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

Diagnosis: Suicidal ideation and self-injurious behavior
Treatment: Residential Behavioral Health Admission 
The insurer denied Residential Behavioral Health Admission. 
The denial is upheld.

The patient is a teenage female who was admitted to a mental health residential treatment center for suicidal ideation and self-injurious behavior as a step-down from acute inpatient care. This is an appeal for those dates. The patient is diagnosed with major depressive disorder (MDD), recurrent, moderate. She was admitted to a residential treatment center. There is no history of suicide attempts. She had family conflict. The last self-injurious behavior was when she used a staple on the unit to self-harm superficially. She reported anxiety and depression.

The Residential Behavioral Health Admission is not medically necessary.

There is no medical or psychiatric instability warranting 24-hour monitoring. The patient was attending and participating in the groups. There was no homicidal ideation or auditory/visual hallucinations. She was reporting wanting to go home. She could have been managed in a less restrictive setting. She has ongoing passive suicidal ideation, but this is evidenced to be chronic. The goal for every patient is to be managed in the least restrictive setting, as it is in the best interest of the patient so as not to create dependency. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: dental issues.
Treatment: crowns for teeth #8, 9, 10, and 18.
The insurer denied crowns for teeth #8, 9, 10, and 18.
The health plan's determination is overturned. 

The patient is a male who presents for the treatment of teeth #8, 9, 10 and 8. Provided for review are letters of appeal and denial, clinical images, radiographic images,1 American Dental Association (ADA) claim forms, and health plan language. 

Crowns for Teeth: Numbers 8, 9, 10, and 18 are medically necessary for this patient.
The patient has decay, lost cusps, and fractures of the teeth requiring replacement of the lost tooth structure to have proper function and to prevent further loss of the tooth structure. With the periodontium being sound, the teeth can remain in function and provide posterior support and chewing function in the anterior preventing further breakdown if restored making the treatment medically necessary. Hence the crowns for teeth #8, 9, 10, and 18 are medically necessary for the patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: ADHD (attention deficit hyperactivity disorder)
Treatment: Concerta
The insurer denied Concerta.  The determination is overturned.

The patient is a male with a history of attention deficit hyperactivity disorder. The patient has been prescribed brand Concerta for many years. His provider has recommended continued use of brand Concerta given recent shortages of generic methylphenidate extended release (ER) as the patient has been stabilized on the brand. The patient has failed trials generic Concerta. He has also failed trials of dextroamphetamine mixed salts ER, dexmethylphenidate ER, and dextroamphetamine ER. At issue is the medical necessity of the use of brand Concerta.

The patient has failed multiple formulary drugs. Per the plan, formulary alternatives are methylphenidate extended release, dextroamphetamine extended release, dexmethylphenidate extended release, and dextroamphetamine mixed salts ER. The patient has documented failures of these medications in a letter provided by his physician. Clinical guidelines for the management of attention deficit hyperactivity disorder (ADHD) recommend the use of stimulant medications for the treatment of ADHD, and it is well accepted that children and adolescents have superior responses to methylphenidate-based compounds as compared to amphetamine based compounds (1,2, 3). In this case, the patient has failed trials of both methylphenidate ER and dexmethylphenidate ER. Per the guidelines, it appears that the patient has tried and failed the required 3 formulary alternatives as stipulated by the plan. In addition. he is currently stable on his medication and has shown stability on the current dosage. The only medication on formulary which has not been tried is brand Azstarys, which does not have the same osmotic release mechanisms as brand Concerta. The above formulary drugs that have been tried and failed would not be as effective as the non-formulary drug the patient is prescribed.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Gestational Diabetes
Treatment: Formulary exception for Contour Next Strip
The insurer denied: Formulary exception for Contour Next Strip
The denial is overturned.

The patient is an adult female with gestational diabetes. She needs to check her blood sugars four times per day. She has the Contour Next EZ Machine, and the request is for the Contour Next Strip test strips. The request has been denied coverage by the health plan as not meeting the formulary requirements. This denial is being appealed.

The health plan should cover the Formulary exception for Contour Next Strip.

