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

Diagnosis: Atopic Dermatitis. 
Treatment: Dupilumab (Dupixent). 

The insurer denied Dupilumab (Dupixent). The health plan's determination is upheld. 

The patient is a female with moderate to severe atopic dermatitis of the axillae, palms, and soles. The patient has paid claims for topical triamcinolone and clobetasol, but not for topical tacrolimus, oral medications, or phototherapy. The patient is reported to have failed topical clobetasol, halobetasol, cetirizine, hydroxyzine, and prednisone. The patient is also human immunodeficiency virus (HIV) positive and on Descovy.

Dupixent is not medically necessary for this patient. 

The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors, or phototherapy, or standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil). Descovy does not interact with the aforementioned oral medications (particularly with an undetectable viral load) and does not interact with either topical tacrolimus and/or phototherapy. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with current medical literature, the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple myxofibrosarcoma
Treatment: Positron Emission Tomography and Computed Tomography (PET CT)
The insurer denied coverage for PET CT.
The denial is upheld.

The patient has diagnosis of multiple myxofibrosarcoma. The treating provider ordered a surveillance, PET CT, which has been denied by the insurance plan, as not medically necessary.

The PET CT is not considered medically necessary for this patient. The treating provider could have used standard magnetic resonance imaging (MRI)/ CT for disease assessment. The standard imaging for management of limb sarcoma for monitoring is to perform MRI/CT of the affected limb.

"Results and conclusion: As discussed in this review, radiography, ultrasound, CT, and MRI all play key roles in the imaging evaluation of bone and soft-tissue sarcomas. In daily practice, advanced MRI techniques complement standard MRI but remain underused, as they are considered time-consuming, technically challenging, and not reliable enough to replace biopsy and histology." (Igrec J, Fuchsjager MH., 2021)

"Imaging of primary tumor using MRI with or without contrast. A CT with contrast might be used with the MRI." (National Comprehensive Cancer Network, 2020)

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

The insurer's denial of coverage Positron Emission Tomography and Computed Tomography (PET CT) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient presented with vomiting and abdominal pain. He had a past history of Crohn's disease and peptic ulcer disease. He was afebrile and the vita! signs were stable. There was no abdominal rebound or guarding. The white blood cell count (WBC) count was 14.9. The blood urea nitrogen (BUN) was 70 and the creatinine was 2.3. The hemoglobin was 18.1. A computed axial tomography (CAT) scan showed a pneumomediastinum but there was no indication of gastrointestinal pathology. There was no extravasation from the esophagus and no acute interventions were needed. The abdominal pain was felt to be related to a gastroenteritis. Intravenous (IV) hydration was given for dehydration. The gastroenterologist advised proton pump inhibitor (PPI) therapy twice a day and outpatient endoscopic testing. He improved with the(IV hydration and PPI treatment and his diet was able to be advanced. 

Clinical indications for admission for Gastroenteritis include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, vomiting that is severe and not responsive to antiemetics, severe or persistent dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. Severe dehydration is defined as acute kidney failure that results in a two-fold rise in serum creatinine along with hemodynamic instability, altered mental status, severe cardiac arrhythmias, severe hypertension, severe acidosis, or the need for dialysis. The patient had dehydration but did not meet the criteria for severe or persistent dehydration. 

This patient had gastroenteritis resulting in dehydration. IV hydration, PPI therapy, and antiemetics were required. This could have been done with observation status. The pneumomediastinum did not require any acute interventions. He responded to the treatment that was given and was able to have his diet advanced. He did not meet Milliman Care Guidelines (MCG) criteria for admission for Gastroenteritis. 

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 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Arm Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with a history of liver transplant, diabetes, and hypertension. She presented with acute on chronic left arm pain. The pain began after a fall earlier this year. No injury was identified. She has failed medications that include Lyrica and robin.  The patient's vital signs were stable. Her exam was remarkable for arm pain elicited with movement and limited range or motion, slightly decreased left hand grip. She was given Toradol, Robaxin, and morphine in the emergency department with improvement. Labs were remarkable for BUN (blood urea nitrogen) equal to 33, creatinine equal to 1.4 from baseline equal to.93, potassium equal to 5.5, bicarbonate equal to 21. Shoulder CT (computed tomography) was unremarkable. EKG (electrocardiogram) showed sinus tachycardia.
The patient was admitted, and the plan of care included IV (intravenous) fluids, pain management with PO (oral) medications, and MRI (magnetic resonance imaging) shoulder. The next day she continues to have pain. Creatinine was equal to 1.26. Mildly elevated liver function tests (LFTs) were noted. 
MRI (magnetic resonance imaging) of the shoulder showed rotator cuff tear and tenosynovitis. PO (oral) medications for pain management were continued. The plan was to refer for rehab. On the second day, the patient was noted to be clinically stable. Creatinine was equal to .99. Immunosuppressants for liver transplant was being adjusted. The plan was for transfer to transplant center at Mount Sinai. On the third day, she was complaining of shoulder pain. LFTs (liver function tests) were trending up. She was being evaluated for transfer. On the following day, the patient was accepted by Mount Sinai for transfer. The next day, the patient's shoulder pain was better. She was referred for outpatient orthopedics. Her LFTs (liver function tests) were better. Mount Sinai recommended discharge with outpatient follow up. She was discharged the day after.

