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

Diagnosis: Pulmonary Embolism
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented with left-sided chest pain radiating to her neck and back for 2 days, rated at a level of 9/10. Her past history is also remarkable for an elevated D-Dimer and she is on hormonal birth control. In the emergency department (ED), her vital signs were stable and an electrocardiogram (EKG) showed sinus tachycardia with a rate of 110, although her heart rate was 71 on presentation and 77 on admission. Computed tomography (CT) imaging of her chest was obtained that showed a subsegmental pulmonary embolism in the right lower lobe, posterior basal pulmonary artery. The chest x-ray was negative for an effusion or pneumothorax. She was given an intravenous (IV) fluid bolus and acetaminophen and was admitted for further treatment of her pulmonary embolism. She was started on Apixaban 10 milligrams (mg) twice a day and had her vital signs monitored every 4 hours with continuous pulse oximetry and cardiac monitoring.
She had a doppler ultrasound of her upper and lower extremities to rule out a deep vein thrombosis, and the results were negative. A thrombophilia work-up was started, she was seen by adolescent medicine, was given a Depo-Provera injection and stopped the oral contraceptive pills. She was discharged home with close outpatient follow-up.
The acute inpatient level of care is under review for medical necessity.
The requested health service/treatment of inpatient stay was not medically necessary for this patient.
This patient was admitted for treatment of a newly diagnosed pulmonary embolism. There are published criteria that are used to identify those patients who are considered low-risk with a pulmonary embolus and are safe for outpatient treatment. The criteria that are analyzed include if the patient is hemodynamically stable (concerns for systolic blood pressure less than 100, heart rate over 100, needing intensive care unit (ICU) care, or by clinician judgment); if thrombolysis or embolectomy is needed, if the patient has active bleeding or is at high risk for bleeding, if more than 24 hours of supplemental oxygen is necessary to maintain saturations 90% or higher, pulmonary embolus occurring while on anticoagulation, severe pain needing intravenous pain medication for more than 24 hours, medical or social reason for admission greater than 24 hours, creatinine clearance less than 30 milliliters per minute (mL/min), severe liver impairment, pregnancy, or documented history of heparin-induced thrombocytopenia (HIT). None of these are clearly present in this case. Based on the Hestia criteria, the patient could have been safely treated as an outpatient and even the short stay that occurred was not clearly necessary.
Therefore, based on the clinical information provided for review, the inpatient stay is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Other/Hand Neuroma. 
Treatment: Inpatient Hospital. 

The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld. 

The patient is a female who had a resection of a traumatic neuroma of the median and ulnar nerves from her hand. The patient had a history of suicide attempts in the past. Medical record notes that the patient tolerated the procedure well and was managed with intravenous antibiotics postoperatively. The patient reportedly had an uneventful orthopedic course. Pain was well controlled with oral medications and there were no significant complications. There is no documentation of any suicidal ideation in the medical record. The procedure was approved for ambulatory status and ultimately required an inpatient stay. 

At issue is the medical necessity of the inpatient stay. 

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

No. Hand procedures such as amputations are routinely performed on an outpatient basis. The patient remained hemodynamically stable, had normal vital signs, was ambulatory, was taking food and fluids without difficulty, and was capable of receiving outpatient occupational therapy and ongoing psychiatric care as an outpatient. There was nothing extraordinary regarding this case that would warrant an inpatient stay. 
Goyal et al performed a study to determine the safety and rate of adverse events in outpatient hand and upper-extremity surgical procedures in an ambulatory surgery center. A retrospective review of cases at a single, freestanding ambulatory surgery center over an eleven-year period was performed. In our analysis, 28,737 cases were performed and were included. Adverse events were defined as serious complications causing harm to a patient or leading to additional treatment. Using state-reportable adverse events criteria as a guideline, the authors divided the adverse events into seven categories: infection requiring intravenous antibiotics or return to the operating room, postoperative transfer to a hospital, wrong-site surgical procedure, retention of a foreign object, postoperative symptomatic thromboembolism, medication error, and bleeding complications. These adverse events were then analyzed to determine if they led to additional laboratory testing, hospital admission, return to the operating room, emergency department visits, or physical or mental permanent disability. The results showed there were fifty-eight reported adverse events, for an overall rate of 0.20%. There were no deaths. There were fourteen infections, eighteen postoperative transfers to a hospital, twenty-one hospital admissions after discharge, one medication error, and four postoperative hematomas. There were no cases of wrong-site surgical procedures or retained foreign bodies. The authors concluded that, with a selected patient population, a very low adverse event rate (0.20%) can be achieved. There review showed few adverse events, no deaths, and no wrong-site surgical procedures support.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis and dissecting cellulitis of the scalp

Treatment 80 milligrams (mg) of Humira a week to treat plaque psoriasis

The insurer denied coverage for 80 milligrams (mg) of Humira a week to treat plaque psoriasis.

