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

Diagnosis: Chronic Obstructive Pulmonary Disease Exacerbation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

The patient has a history of sickle cell trait and chronic obstructive pulmonary disease (COPD) and presented to the emergency department (ED) with complaints of a productive cough with white sputum for about a week.  The patient also had some upper respiratory tract infection symptoms with sore throat and chills.

The patient's vital signs at presentation were: temperature 97.2 Fahrenheit, blood pressure (BP) 118/79, heart rate 110, respiratory rate (RR) 17, and oxygen saturations 95% on room air (RA).  The patient was noted to have bilateral wheezing.  The patient was treated with bronchodilators via nebulizer, magnesium, and intravenous (IV) steroids.  The patient was also started on oral Azithromycin.  The patient was admitted for a COPD exacerbation.

As per the history and physical, the patient was afebrile and hemodynamically stable.  Oxygen saturations were 98% on room air, the patient was in no acute distress, and there was scant bilateral rhonchi noted.  The patient was alert and oriented x 3.  The patient's white blood cell count (WBC) was 7.9 and hemoglobin was 12.3.  The patient had a chest x-ray (CXR) that revealed no acute pathology.  There was no pneumonia (PNA) or congestive heart failure (CHF).  The patient's electrocardiogram (EKG) showed sinus tachycardia with no acute ST or T wave changes.  The patient was continued on bronchodilators via nebs, Singulair, oral Azithromycin, and a steroid taper.  The patient remained stable after admission and was discharged after a few days.  

The patient did not need acute inpatient hospitalization.  The patient was afebrile and hemodynamically stable.  The patient was not hypoxic, WBC was normal, and there was no evidence of PNA, CHF, or myocardial infarction (MI).  The patient was tolerating oral intake and described to be in no acute distress.  The patient could have been placed in observation status while diagnostic testing and treatment were initiated.  The observation period could be for up to 48 hours.  The patient could have been discharged home on an oral steroid taper, oral antibiotics, bronchodilators, and Singulair after a period in observation with close follow-up in the outpatient setting.  Acute inpatient hospitalization was not necessary.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal cord injury. 
Treatment: Physical therapy. 
The insurer denied physical therapy. 
The health plan's determination is overturned. 

The patient is a female with a cervical spinal cord injury due to a gunshot wound. She has quadriplegia as well as a neurogenic bladder. She has bowel and neurogenic pain. At issue is whether 30 additional physical therapy visits are appropriate and medically necessary. 
The requested health service/treatment of 30 additional physical therapy visits is medically necessary for the patient. 
The health plan did not act reasonably or with sound judgment in their determination to deny further physical therapy visits for this patient. The patient has a complete cervical spinal cord injury (SCI) and has noted improvements in the Segmental Assessment of Trunk Control (SATCo) with previous treatments. While these do not translate to large improvements in function, they do show improvements in trunk stability and the ability to perform some independent trunk movements. Current literature notes that physical therapy (PT) and specifically locomotor programs in complete spinal cord injuries can help with benefits in core strength and function but also help greatly in overall health, cardiac functioning, respiratory functioning, and bone strength and health. "Increasing the level of physical activity is crucial for individuals with SCI, whose physical activity has been significantly reduced."(Lee 2023). "In humans with SCI, locomotor training improves limb coordination, limb kinematics, step symmetry, walking speed, endurance, and balance, reduces systolic blood pressure and heart rate, improves respiratory function, and reduces inflammatory status." (Smith 2016)
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Acute Renal Failure.

Treatment: Continued stay at a skilled nursing facility (SNF).

The insurer denied coverage for a continued stay at a skilled nursing facility (SNF).

The denial is modified.

The patient is an adult with the following diagnoses: hypertension, schizoaffective disorder, gastroesophageal reflux disease (GERD) with a hiatal hernia, bipolar disorder, obesity, and paranoid schizophrenia. The patient also has a history of falls.  The patient was living in supervised housing before admission to an acute care setting due to acute renal failure.  Following discharge from the hospital, the patient was admitted to a post-acute skilled care setting.  The patient required maximal assistance and training to return the patient to the independence they had before their hospitalization. The medical record indicates that the patient made remarkable progress with skilled interventions. Within several weeks, the patient was managing with a rolling walker with limited assistance and required minimal assistance for dressing and personal hygiene. The patient still required partial assistance for standing.  The record states the patient also needed skilled training for negotiating stairs, as their apartment required managing six steps.  The patient was more independent in activities of daily living (ADLs) but the notes reflect that a barrier to discharge existed.  These are related primarily to finding a home health agency for home health aides to prevent deterioration of the gains made and falls. It appears that discharge was delayed for these reasons and for securing an outpatient mental health provider. The patient could have been discharged and received non-skilled care in a less intense setting.  Although there were barriers to discharge, skilled care in a skilled nursing facility did not appear to be needed.

