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

Diagnosis:  Chronic kidney disease.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

This man was referred to the emergency department (ED) for evaluation for initiation of chronic hemodialysis. His medical history was remarkable for diabetes, hypertension, congestive heart failure and chronic kidney disease. Two weeks prior to presentation in the ED, he had been hospitalized for decompensated heart failure. Initiation of hemodialysis was recommended. However, the patient wished to get a second opinion. On the day of presentation, he saw a nephrologist who also recommended that he start hemodialysis and referred him to the ED. In the ED, he had no complaints other than generalized fatigue. His blood pressure was 163/91 with a heart rate of 94. His respiratory rate was 22/minute with a room air oxygen saturation of 98%. His physical exam was remarkable for pulmonary rhonchi and 2+ lower extremity edema. 

Based on the documentation provided an inpatient stay was not medically necessary.
This patient, with known chronic kidney disease, was sent to the emergency department for evaluation for initiation of dialysis therapy. He had no acute symptoms. He was hemodynamically stable and did not have an indication for emergent hemodialysis, such as encephalopathy, pericarditis, pleuritis, severe volume overload, pulmonary edema, severe acidosis or hyperkalemia. While his serum troponin level was mildly elevated, this is common in patients with significant renal disease and, in and of itself, is not indicative of myocardial infarction. He tested positive for COVID but had no evidence of pneumonia and normal oxygen saturation at rest and with walking. The patient tolerated the dialysis that was performed without complications. Based on the documentation provided, he did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Humira Pen-Psoriasis-Uveitis Starter 80 milligrams (mg)/0.8 milliliter (ml) and 40 mg/0.4 ml subcutaneous (SC) pen-injector kit (PNKT)
The insurer denied the request for Humira Pen-Psoriasis-Uveitis Starter 80 mg/0.8 ml and 40 mg/0.4 ml SC PNKT.
The health plan's determination is upheld.

The patient is a male with plaque psoriasis affecting 5 percent (%) of his body surface area including intertriginous and facial involvement. He has failed therapy with topical Hydrocortisone 2.5% ointment and Tacrolimus 0.1% ointment. The request is for the coverage of Humira [Humira Pen-Psoriasis-Uveitis Starter 80 milligrams (mg)/0.8 milliliter (ml) and 40 mg/0.4 ml subcutaneous (SC) pen-injector kit (PNKT)]. The prescriber is appealing the prior denial by stating that Humira is safer than oral immunosuppressants for the treatment of this patient's plaque psoriasis.

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

The requested health service/treatment of Humira is not considered as medically necessary for this patient. The prescriber is requesting for coverage of Humira for the treatment of this patient's plaque psoriasis. According to the health plan criteria, Humira may be considered medically necessary for the treatment of plaque psoriasis if there is a history of treatment failure or clinical contraindication to oral immunosuppressants such as Methotrexate or Cyclosporine. The patient has not yet tried treatment with either Methotrexate or Cyclosporine. 

According to the Food and Drug Administration (FDA) label, contraindications to these oral immunosuppressants include hypersensitivity to any of the drugs, pregnancy, breastfeeding, concurrent Nitrous Oxide use, active peritoneal dialysis, history of immunodeficiency and history of alcohol abuse. It also includes hepatic disease or impairment, renal disease or impairment, history of blood dyscrasias, history of myelosuppression, active infection, uncontrolled hypertension, history of malignancy, concurrent psoralen-ultraviolet A (photochemotherapy) (PUVA)/ultraviolet B (UVB) use (for Cyclosporine), and concurrent radiation therapy (for Cyclosporine).

The patient does not have documentation of any of these contraindications to either Methotrexate or Cyclosporine. These therapies are FDA-approved for the treatment of plaque psoriasis with improved efficacy over topical therapies and represent valid alternative treatment options which can provide adequate treatment for the patient's plaque psoriasis. Furthermore, although the prescriber considers Humira to be safer when compared to oral immunosuppressants, Humira is an immunosuppressant biologic with FDA Black Box warnings including a risk of serious infection, malignancy such as lymphoma, demyelinating disease, cytopenia, and heart failure. For these reasons, the use of Humira for the treatment of this patient's plaque psoriasis is not considered medically necessary at this time.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity.
Treatment: Saxenda.
The insurer denied: Saxenda.
The denial is: Upheld.