The denial is overturned.

The patient has a diagnosis of psoriasis and dissecting cellulitis of the scalp.  Based on the provided medical records and appeal letter, the patient has had partial response to Humira 40 mg weekly treatments.  The request is for Humira 80 mg weekly.  Based on the medical literature as well as the Humira prescribing guide, Humira 80 mg injections are within the guidelines of care for adult patients.  This dose is higher than what is traditionally used for treatment of psoriasis; however, dosing for dissecting cellulitis is generally higher than that for psoriasis alone.  With appropriate monitoring the dosing regimen requested is within the standard of care.  As such, the decision is overturned and the use of Humira at the requested dose is medically necessary at the medical discretion of the providing physician based on the unique circumstances required for the care of this patient.  The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for 80 milligrams (mg) of Humira a week to treat plaque psoriasis is overturned.  Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fractured metal coping on crown of tooth #11.
Treatment: D2791--All Metal Crown, Tooth #11.
The insurer denied the D2791--All Metal Crown, Tooth #11.
The denial is overturned. 

The patient is a female requesting dental benefits for the replacement of an all metal crown on tooth #11. X-rays were taken.

The patient presents with a fractured metal coping of crown #11. The chief complaint was that the tooth feels uncomfortable. The crown is 10 plus years old.

The Health Plan said that the crown replacement is not medically necessary. The provider appealed because of the fracture of the old crown.

The proposed new all metal crown on tooth #11 is medically necessary.
Crowns are placed on teeth usually after root canal therapy or if a tooth cannot be restored with only a filling because the amount of natural tooth structure is inadequate. The purpose of the crown is to protect the underlying natural tooth structure from fracture and restore function.

Clinical exam and x-rays reveal a fracture in the metal coping of tooth #11. This is the patient's chief complaint for visiting the dentist. The metal coping is the underlying structure of the crown that provides the coverage and protection of the tooth. Therefore, if this structure is undermined, it renders the crown useless as it is now susceptible to further fracture of both the coping and the underlying natural tooth structure. Thus, the proposed new all metal crown on tooth #11 is medically necessary.

A fractured metal coping of a crown indicates that the structural integrity of the crown has failed and it no longer can serve its function, which is to protect the underlying natural tooth. This then puts the patient's underlying natural tooth at risk for fracture.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Respiratory System- pulmonary disease (COPD) and hyperinflation.
Treatment: Surgical Services-Zephyr.
The insurer denied the Zephyr valve procedure as Experimental/Investigational. The denial was overturned. 

The patient is a male with a history of severe chronic obstructive pulmonary disease (COPD) based on pulmonary function testing. He has been evaluated for bronchoscopy lung volume reduction surgery with zephyr valve.
The patient is a former smoker with known COPD and coronary artery disease with stenting. His medical management has been optimized and is currently on Brezetri. He has also required intermittent prednisone burst and taper. He is functionally limited because of his COPD with severely reduced exercise tolerance. He has a normal body mass index (BMI). His body-mass index, airflow obstruction, dyspnea, and exercise (BODE) score was 8.
His pulmonary function test (PFT)s show severe COPD with reduced forced expiratory volume (FEV1), increased total lung capacity (TLC) and reduced diffusing capacity of the lung for carbon monoxide (DLCO). He is currently not on oxygen. His echocardiogram was unremarkable. A computed tomography (CT) scan showed moderate diffuse centrilobular emphysema. Physician documentation showed him to be an ideal candidate for endobronchial valve placement.
At issue is whether the Zephyr valve procedure is likely to be more beneficial than any standard treatment.

The health plan's determination regarding the proposed health service or treatment is overturned in whole.

Based on review of the medical records available, the proposed health service and treatment with Zephyr valve procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This is a United States Food and Drug Administration (FDA) approved treatment for COPD patients with ongoing symptoms who have been optimized on medical management. Based on literature from multiple randomized control trial studies, this patient meets inclusion criteria for this procedure and does not have any exclusions based on review.
Therefore, the proposed treatment of Zephyr valve procedure is likely to be more beneficial than any standard treatment or treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lymphedema.
Treatment: Additional 7 physical therapy sessions.

The insurer is denied coverage for additional 7 physical therapy sessions.  The denial is upheld. 

