical spine vertebra) and C5 (fifth cervical spine vertebra) facet medial branch nerve blocks with adequate and positive improvement of her pain.

X-ray cervical spine showed degenerative spondylosis C4 (fourth cervical spine vertebra) through C7 (seventh cervical spine vertebra).

The request is for Right C3 (third cervical spine vertebra), C4 (fourth cervical spine vertebra) and C5 (fifth cervical spine vertebra) facet medial branch nerve Radiofrequency Ablation (RFA).

Yes, the requested Facet Neurotomy (64633, 64634) is medically necessary.
There is documented evidence of chronic cervical pain and failure of many conservative treatment options. The patient is document to have had diagnostic Bilateral C3 (third cervical spine vertebra), C4 (fourth cervical spine vertebra) and C5 (fifth cervical spine vertebra) facet medial branch nerve blocks with adequate positive relief of pain on two different occasions. She  tried and failed conservative measures that included supervised home exercise program for over 6 months, Fentanyl patch, gabapentin, Tylenol, Topamax, Tizanidine and NSAIDs (nonsteroidal anti-inflammatory drugs) over 3 months, etc. The recurrence of the pain led to a request for right C3 (third cervical spine vertebra), C4 (fourth cervical spine vertebra) and C5 (fifth cervical spine vertebra) facet medial branch nerve Radiofrequency ablation/neurotomy.

The procedure is being performed in accordance with nationally accepted standards of medical practice as stated above. It is clinically appropriate for cervical facet pain, not primarily for the personal comfort or benefit of the patient or provider, etc.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The health plan had noted that no specific percentage improvement was documented, but the treating physician stated that the patient had two positive cervical facet blocks.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer
Treatment: Outpatient iTind procedure
The insurer denied outpatient iTind procedure.
The determination is upheld.

The patient has a diagnosis of prostate cancer status post high-intensity focused ultrasound (HIFU), benign prostatic hyperplasia (BPH) refractory to tamsulosin. Magnetic resonance imaging (MRI) showed a 28 cubic centimeter (cc) prostate with a Prostate Imaging Reporting and Data System (PI-RADS) 4 lesion. At issue is the medical necessity of an outpatient iTind (Temporarily Implanted Nitinol Device) procedure.
The requested procedure is not medically necessary. iTind is a novel procedure for management of BPH. The procedure involves placement of a temporary prostatic stent. Current medical literature is limited to a few studies with limited long-term outcomes. As such, use of iTind is not considered a clinically appropriate and generally acceptable standard of care for managing patients with BPH. It would not be medically necessary. The American Urological Association (AUA) guidelines on BPH, 2019 and European Association of Urology (EAU) guidelines on management of nonneurogenic male urinary tract symptoms, 2019 do not recommend this procedure as an accepted treatment for management of BPH.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient admission

The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with prior episode of diverticulitis in March for which he was given oral antibiotics. The patient returned with worsening abdominal pain. The patient had persistent left lower quadrant (LLQ) pain. His initial white blood cell (WBC) count was 14. Computed tomography showed worsening diverticulitis with microperforation with free loci of air and possible unorganized fluid collection.

Yes, the proposed inpatient hospital admission was medically necessary.
Inpatient admission is indicated as the patient failed outpatient therapy, had evidence of possible evolving abscess / microperforation, and presented with persistent pain and leukocytosis. Given all the clinical data presented, the patient meets criteria as he has evidence of complicated diverticulitis. This could not have been managed at the observation level as these patient may develop worsening abscess, sepsis or perforation requiring emergency surgery. The patient did respond to intravenous antibiotics and bowel rest which is the treatment for complicated diverticulitis with microperforation.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
This patient had evidence of complicated diverticulitis with evolving phlegmon and evidence of extraluminal foci of air. This should be an inpatient admission for intravenous antibiotics and bowel rest. The patient improved greatly with antibiotics and liquid diet by hospital day #2. These patients should be watched for evidence of evolving abscess, sepsis or perforation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Growth Hormone Deficiency (GHD)
Treatment: Genotropin
The insurer denied coverage for Genotropin
The denial is overturned

This is a patient diagnosed with GHD. This request is for Genotropin. Her GH (growth hormone) stimulation test with arginine and clonidine peaked at 1.86. Her MRI (magnetic resonance image) was normal. Her height velocity is reported to be 4.34 cm/yr (centimeter per year). Her iGF1 (insulin-like growth factor 1) was 207. Her breasts were at tanner 3 but the description reports that puberty is progressing very slowly, and that breast development appears to be primarily fatty. 
Her weight was 43.9 kg kilogram. 

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2, 3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD (standard deviation) below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 year of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 year. The biochemical criteria include low IGF1 or IGFBP3 (insulin-like growth factor binding protein 3) or GH stimulation testing with a peak GH less than 10ng/ml (nanogram per milliliter).

This patient met biochemical criteria. GH stimulation testing peaked at less than 10ng/ml. the patient had a low IGF1. The patient met height criterion 3 as she had a decrease in height SD of more than 0.5 over 1 year. The patient used to be near the 50th percentile and is now the 10th percentile. The patient met both height and height velocity and biochemical criteria for the diagnosis of GH deficiency. GH in the treatment of GH deficiency is medically necessary.