The formulary options are ineffective. The non-formulary request is the only effective option. Without this, the patient is unable to check blood sugars, which can lead to poor sugar control and multiple adverse effects. In addition to routine pregnancy issues, the prenatal care of women with gestational diabetes mellitus (GDM) focuses upon identifying and managing conditions that are more common among women with glucose impairment. In contrast to women with pregestational diabetes, women with true GDM (gestational diabetes mellitus) typically do not have diabetes-related vasculopathy or an increased risk of infants with congenital malformations because of the short duration of the disorder and late pregnancy onset.  The management of gestational diabetes is important for both maternal and fetal outcomes. Without well-controlled sugars, the risk of maternal illness increases, i.e., risk of preeclampsia. The risk to the fetus is even greater, as uncontrolled diabetics have an increased risk of stillbirth. Although the Contour Next strips are not the formulary option, these are the only test strips that are compatible with the patient's glucometer. The formulary options (Acu-chek and OneTouch) are not compatible and would be ineffective. The only test strips that work and are effective for this patient are the Contour Next Strips. Without these strips, the patient is not able to properly check her sugars four times per day to make sure that her gestational diabetes is controlled, causing an adverse effect. The patient has gestational diabetes and does not require an insulin pump.
In summary, the health plan should cover the Formulary exception for Contour Next Strip, as these are necessary for the health of the patient and her unborn child.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

The patient is an adult with a history of diabetes, retinopathy, nephropathy, hypertension, hyperlipidemia, hyperthyroidism and toxic adenoma, status post left hemithyroidectomy. The patient presented to the emergency room (ER) with persistent 10/10 worsening sharp lower quadrant abdominal pain radiating to the lower back for the previous 3 days. 

In the emergency room (ER), the patient was hypertensive with blood pressure (BP) 143/101, lower left quadrant and the left lumbar region was tender to palpitation. Elevated lactate was 4.8. The urinalysis was positive for high leukocyte esterase and polyuria. Glucose 355, Bicarbonate 18, anion gap 19. On day 3 of admission, Calcium 9.2, Phosphorus 4.4, Magnesium 1.8, estimated glomerular filtration rate (EGFR) 102. The patient continued to have an elevated lactate of 4.4 even after intravenous (IV) fluid resuscitation. 

The patient was admitted with the diagnosis of acute urinary tract infection and hyperlactatemia and uncontrolled diabetes. The patient was managed for uncontrolled diabetes and was on antibiotics. The patient achieved hemodynamic stability and controlled glucose levels on the by discharge. 

Acute inpatient admission for patients with symptomatic diabetes is necessary when the patient has evidence of ketoacidosis or a hyperosmolar state. Acute inpatient admission is also medically necessary for patients with uncontrolled diabetes, who have other comorbidities that require inpatient treatment. The patient presented with uncontrolled diabetes, fever, abdominal pain and was diagnosed with acute urinary tract infection as well as elevated lactate levels. Patients with uncontrolled diabetes fever, and urinary tract infection (UTI) are at high risk of sepsis. The admission for ruling out sepsis with blood culture, treatment with intravenous antibiotics, and treatment of the elevated lactate level is consistent with generally accepted standards of medical practice. During the hospitalization, the patient was continued on intravenous antibiotics and had the insulin dose adjusted to treat ongoing hyperglycemia.

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chest pain on exertion.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This is an adult that presented to the hospital complaining of chest pain on exertion.  Symptoms were noted at work while the patient was packing boxes. Past medical history was significant for hypertension.  On arrival to the hospital vital signs were stable (BP 146/74, Pulse 68).  Physical examination revealed no major abnormality.  A 12-lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T (heart rhythm) wave abnormalities. Serum blood testing revealed normal troponin levels. The patient was admitted to the hospital and referred for cardiac catheterization that revealed a 50 percent mid and 90 percent distal left circumflex artery obstruction, 50 percent mid left anterior descending artery obstruction, and 40 percent proximal right coronary artery obstruction.  She underwent successful percutaneous intervention of the left circumflex artery.  Her post-operative course was complicated by bradycardia and a 10 second pause with near syncope that required urgent transfer to the cardiac catheterization laboratory and temporary transvenous pacemaker placement. The patient was discharged home on medical therapy with cardiology follow up.

This patient presented with typical anginal chest pain. Her pretest probability of coronary artery disease was intermediate. Although the patient had no elevation of serum troponin and an intermediate HEART (score of cardiac event risk) score, careful evaluation for the etiology of crescendo chest pain was indicated. Patients with high-risk coronary lesions and post operative complications require hospital admission and cannot be discharged following a short period of observation. Inpatient admission for work up and treatment was medically necessary. This patient was ultimately diagnosed with severe obstruction of the left circumflex artery. Following percutaneous intervention, additional treatment was necessary due to bradycardia and poorly controlled hypertension.  Inpatient admission to the hospital was medically necessary.

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 the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pain and bleeding when urinating. 
Treatment:  Inpatient admission. 
The insurer denied coverage for inpatient admission.  The denial is upheld.