The patient is a female with obesity. Body mass index 38.9 kilograms per square meter (kg/m2). The prior request was denied because approval on criteria requires that the patient is currently enrolled in a qualified complete weight management program for at least the past 3 months with proof of current and prior enrollment and at least monthly participation. The subject under review is the medical necessity for Saxenda.

The Endocrine Society Guidelines on the management of obesity recommend weight loss medications be considered as an adjunct to lifestyle changes for patients who have been unsuccessful with diet and exercise alone. The submitted documentation does not provide any details on the patient's engagement with Weight Watchers, only receipts. The information provided does not support that the requested Saxenda is being requested in a manner consistent with the Endocrine Society Guidelines. Saxenda has risks, including nausea and vomiting. Therefore, the requested Saxenda is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath and cough.
Treatment: Inpatient Admission.
The insurer denied inpatient Admission.
The denial is upheld.

The patient is a female with a history of Corona Virus 2019 (COVID), asthma, hypertension, diabetes, allergic rhinitis, obesity, arthritis, depression, anxiety, seizures, status/post (s/p) ventricular-atrial shunt, neuropathic pain, and sleep apnea. She presented to the emergency room with a several day history of shortness of breath and cough. Vital signs were notable for a pulse of 109. She was speaking in full sentences, awake, and alert. Physical exam revealed scattered wheezing and decreased breath sounds. Labs revealed a glucose of 207. The chest x-ray showed clear lung fields. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation.

Upon admission, the patient was treated with nebulizers and oral medications. Upon admission, there were no wheezes, rales, or rhonchi on exam. The pulmonologist evaluated the patient and recommended the addition of montelukast. The remainder of the stay was clinically uneventful and the patient was discharged.

The requested health service/treatment of inpatient admission was not medically necessary for this patient.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, mental status changes, or severe metabolic disarray. The etiology of her symptoms was readily apparent and she responded quickly to straightforward treatment. The services provided - nebulizers, inhalers, oral medication - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature cited the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic arthritis and plaque psoriasis

Treatment: Otezla 30 milligram (mg)

The insurer denied coverage for Otezla 30mg

The denial is overturned

This case involves a patient requesting Otezla. Rheumatology note reported the patient was being seen for joint pain. The patient reported pain in hips and hands after 10 days of taking Humira. It was noted that the patient felt better when taking both Humira and Otezla, but Otezla had not been approved. It was noted that Plaquenil was stopped previously due to lack of efficacy. The patient continued to complain of dry eyes, stiffness, and severe fatigue.  Treatment plan was for Humira, Prednisone, and Otezla. A letter stated the patient had a diagnosis of psoriatic arthritis and plaque psoriasis that were both well controlled with Otezla. The provider stated Otezla was previously initiated, and the patient had positive clinical response. It was stated that given inflammatory arthritis and joint pains consistent with osteoarthritis, Humira was added. In a determination letter the request was denied as Otezla was being used in combination with another biologic or targeted synthetic disease modifying antirheumatic drug.

Apremilast can be safely combined with biologic agents in patients with plaque psoriasis or psoriatic arthritis not responding adequately to biologics alone. Given past results, continuation of Otezla would be supported. As such, the request for Otezla 30mg is considered medically necessary for this patient.