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 the continued stay at a skilled nursing facility (SNF) is partially substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Sotyktu
The insurer denied Sotyktu.
The determination is upheld.

The patient is a female with psoriasis. The trunk and extremities are affected. She has tried and failed triamcinolone, mometasone, and calcipotriene. She has also tried Vtama and Zoryve. The medication under review for medical necessity is Sotyktu.

The requested health treatment of Sotyktu is not medically necessary for this patient. According to the "national physician specialty society recommendations" for psoriasis- the American Academy of Dermatology Psoriasis Guidelines- and dermatology literature, phototherapy and methotrexate are effective treatments for the management of psoriasis (1, 2).
Within the peer-reviewed literature, Racz et al writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks" (3). Mehta et al writes "Ultraviolet (UV) B phototherapy is most appropriate for patients with greater than (>) 10 percent (%) affected body surface area who have not responded to topical treatments... narrow band ultraviolet B (NB - UVB) ..effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile" (4).
Additionally, West et al 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve psoriasis area and severity index (PASI) 75 at primary endpoint, Thus, methotrexate is an effective first-line treatment for the management of psoriasis (5).
Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Sotyktu is not medically necessary. It is noted that the patient has failed topical steroids. However, there is no documentation provided that the patient has failed the standard of care treatments phototherapy or methotrexate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute on Chronic Pancreatitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient has a history of alcoholic pancreatitis and presented with upper abdominal pain. The patient was afebrile but had hypertension. There was no abdominal rebound or guarding. The initial lipase was 421 (normal to 83). A previous computed tomography (CT) scan was equivocal for acute pancreatitis. The CT scan was not repeated on this admission, but an ultrasound was negative except for hepatomegaly. Intravenous (IV) hydration and pain medications were given. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score was 0. The patient's blood pressure was treated. The patient was diagnosed with acute on chronic pancreatitis. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-250 for Pancreatitis. Clinical indications for admission for acute pancreatitis include having 2 or more of the following: abdominal pain, serum lipase greater than 3 times the upper limit of normal, and CT scan findings of acute pancreatitis. In this case, the patient had upper abdominal pain and a serum lipase greater than 3 times the upper limits of normal. This met MCG criteria for admission. 

This patient was diagnosed with acute pancreatitis on top of the chronic pancreatitis. The patient had upper abdominal pain for several days and a lipase greater than 3 times the upper limit of normal. This met the MCG guideline for an inpatient admission. The health care plan did not act with sound medical judgment. An inpatient stay was medically necessary. The denial is reversed.

Based on the above, the insurer's denial must be reversed. 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 an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease

Treatment: Personal care aide (PCA) services, 47 hours per week

The insurer denied coverage for personal care aide (PCA) services, 47 hours per week

The denial is overturned

 
This is an elderly male with chronic medical problems including Parkinson's disease. He lives with his spouse in a 1 bedroom apartment in his daughter's home. His daughter visits daily and he is never left alone. The daughter is going back to work. The plan approved personal care aide (PCA), 27 hours per week in conjunction with consumer directed personal assistance (CDPA) Basic: 15.5 hours per week with CDPA shared hours: 11.5 hours per week; the patient's combined home care hours are 54 hours. The patient is requesting additional PCA of 47 hours/week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as minimally impaired. He is reportedly total dependent to maximal assistance for completing much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is reportedly total dependent for bathing and toilet use. Maximal assistance is reportedly needed for personal hygiene, dressing and bed mobility. Extensive assistance is reportedly needed for locomotion, toilet transfer and ambulation. He reportedly requires supervision with eating. The patient is reportedly frequently incontinent of bladder and continent of bowel. There has been no change in his functional ability or reported falls over the prior 90 days. The patient's cognitive status has modestly declined when compared to the prior UAS report. His ability to perform activities of daily living (ADL) tasks has remained much the same. 

A physician note indicates a need for full daytime and nighttime help. Patient needs assistance getting in/out of bed, "unable to toilet himself, shower himself, dress himself and cannot get up and down from a sitting position without assistance."  Also notes early dementia, Parkinson's limiting his ability to communicate. It is also noted that the recent UAS refers to a healed pressure ulcer on the coccyx along with bruising on the extremities consistent with limited bed mobility and need for assistance to change position during day.  Patient is frequently incontinent of urine in part due to inability to get to the bathroom. 