This is a child with a diagnosis of suspected von Willebrand disease, who presented with dysuria and hematuria for 2 days. The review of systems was otherwise negative.

In the emergency department (ED) he had a temperature of 98.2 degrees Fahrenheit and a heart rate of 125 beats per minute. On exam, the child was active, not in acute distress, but had erythema and swelling present at the penile tip. Other systems exams were normal. 

Laboratory results were significant for white blood cells (WBC) 19.1 (elevated) with a slight neutrophil predominance, and an abnormal urinalysis, including proteinuria, red blood cells (RBC) 51-100, white blood cells (WBC) 21-50, small leukocyte esterase count and many bacteria seen. 

The child had no signs of hemodynamic instability, pyelonephritis, a toxic appearance or anatomic abnormality of his urinary tract. He could have been safely followed as an outpatient while awaiting results of the urine culture. Specifically with regard to urinary tract infection (UTI), the record supports a diagnosis of balanitis in this uncircumcised male who has no previous history of UTI. Cloudy urine is rarely seen in pediatric UTIs and was likely due to pus cells from balanitis. His mild bleeding, manifesting as hematuria, could have been due to his clotting factor deficiency. 

As discussed in Tews et al., in young children, application of topical antibiotic ointment is the treatment regimen of choice. In conjunction systemic antibiotics are indicated if staphylococcal or group A streptococcal balanoposthitis or cellulitis is suspected. The route of administration should be oral, although initially a dose of intravenous antibiotics can be administered. However, an admission level of care was not justified, especially as there was no urinary obstruction from the balanoposthitis, fasciitis or gangrene. 

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:  Osteoarthritis, depression and vertigo.
Treatment:  Increase Consumer Directed Personal Assistance Program (CDPAP) services for a total of 84 hours per week.

The insurer denied coverage for increase Consumer Directed Personal Assistance Program (CDPAP) services for a total of 84 hours per week.  The denial is overturned.

This is an elderly adult with chronic medical problems including osteoarthritis, depression and vertigo.  She reportedly now lives alone.  However, according to prior UAS (Uniform Assessment System) report the patient formerly resided with her 3 daughters in a private house. The insurer approved Consumer Directed Personal Assistance Program (CDPAS) 56 hours/week, and the request is now for CDPAS 84 hours/week (12 hours/day, 7 days/week). 

The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as modified independent.  She is able to activate her Personal Emergency Response System (PERS).  She reportedly requires maximal assistance to total dependence for completing much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires maximal assistance for bathing, lower body dressing and toilet transfer/use.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing, locomotion and ambulation which would support the need for Consumer Directed Personal Assistance Program (CDPAS) 84 hours /week (12 hours/day, 7 days/week).  Limited assistance is reportedly needed for bed mobility and eating.  The patient reports being frequently incontinent of bladder and occasionally incontinent of bowel control. 

Based on the enclosed clinical documents, the patient does have functional incapacity, personal hygiene and toileting needs, which requires the requested Consumer Directed Personal Assistance Program (CDPAS) 12 hours a day, 7 days a week, totaling 84 hours per week. There is also concern that she now lives alone. 

This physician would agree that the patient may benefit from additional monitoring; particularly due to her weakness, unanticipated toileting and hygiene needs and falls risk.  From a physical medicine and rehabilitation perspective, increase CDPAP services for a total of 84 hours per week are medically necessary.    

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 increase Consumer Directed Personal Assistance Program (CDPAP) services for a total of 84 hours per week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Cibinquo
The insurer denied Cibinquo.  The determination is upheld.

The patient is a male with atopic dermatitis. Body surface area affected is 30 percent (%). He has tried and failed Eucrisa, tacrolimus, triamcinolone, clobetasol, desonide, and betamethasone. The medication under review for medical necessity is Cibinqo.