The Inpatient Hospital Admission was not medically necessary.

This patient with a history of liver transplant was admitted on with acute on chronic arm pain. She was hemodynamically stable and afebrile. She was found to have a rotator cuff tear. Her 
pain improved with management in the emergency department. Labs were remarkable for mildly elevated creatinine and liver function tests (LFTs). She was able to be managed with PO (oral) medications. On the second day, creatinine returned to baseline after IV (intravenous) hydration. The hospital stay was prolonged for monitoring of LFTs (liver function tests) and possible transfer. An acute inpatient admission was not indicated for pain management of a rotator cuff tear or abnormal 
labs. The patient had not failed an observation level of care. The monitoring and consultations preformed during hospital stay could have been performed at a lesser level of care. The inpatient hospital admission from was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

Diagnosis: Abdominal pain with nausea and vomiting
Treatment: Inpatient admission
The insurer denied the hospital stay.
The health plan's determination is upheld.

The patient is a female with peptic ulcer disease, gastritis and cannabis use, who presented to the emergency room (ER) with nausea, vomiting and epigastric abdominal pain. She was noticed to be actively retching. A computed tomography (CT) of her abdomen done 2 days before was unremarkable. The patient was admitted for gastritis, nausea and vomiting thought secondary to marijuana induced hyperemesis. She was given intravenous (IV) fluids, a proton pump inhibitor and anti-emetics.
Her initial vital signs were, blood pressure (BP) 152/84, respiratory rate (RR) 18, heart rate (HR) 51 and her temperature was 99.7. Her laboratory studies were significant for hypokalemia (K) at a level of 3.5. The CT of her abdomen showed low density wall thickening of the lower esophagus and lower peri-esophageal fluid.

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient.
The patient was admitted for nausea and vomiting felt secondary to a marijuana induced hyperemesis syndrome. She did not have intractable vomiting beyond the ER. She did not have severe dehydration with acute renal failure or major electrolyte abnormalities requiring inpatient care. She was hemodynamically stable.
The evaluation of marijuana induced hyperemesis does not require acute inpatient care. "Leaving aside risk factors dependent on the basis of age (e.g., cardiac markers for atypical presentations of coronary syndromes in the elderly, vasculopathy, or neuropathology in patients with diabetes), an appropriate workup in the emergency department includes a metabolic panel to assess for electrolyte derangements as well as degree of dehydration in the form of a prerenal azotemia. Furthermore, a complete blood count (which, paired with an appropriate history, including travel history, which can assess for infectious etiologies), and a urinalysis to determine the presence of a urinary tract infection as well as ketones as a marker for metabolism and nutrition status, are required. An electrocardiogram may be useful to assess the patient's heart rate-corrected (QTc) interval, especially in the context of antipsychotic medication use, as well as before the administration of certain antiemetics, which may prolong the QTc interval to extreme lengths." [1]
The patient did not have a prolonged QTc interval or any dangerous cardiac arrythmias.

The patient had possible gastritis for which she was given a proton pump inhibitor. There was no concern for a gastrointestinal (GI) bleed and she did not require an urgent endoscopy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: 24-hour care, either split shift or live-in Consumer Directed Personal Assistance Services (CDPAS) 
The insurer denied 24-hour care, either split shift or live-in CDPAS.
The denial is overturned.