The insurer's denial of coverage for Genotropin is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain (Nausea, Vomiting and Constipation)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female who was admitted to the hospital with abdominal and back pain. Approximately three days prior to admission the patient had back surgery. She said since that time she had increased back pain. She was having difficulty with bowel movements. She subsequently presented to the emergency department. She was kept in the hospital until the patient left against medical advice.

No, the proposed inpatient hospital admission was not medically necessary.
This is a female who was admitted to the hospital with abdominal and back pain. Approximately three days prior to admission the patient had back surgery. She said since that time she had increased back pain. She was having difficulty with bowel movements. She subsequently presented to the emergency department. The patient was kept in the hospital until she left against medical advice.

While admitted the patient did require intravenous medications. The patient was seen by infectious disease and incidentally was found to be COVID (coronavirus disease) positive. If there was concern about a neurological injury following surgery or infection, an magnetic resonance image (MRI) should be ordered immediately/stat. There was no white count, there was no signs of infection at the surgical site to indicate this, however the patient was complaining of increased pain and was having difficulty ambulating and was having issues with her bowels. Therefore immediate imaging with a magnetic resonance image (MRI) would be reasonable. However, a magnetic resonance image was not done immediately, and when completed revealed no acute/neurologic findings such as a hematoma or infection. Furthermore a concern of deep vein thrombosis (DVT) was raised which was addressed and was found to be negative in the emergency department. 

Therefore, inpatient admission was not medically necessary. There was a delay in obtaining a magnetic resonance image and a Doppler. Intravenous medications do not require inpatient level of care and patients the patient could have been discharged on a regimen of oral (PO) medications with a follow up with her surgeon. Given the above the requested inpatient stay was not medically necessary.

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

Diagnosis: Abdominal pain.
Treatment is an inpatient admission.
The insurer denied coverage for an inpatient admission. 
The denial is upheld.

The patient is a female with a past medical history significant for small bowel obstruction who presented to the emergency room with complaints of abdominal pain and constipation.   

Vitals on presentation included: Temperature 98.3 degrees F (Fahrenheit), Blood Pressure 119/74, Pulse 60, Respiratory Rate 16, oxygen saturation 100% on room air. Laboratory results included the following: White blood cells (WBC) 20.4, hemoglobin (HGB) 12.5, hematocrit (HCT) 38.7, creatinine 0.8, glucose 100, and lactic acid 0.8.

The patient was admitted for abdominal discomfort. She was empirically started on intravenous antibiotics (doxycycline, ceftriaxone, metronidazole). A computerized tomography (CT) scan of abdomen/pelvis showed 7.7 x 4.3 x 5.6 cm (centimeter) heterogeneous soft tissue mass in right adnexal region suspicious for ovarian torsion. An ultrasound was negative for torsion. Gynecology was consulted. Cultures remained negative. The patient remained afebrile and hemodynamically stable. She was discharged to continue outpatient management.

The patient was afebrile and hemodynamically stable. Laboratory values were normal except for an elevated WBC. While in the ED (emergency department), abdominal ultrasound was negative for ovarian torsion, and no surgical intervention was required. Based on above findings, the patient could have been managed at the observation level of care. 

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

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

Diagnosis: Skull fracture.
Treatment is an inpatient admission. 
The insurer denied coverage for an inpatient admission. 
The denial is upheld.

According to the clinical documentation provided for review, the patient is a female. The patient was being seen and treated for a skull fracture. The patient was transferred to the hospital and admitted with a skull fracture. The medical records do not support that the inpatient admission was medically necessary. InterQual criteria were not met for the acute inpatient level of care. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service (LOS). The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting, such as outpatient. 

"Head injury is a leading cause of morbidity and mortality in childhood. More than 1.5 million head injuries occur annually in the United States, resulting in approximately 300,000 pediatric hospitalizations, with males twice as likely as females to sustain a head injury. Overall, up to 90% of injury-related deaths among children are associated with head trauma. Motor vehicle collisions are the most common cause of pediatric head injury, followed by falls. Football is the most common cause of sports-related head injury, with 75% of fatal head injuries occurring in high school students and 74% of football-related head injury fatalities associated with subdural hematomas. Head trauma injuries include scalp hematoma and laceration, skull fracture, intracranial hemorrhage, cerebral contusion, and diffuse axonal injury (DAI). Most children sustaining blunt head trauma have minor traumatic brain injury." (Atabaki, 2007). 

"A child's skull is thinner and more pliable than an adult skull, thus providing less protection to the brain. Head trauma is a common cause of morbidity and mortality in children. It is a regular presentation in the Pediatric Emergency Department (PED) and primary care. Suspected pediatric skull fractures should be evaluated using a CT (computed tomography), plain radiograph, MRI (magnetic resonance imaging), and ultrasound to determine the extent of the injury." (McGrath, et al., 2022).       
                                         
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.