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 Otezia 30mg is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status Post Surgery (lumbar laminectomy)
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult male. He had an inpatient hospital admission status post spinal surgery with a lumbar laminectomy. The patient has a past medical history of hypertension, lumbar spinal stenosis and progressive pain. The patient had stenosis symptoms with bilateral leg pain and a left foot drop. Radiographic imaging shows multilevel radiographic stenosis. The patient had non-operative treatment without 
improvement. The patient had surgery for an L (lumbar) 2-S (sacral) 1 laminectomy and posterior decompression. The estimated blood loss was 400 mL (milliliters). The patient was in the operating room for 6 hours. The patient was transferred to the PACU (post anesthesia care unit) and was stable and transferred to the floor. The patient had a Foley catheter and a drain. The Foley catheter was removed on the first postoperative day. The patient was evaluated in physical therapy and ambulated 150 feet with a walker with minimal assistance. The patient was ordered an AFO (ankle foot orthosis). The patient had a hemoglobin and hematocrit of 11/32.6. On postoperative day 2, the patient was anxious and had a blood pressure of up to 206/98. The patient received hydralazine and Xanax. On day 3, the patient had an elevated blood pressure of 172/92. The patient was given labetalol and losartan. The patient was voiding freely and discharged to home. This is a review for the inpatient level of care.

The inpatient hospital admission was not medically necessary.

The lumbar laminectomy and postoperative care were appropriate. However, the inpatient hospital admission was not medically necessary. The patient had lumbar spinal stenosis causing neurogenic claudication and a foot drop. Thus, surgical intervention was appropriate. This would require postoperative care. However, the need for the inpatient level of care has not been established. On hospital day 1, the patient was safe for 
discharge. The patient had a stable blood pressure and was voiding spontaneously. The patient had cleared physical therapy with ambulation of 150 feet. Given the functional status of the patient, the patient could have been safely discharged to home at this time and did not require further hospital care. Thus, the need for the inpatient hospital admission has not been established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain; s/p Cardiac Catheterization with Percutaneous Cardiac Intervention.
Treatment:  Inpatient Stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld.

The patient is a male, who has a history of hypertension, hyperlipidemia, diabetes, chronic obstructive pulmonary disease (COPD), morbid obesity, a non-segment (ST) elevation myocardial infarction with multivessel coronary artery disease (CAD) diagnosed at that time. He was admitted electively for percutaneous intervention of the left anterior descending (LAD) and circumflex. The left ventricular ejection fraction (LVEF) was normal. The patient's creatinine was normal. The electrocardiogram (ECG) was not acute. His vital signs were normal. He underwent a successful percutaneous intervention. He remained stable and was discharged.

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

The requested health service/treatment of an inpatient stay was not medically necessary for the patient. This patient presented for an elective percutaneous intervention. He remained stable. There was no congestive heart failure (CHF), respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, other serious cause for chest pain, such as a pulmonary embolism (PE) or the need for an aortic dissection. The patient did not need prolonged intravenous (IV) medications or oxygen support, introduction of high risk medications requiring ongoing in-hospital monitoring, he did not have a severe catheterization related complication (i.e., severe bleeding, cerebrovascular accident (CVA)), need for invasive hemodynamic monitoring or the need for vasopressor or mechanical cardiac support. The patient did not have supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal ECG. In the setting of this case an acute inpatient level hospitalization, compared to for example an alternate level of care, has not been established as standard of care towards improved cardiac outcomes. It is therefore considered not medically necessary in this case.
The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Coronary artery disease, atrial fibrillation, and hypertension.
Treatment:  Personal Care Aide Level 2: 8 hours per day - 7 day(s) per week, a total of 56 hours per week.

The insurer denied Personal Care Aide Level 2: 8 hours per day - 7 day(s) per week, a total of 56 hours per week.  The denial is overturned.

The patient is an elderly male. His conditions include coronary artery disease, atrial fibrillation, and hypertension. He had a recent admission after a fall. Denial of personal care aide level 2: 8 hours per day - 7 days per week, for a total of 56 hours per week, is being appealed. The health plan approved 35 hours per week. The Uniform Assessment System (UAS) evaluation completed recently shows modified independent cognition and functional status: total dependence with housework and managing finances; maximal assistance with meals preparation, and shopping; extensive assistance with bathing, lower body dressing, walking, and locomotion; limited assistance with managing finances, personal hygiene, upper body dressing, toilet transfer, and bed mobility; set up with phone use; and independent with eating. The patient has occasional bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed last year, the patient shows a decline in functioning with walking and locomotion. A letter from the patient's provider notes the patient has difficulty ambulating and is a fall risk. His ADLs (activities of daily living) are limited.