The patient's condition and functional deficits are at a level or unpredictable as to require the additional PCA 47 hours/week. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained with the addition of the requested 47hrs (hours) / week. 

Based on the above, the insurer's denial must be overturned. 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 aide (PCA), 47 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II occlusion.
Treatment: Braces and monthly visits.
The insurer denied braces and monthly visits.
The determination is overturned.

The patient in question is a male with a Class II (two) occlusion. He has minor spacing in the maxilla and minor crowding in the mandible. Teeth 7 and 10 are missing. Tooth D is retained and tooth 11 is erupting in the position of tooth 10. He has had a medical sleep study performed and has been diagnosed with Pediatric Obstructive Sleep Apnea (OSA). He has treatment planned for orthodontics. 
At issue is the medical necessity of braces and monthly visits. 

The requested health service/treatment of Braces and monthly visits is medically necessary for this patient. 
The health plan has not acted with sound medical judgement or in the best interest of the patient. It has been shown that Orthodontic Rapid Maxillary Expansion (RME) can increase the airway volume up to 41% (percent). (1) Meta-analyses on this topic have shown that RME is an effective treatment strategy for children with OSA. (2) Multiple well-controlled studies have shown that not only does RME resolve sleep apnea in children, but that the effects persist for years after treatment. (3,4) 
Therefore, the requested health service/treatment of Braces and monthly visits is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Juvenile idiopathic arthritis (JIA).
Treatment:  Humira (CF) 40 mg/0.4 mL (Milligram per Milliliter) Weekly Pen Injection Kit.

The insurer denied Humira (CF) 40 mg/0.4 mL (Milligram per Milliliter) Weekly Pen Injection Kit.  The health plan's determination is overturned. 

The patient is a female with a history of rheumatoid factor (RF) -negative polyarticular juvenile idiopathic arthritis (JIA) with insufficient response to Humira 40 milligrams (mg) every 2 weeks for whom weekly Humira is being requested.

Humira (CF) 40 mg/0.4 mL (Milligram per Milliliter) Weekly Pen Injection Kit is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Weekly Humira is frequently prescribed by pediatric rheumatologists for patients with polyarticular juvenile idiopathic arthritis (JIA) who have partial/insufficient response to every 2-week dosing.
Weekly Humira has been studied (and is FDA approved) in pediatric patients with other immune-mediated diseases, specifically pediatric ulcerative colitis and pediatric hidradenitis suppurative.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Juvenile idiopathic arthritis (JIA).
Treatment:  Humira (CF) 40 mg/0.4 mL (Milligram per Milliliter) Weekly Pen Injection Kit.

The insurer denied Humira (CF) 40 mg/0.4 mL (Milligram per Milliliter) Weekly Pen Injection Kit.  The health plan's determination is upheld. 

The patient is a girl with rheumatoid factor (RF) negative juvenile idiopathic arthritis (JIA). She was dx (diagnosed) and started on methotrexate (MTX) immediately. Humira every 2 weeks was added. However, the patient continues to have active disease. 

Humira weekly injections are not likely to be more beneficial than any standard treatment for this patient. There is no reason the patient cannot try another FDA approved medication for JIA such as Enbrel, Simponi, Actemra.
As per UpToDate, 'the most common biologic agents used to treat polyarticular JIA are the tumor necrosis factor (TNF) inhibitors (eg, etanercept, adalimumab, infliximab, golimumab). Other biologic agents act by blocking the interleukin (IL) 6 receptor, T cell costimulation, or CD20'. For example, as published in Ann Rheum Dis in 2009 in a study looking at the safety and efficacy of combination of etanercept and methotrexate compared to treatment with etanercept only in patients with juvenile idiopathic arthritis, 'the patients' disease activity improved during etanercept monotherapy and etanercept and methotrexate combination therapy. Tolerability in both treatment groups was comparable'.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Juvenile idiopathic arthritis (JIA).
Treatment:  Humira (CF) 40 mg/0.4 mL (Milligram per Milliliter) Weekly Pen Injection Kit.

The insurer denied Humira (CF) 40 mg/0.4 mL (Milligram per Milliliter) Weekly Pen Injection Kit.  The health plan's determination is overturned. 