According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications, such as Adbry, are effective treatments for the management of atopic dermatitis (1-3). Blair et al. writes in "Tralokinumab in Atopic Dermatitis: A Profile of Its Use" that "Tralokinumab (tralokinumab-ldrm) [Adbry(USA); Adtralza (EU)], a human immunoglobulin (Ig (G4 monoclonal antibody that binds specifically to interleukin (IL)-13, is an effective and generally well tolerated treatment option for adult patients with moderate to severe atopic dermatitis who are candidates for systemic therapy. In pivotal phase III trials, subcutaneous tralokinumab improved the clinical signs and symptoms of atopic dermatitis as well as quality of life (QOL). In ECZTRA [tralokinumab monotherapy] 1 and 2, tralokinumab monotherapy was superior to placebo in the first 16 weeks of treatment, with improvements in pruritus and sleep scores seen as early as week 1. Many patients who met the criteria for clinical response at week 16 maintained this response at week 52. Tralokinumab was also more effective than placebo when used in combination with 'as needed' topical corticosteroids (TCS) in ECZTRA 3 and 7; most tralokinumab recipients used no or very little amounts of TCS" (1). Blauvelt et al writes in "Long-term 2-year safety and efficacy of tralokinumab in adults with moderate-to-severe atopic dermatitis: Interim analysis of the ECZTEND open-label extension trial" that "With 2 years of tralokinumab, improvements in extent and severity of AD were sustained, with Eczema Area and Severity Index (EASI-75) in 82.5% of participants (number (N) = 345)." (2).
It is noted that the patient has tried and failed many topicals. However, the patient has no true contraindications to the other preferred, formulary medications, which have been shown to be effective for the treatment of atopic dermatitis. The evidence-based literature is consistent and in line with the patient's medical policy. The preferred agents, such as Adbry, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Cibinqo. Therefore, Cibinqo is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hidradenitis Suppurativa
Treatment: Avsola
The health plan denied Avsola.  The determination is upheld.

The patient is a male with hidradenitis suppurativa. He has tried and failed Doxycycline. He has also failed Rinvoq, Prednisone, Isotretinoin, Cosentyx, topical Clindamycin, and intralesional Kenalog.

At issue is the medical necessity of Avsola.

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

The requested health treatment of Avsola is not medically necessary for this patient. There is no documented trial and failure with the standard of care biologic treatment Humira, which is Food and Drug Administration (FDA)-approved for hidradenitis suppurativa. Hidradenitis suppurativa is a scarring, debilitating, and disfiguring skin disease.
Humira, rather than Avsola, should be used for treatment for hidradenitis suppurativa in this patient. There are several reports in the dermatology peer-reviewed literature that show that Humira is effective for the management of hidradenitis suppurativa, and it is indicated for this purpose (1-3).
Kimball et al writes "Treatment with adalimumab (40 milligrams (mg) weekly), as compared with placebo, resulted in significantly higher clinical response rates in both trials at 12 weeks; rates of serious adverse events were similar in the study groups" (1). Zouboulis et al writes that "Continuous weekly dosing with anti-drug antibodies (ADA), 40 mg, is a reasonable treatment option for long-term control of moderate-to-severe hidradenitis suppurativa " (2).
Avsola is not FDA-approved for the treatment of hidradenitis suppurativa, whereas Humira is. Therefore, Avsola is not medically necessary prior to a trial with Humira.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Paraplegia, incontinence. 
Treatment: Home Care / Personal Care Level 2 Personal Care Services - live-in Increase to 24 Hour(s) per Day (Split Shift). 
The insurer denied coverage for Home Care / Personal Care Level 2 Personal Care Services - live-in Increase to 24 Hour(s) per Day (Split Shift). 
The denial is upheld. 

This is an elderly patient with paraplegia, right shoulder problems, incontinence and requires assistance with all activities of daily living. The patient has a 24-hour live in. A request has been made for 24 hour split shift. The patient stays in the same position at night and cannot go to the bathroom without assistance. 

The Uniform Assessment System (UAS) is reviewed. Cognition is noted as modified independence with the patient being alert and oriented X2, forgetful but able to make needs known and direct care. The patient is total dependent for Instrumental Activities of Daily Living (IADLs) including meal preparation, ordinary housework, shopping and  transportation. The patient needs extensive assistance with telephone use and managing medication. With respect to Activities of Daily Living (ADLs), the patient is total dependence to max assistance for bathing, personal hygiene, dressing upper and lower body, transfer to toilet, toilet use, bed mobility and is extensive assistance for eating. The patient's ADL status has declined compared to 90 days ago. The patient is frequently incontinent of bladder daily but has some control, and is continent of bowel. No falls were noted in the last 90 days. The patient's skin is intact. No nighttime logs are provided for review. 

No clear medical reason was provided to support the need for split shift. There was no documentation of progression, complications nor inability to receive the care necessary. As noted, no nighttime logs were provided showing the live-in could not have 5 hours of uninterrupted rest. It is unclear what the benefit of split shift would provide other than convenience. Basic scope of care is provided without extenuating circumstance. 

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 Home Care / Personal Care Level 2 Personal Care Services - live-in Increase to 24 Hour(s) per Day (Split Shift) is not substantiated.