This female patient has a history of tendonitis, allergic rhinitis, B12 deficiency, breast cancer, lymphedema, paroxysmal supraventricular tachycardia, and obstructive sleep apnea (OSA). She presented to the Physical Therapist's (PT) office on for the treatment of lymphedema in the left upper extremity (LUE). The patient was able to reduce her risk for cellulitis with PT visits every 2 weeks. The patient's measurements were less than measurements at the last visit. Modalities to improve tissue healing in PT were electrical stimulation, ultrasound/phonophoresis, cold laser therapy, cryotherapy, and hot packs. The patient did therapeutic exercises, neuromuscular rehabilitation, manual therapy, and splinting/taping. Lymphedema education was provided. The patient requested additional PT visits to treat lymphedema.

The number of physical therapy sessions for this patient's underlying lymphedema has been extensive.  The medical necessity of continued structured physical therapy has not been established.  The therapy notes submitted for review do not provide any specific rationale for the medical necessity for the several years of physical therapy treatment.  According to the physical therapy note, treatment was initiated, and this was visit number 379.  Also according to this note, the patient "has been able to reduce her risk of cellulitis with visits every 2 weeks for MLD [manual lymph drainage], laser and MFR [manual fluid reduction] to LUE [left upper extremity]."  However, the patient should have long ago been independent with a home exercise program, as well as with other home modalities if needed, compression garments and lymphedema pumps, etc.  

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the additional 7 physical therapy sessions is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction-detoxification.
Treatment: Mental Health: Inpatient.
The health plan denied the requested mental health stay. 
The health plan's determination is overturned.

The patient is a male who presented to the emergency department with a request for detoxification from heroin, cocaine, and Xanax with acute withdrawal symptoms. The patient had a prior diagnosis of opioid abuse and dependence, crack cocaine abuse, and benzodiazepine dependence. The patient presented with significant withdrawal symptoms including malaise, diaphoresis, muscle cramps, diarrhea, sleep disturbance, rhinorrhea, stomach cramps, aches in his joints and bones, restlessness, and yawning.
Clinical history included multiple prior detoxification admissions, one prior rehabilitation admission, and one prior outpatient program with subsequent relapse into substance abuse. The patient reportedly was using 15 bags of heroin daily, using an eight ball of crack cocaine daily and ingesting two sticks of Xanax daily. He reported last used of these substances the day prior to admission.
The patient was treated using a Methadone taper, and as needed medications including Ativan.

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

Yes. The requested health service/treatment of inpatient stay was medically necessary for this patient. Based on responses to questions on the LOCADTR tool, the LOCADTR Level of Care is Hospital Based Inpatient Detoxification
The patient did not have an immediately life-threatening medical condition or severe psychiatric crisis. The patient met criteria for substance use disorders to multiple substances including opioids and benzodiazepines. The patient clearly met criteria for severe substance use disorders related to both of these substances. The patient was not in full remission from a substance use disorder. The patient was taking a substance that placed him at risk for medical complications from withdrawal. The patient did have a serious psychiatric or medical symptom that were required 24-hour inpatient medical management. The symptoms that were present were the combination of opioid and benzodiazepine withdrawal. Benzodiazepine withdrawal can be life-threatening. Treatments for opioid use disorder have to be monitored carefully along with a benzodiazepine withdrawal protocol given the potential additive central nervous system depressant effects. Detoxification medications were needed to prevent or modify withdrawal. An acute intervention was needed to prevent seizures or severe withdrawal symptoms.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Relapsing remitting multiple sclerosis (RRMS)
Treatment: Rituxan
The insurer denied Rituxan.
The health plan's determination is upheld. 

The patient is a woman with relapsing remitting multiple sclerosis (RRMS). The patient is currently treated with Rituximab. The patient is both clinically and radiographically stable. The Rituxan was denied because the patient has not tried and failed the health plan's recommended biosimilar products of Truxima or Ruxience.

Rituxan is not medically necessary for this patient. The patient has RRMS. Rituximab (Rituxan, Truxima, and Ruxience) are off-label for treatment of multiple sclerosis (MS). Nonetheless, rituximab has been widely used off-label to treat MS in some centers for years. In a preliminary randomized trial of 104 adult patients with RRMS, treatment with intravenous (IV) rituximab (1000 milligrams (mg)) given on days 1 and 15 reduced reduction in both total and new gadolinium-enhancing lesions on brain magnetic resonance imaging (MRI) at 24 weeks when compared with placebo. In addition, rituximab treatment reduced the proportion of patients who had a clinical relapse by week 24. Further randomized trials would be needed to establish the long-term effectiveness and safety of rituximab for RRMS, but such trials are unlikely. In an observational study of 256 patients with stable RRMS who switched to rituximab or fingolimod after stopping natalizumab due to JCV (John Cunningham virus) antibody positivity, the rituximab group had lower rates of clinical relapse, adverse events, and treatment discontinuation compared with the fingolimod group. In another observational study of 494 patients diagnosed with RRMS identified from a Swedish MS registry, rituximab treatment was associated with a lower discontinuation rate compared with other disease modifying therapies, including interferons, glatiramer acetate, dimethyl fumarate, fingolimod, and natalizumab. In addition, rituximab treatment was associated with a lower rate of clinical relapses and MRI measures of disease activity compared with interferons, glatiramer acetate, and dimethyl fumarate.