The patient is a young female who presents for a follow-up of seronegative polyarticular juvenile idiopathic arthritis (JIA) with temporomandibular joint (TMJ) involvement. She is currently on methotrexate 20 milligrams (mg) by mouth (PO) weekly and naproxen 500 mg twice daily (BID), but despite treatment, she has active arthritis in multiple joints, wrists, elbows, ankles, and left knee. 

Humira (CF) 40 mg/0.4 mL (Milligram per Milliliter) Weekly Pen Injection Kit is likely to be more beneficial than standard treatment for this patient. 
Weekly adalimumab dosing is used to treat juvenile idiopathic arthritis (JIA), uveitis, and other pediatric rheumatic diseases. A retrospective chart review was conducted to assess the safety of weekly adalimumab as per study. Sixty-nine patients at the University of Minnesota or Gillette Children's Hospital were identified as treated with weekly adalimumab. Sixty (87% [percent]) were eligible for the chart review. Weekly adalimumab was used most commonly to treat uveitis (28%, 17/60) and rheumatoid factor-negative polyarticular JIA (25%, 15/60). Mean age at the start of weekly dosing was 13.9 years. The majority of patients were concurrently treated with a non-steroidal anti-inflammatory drug and methotrexate. Fifty-three (90%) patients continued weekly dosing for greater than 3 months. The mean duration of weekly adalimumab was 2 years. Throughout the duration of weekly dosing, 24/60 (40%) patients had documented minor infections not requiring antimicrobials and 24/60 (40%) had documented infections requiring antimicrobial treatment. Only three patients (5%) had an infection requiring hospitalization. Two patients (3%) developed autoimmune disease. Laboratory abnormalities and injection site reactions were rare. Weekly adalimumab was used most commonly to treat uveitis and rheumatoid factor-negative polyarticular JIA, and mean duration of weekly dosing was 2 years. Serious adverse events were rare.
Therefore, in this patient who has responded partially to Humira, the weekly dosing is likely to be more beneficial than standard treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: palpitations and chest pain

Treatment: Inpatient hospital

The insurer denied coverage for Inpatient hospital

The denial is overturned

 
Asked to review the case of an adult male that presented to the hospital complaining of palpitations and chest pain.  On arrival to the hospital pulse was noted to be 217 and he was treated with adenosine. Following termination of tachycardia vital signs remained stable: Blood Pressure (BP) 117/76, Pulse 100. Physical examination revealed no abnormality.  Electrocardiogram (ECG) post adenosine revealed sinus rhythm without ischemic changes. Serum blood testing revealed an elevated troponin level (89). The patient was admitted for observation and treatment. Echocardiogram revealed a left ventricular ejection fraction (LVEF) of 60% without significant valvular abnormalities.  The patient was diagnosed with demand ischemia and discharged home on medical therapy.

This patient presented with narrow complex tachycardia at a rate of 217.  Tachycardia terminated following treatment with adenosine. ECG while in normal sinus rhythm revealed  no significant abnormality. Patients with narrow complex tachycardia with rapid ventricular rates require evaluation and treatment and should be risk stratified for high-risk features such as pre-excitation. (Reference 1) This patient also had an elevated troponin level, a known predictor for hospital admission ( Reference 2, 3). Given symptomatic tachyarrhythmia and super ventricular tachycardia (SVT) on ECG along with elevated serum troponin, inpatient hospital admission was medically necessary. This patient could not have been managed at a lower level of care.

Based on the above, the insurer's denial must be overturned. 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 the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Facial swelling and pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is a preschool male who was initially seen at an emergency department for facial swelling and pain. He was subsequently transferred to the hospital for definitive care and admitted to their emergency department. The decision was made to start the patient on intravenous antibiotics and obtain a pediatric dental consult. The patient remained admitted as an inpatient, intravenous antibiotics continued, and consults were obtained. The child was taken to the operating room (OR) on the morning of the next day and the offending tooth was removed and the area drained. Intravenous antibiotics were continued, and the patient discharged on the same day. The health plan denied coverage of the inpatient admission as not medically necessary. The denial is being appealed.

The inpatient admission was medically necessary.

This is a pediatric patient who had been to another emergency department prior to coming to this hospital's emergency department. He had not been responsive to oral antibiotics and was placed on intravenous antibiotics as the first round of treatment. Once the consults were done and it was determined that the next step was draining the area and removing the offending tooth, the patient still needed intravenous antibiotics. The child was febrile with an ongoing infection unresponsive 
to oral antibiotics and could not receive the necessary intravenous antibiotics without being in the hospital as an inpatient. Therefore, the inpatient admission was medically necessary.