There is a note on a prescription that the patient needs 8 hours daily attendant.

The requested Personal Care Aide Level 2: 8 hours per day - 7 day(s) per week, a total of 56 hours per week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of personal care aide level 2: 8 hours per day - 7 days per week, for a total of 56 hours per week, is being appealed. The health plan approved 35 hours per week.

This patient has multiple chronic conditions and is status post recent hospitalization after a fall. The Uniform Assessment System (UAS) evaluation completed recently shows the patient requires assistance with all ADLs (activities of daily living), except eating. He is incontinent of bladder. Compared to UAS (uniform assessment system) evaluation completed last year shows a decline in functioning with walking and locomotion. Appeal statements recommend additional hours due to limitations with ability to perform ADLs (activities of daily living). The information provide show that this patient has significant limitations in functioning with progression between UAS (uniform assessment system) evaluations. Based on the need for assistance with all ADLs (activities of daily living), except eating, the approved personal care aide for a total of 35 hours per week is insufficient to meet the patient's needs. The requested increase to a total of 56 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chronic obstructive pulmonary disease; chronic hypercapnic respiratory failure.
Treatment:  Home Ventilator.

The insurer denied the Home Ventilator.  The denial is overturned.

The patient is an adult female with severe chronic obstructive pulmonary disease (COPD) with chronic hypercapnic respiratory failure. She has been prescribed a non-invasive home ventilator (NIV). The patient is on Trelegy Ellipta, prednisone and Duonebs for chronic obstructive pulmonary disease (COPD). For hypercapnic respiratory failure the patient has tried and failed bi-level positive airway pressure (BIPAP) 10/5. The non-invasive home ventilator is denied due to lack of medical necessity. This denial is being appealed.

The proposed treatment was medically necessary.

This patient with severe chronic obstructive pulmonary disease (COPD) with chronic hypercapnic respiratory failure is prescribed a non-invasive home ventilator (NIV). The patient is on Trelegy Ellipta, prednisone and Duonebs for chronic obstructive pulmonary disease. For hypercapnic respiratory failure, the patient has tried and failed bi-level positive airway pressure 10/5. Despite being on bi-level positive airway pressure, the patient continues to have daytime hypercapnia. 

Chronic non-invasive ventilation (NIV) has become evidence-based care for stable hypercapnic chronic obstructive pulmonary disease patients. In acute settings non-invasive ventilation is beneficial as a first-line intervention in conjunction with usual care for reducing the likelihood of mortality and endotracheal intubation in patients admitted with acute hypercapnic respiratory failure secondary to an acute exacerbation of chronic obstructive pulmonary disease (COPD). The magnitude of benefit for these outcomes appears similar for patients with acidosis of a mild (potential of hydrogen [pH] 7.30 to 7.35) versus a more severe nature (potential of hydrogen less than 7.30), and when non-invasive ventilation (NIV) is applied within the intensive care unit (ICU) or ward setting. According to European Respiratory Society, "Managing hypercapnia may be an important intervention for improving the health outcome of COPD patients with chronic respiratory failure. The task force conditionally supports the application of LTH-NIV to improve health outcome by targeting a reduction in carbon dioxide in COPD patients with persistent hypercapnic respiratory failure. These recommendations should be applied in clinical practice by practitioners that routinely care for chronic hypercapnic COPD patients." The non-invasive ventilator, Trilogy ventilator at home, is medically necessary, as the patient has tried and failed the alternative machine, bi-level positive airway pressure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous basivertebral nerve ablation
The insurer denied: Intraosseous basivertebral nerve ablation 
The denial is: Upheld.

The patient is a male with chronic low back pain for more than 2 years. Prior treatment has had injections, medications, and therapy. Pain impacts activities of daily living (ADL). Medications include Lyrica and Oxycodone. A magnetic resonance imaging (MRI) of the lumbar spine reported (lumbar-sacral) L5-S1 degenerative changes.

The health plan's determination is upheld in whole.

The proposed health service or treatment of an Intraosseous basivertebral nerve ablation (BVN) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has complaints of low back pain.
There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry Disability Index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as a treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment of Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.