Rituxan is biosimilar to both Truxima and Ruxience and there is no medical reason why the patient cannot use these agents as they have the same mechanism of action. There are no guidelines that recommend or require brand Rituxan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Immunologic Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Taltz 80MG/SC SOAJ for medical necessity. 
The denial was upheld.

The patient is a female with a history of psoriatic arthritis, fibromyalgia, gastric ulcer, and iron deficiency anemia. The patient has been ordered Taltz 80 milligrams (MG)/subcutaneous (SC) solution auto-injector (SOAJ) for treatment of her psoriatic arthritis. Prior treatment includes meloxicam, Humira, Otezla, Xeljanz, Cosentyx, and methotrexate.

The issue in this case is that Taltz 80MG/SC SOAJ is being denied by the health plan. The reason cited is not medically necessary as there is "inadequate evidence to bypass the use of anti-tumor necrosis factor (TNF) agents" and there was "no indication that antibody levels were drawn." 

At issue is the medical necessity of Taltz 80MG/SC SOAJ.

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

No, the requested health service/treatment of Taltz 80MG/SC SOAJ is not medically necessary for this patient.

There is no medical reason noted why the patient cannot try another TNF inhibitor. Because the patient failed Humira does not mean she will have the same outcome with another TNF inhibitor. There is no medical reason or contraindication noted to a trial of another TNF inhibitor.

According to UpToDate, "in patients whose joint counts do not improve substantially after three months of treatment with a conventional nonbiologic disease modifying anti-rheumatic drug (DMARD) (e.g., methotrexate (MTX)) or who still have more than three tender and swollen joints, we recommend a TNF inhibitor rather, than sequential trials of other conventional DMARDs... We prefer a TNF inhibitor in this setting because of the greater experience that exists with these agents, as well as the greater number of trials providing evidence of benefit." It is keeping with the standard of care to treat psoriatic arthritis (PsA) with TNF inhibitors. In this case, there is no contraindication or medical reason to try another agent at this time due to failure with one TNF agent (i.e., Humira). There is no medical basis to assume that this entire class of drug will not work in this patient. 

Therefore, the requested treatment of Taltz 80MG/SC SOAJ is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure disorder
Treatment: Skilled Nursing Care in the Home
The insurer denied the Skilled Nursing Care in the Home 8 Hours per Day x 7 Days per Week. 
The health plan's determination is overturned. 

The patient is a female child with medical history significant for chromosome ring 22, seizure disorder with breakthrough seizures particularly in the morning, sensorineural hearing loss with bilateral hearing aids, vocal cord paresis, hypoplastic optic nerve, hypotonia, feeding intolerance status post gastrostomy tube placement, and severe dumping syndrome. As a result of her dumping syndrome, her blood sugar is very labile and unstable, with episodes of profound hyperglycemia and profound hypoglycemia. To maintain some semblance of stability, the first feeding of the day is provided as a slow bolus, with blood sugar checks before and after. She is very stiff upon awakening, requiring stretching and massage to manage her pain. She is fully dependent upon caregivers for all activities of daily living.

Skilled Nursing Care in the Home: 8 Hours per Day x 7 Days per Week is medically necessary for this patient.

According to the American Academy of Pediatrics Guidelines for Home Care of Infants, Children, and Adolescents With Chronic Disease, "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens." Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities."
This medically fragile child has a number of disabilities and medical problems as a result of her genetic condition and more recent diagnosis of dumping syndrome, with numerous skilled nursing needs as detailed above. Her family and the school nurse manage her skilled needs but are limited by her school schedule, personal disability (severe in the father, present in the mother), medical needs of other family members (brother with autism), and need to work to provide for the needs of the family (mother). It is neither possible nor reasonable/safe to expect the mother, the primary caregiver and only parent able to care for the child, to be able to meet her child's complex and numerous skilled needs while maintaining a full-time work schedule and managing the rest of the household (including the sibling with autism). The requested skilled nursing hours 8 hours per day, 7 days per week are the minimum necessary to maintain the health and well-being of this child and are thus medically necessary and appropriate.