This is a case review for a female with medical history notable for dementia, congestive heart failure, and chronic obstructive pulmonary disease (COPD). The patient was approved for 96 hours/week of consumer directed personal assistant services (CDPAS). The patient and her care team requested an increase to 24-hour care, either split shift or live-in, and this request was denied by the health plan. This denial is the subject under review.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was found to have severely impaired cognition; she was alert to person and place and able to follow only simple commands. From a functional standpoint, she requires total dependence for meal preparation, housework, managing medications, stairs, and transportation. For her activities of daily living (ADLs), she requires total dependence for bathing, locomotion, and toilet use. She requires maximal assistance for hygiene, dressing upper/lower body, toilet transfer, bed mobility, and eating. Skin integrity is intact. She is frequently incontinent of urine and stool. She has diaper changes every 2-3 hours during the day, and whenever she wakes up at night (which is also usually every 2-3 hours). She requires repositioning in bed which does not always coincide with changing. A task tool associated with the assessment recommended 65 hours/week to meet her personal care needs.

The health plan's determination is overturned.

The requested health service of 24-hour care, either split shift or live-in CDPAS is medically necessary for this patient.

The patient's physician attested that she has continuous personal care needs. This is also reflected in the UAS, which states that the patient needs assistance with turning/positioning and toileting every 2-3 hours during the day and night. This meets the definition of medical necessity for continuous personal care, which is required if the patient's needs cannot be scheduled to occur at certain times during the day and night.

The health plan does not cover personal care services for safety monitoring and supervision alone. Continuous service would not be medically necessary if she did not have demonstrated personal care needs. However, this is not the case. She requires turning and positioning, as well as toileting, every few hours throughout the day and night. Therefore, using a task tool to determine hours is not a valid method of assigning personal care hours. If the patient did not have 24-hour continuous supervision, she would be forced to stay in soiled diapers and not change positions in bed. This could lead to skin breakdown and infection. Attendance to these personal care needs is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sleep Apnea. 
Treatment: Transvenous phrenic nerve simulation. 
The insurer denied transvenous phrenic nerve simulation. 
The determination is upheld. 

The patient has a history of central sleep apnea, hyperlipidemia, and hypothyroidism who was referred for Remede device implantation, a phrenic nerve stimulator. He was seen in consultation and was originally diagnosed with sleep apnea with polysomnography with 29.6 percent (%) of all events central sleep apnea. He had been treated with continuous positive airway pressure (CPAP), which was not tolerated, and subsequently bilevel titration, with which he was compliant. However, he continued to show residual apneas with 23 per hour central apneas. At issue is the medical necessity of transvenous phrenic nerve simulation. 

While the Remede system was approved by Food and Drug Administration (FDA) in 2017, for treating moderate to severe central sleep apnea, data supporting its use are limited, and studies are ongoing. 
Current guidelines, including Milliman guidelines (referenced below) recommend the implantable phrenic nerve stimulator for patients with chronic ventilator dependence due to central alveolar hypoventilation and central alveolar hypoventilation disorder or spinal cord lesion above cervical (C) 3 with certain other conditions, and preoperative confirmation of phrenic nerve and diaphragm function. In this case, the patient does not meet criteria for the phrenic nerve stimulator. The benefits of this new technology have not been definitively established. Some data (reference 2 below) suggest that improvements in central sleep apnea indices ( apnea- hypopnea index) are similar to that with continuous positive airway pressure (CPAP) and other studies (reference three below) have shown a significant (9 percent (%)) incidence of serious adverse events with this new technology.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Back pain.
Treatment:  Intraosseous Basivertebral Nerve Ablation.

The insurer denied Intraosseous Basivertebral Nerve Ablation. The health plan's determination is upheld.

This is a male patient diagnosed with low back pain. Records show that the patient was recommended to undergo the Intracept procedure (intraosseous basivertebral nerve ablation) to treat his low back pain.

The proposed 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.

The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment and injections have not provided lasting relief. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). Although the magnetic resonance imaging (MRI) does show Modic I and II changes, there are also multiple other findings including multilevel annular fissures, varying degrees of canal and neuroforaminal stenosis, as well as facet arthropathy, which are likely pain generators as well. The intracept procedure is not standard of care, as there is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Back pain.
Treatment:  Intraosseous Basivertebral Nerve Ablation.

The insurer denied Intraosseous Basivertebral Nerve Ablation. The health plan's determination is overturned.

The patient is a male who has a 10-year history of low back pain. His pain is localized in the back without radiation to his lower extremities. He had tried epidural steroid injections, medial nerve branch blocks, chiropractic manipulation, and heat and ice therapies without adequate pain relief. Physical exam (PE): significant pain with forward flexion and neurologic examination is intact. Magnetic resonance imaging (MRI): Modic type 2 changes at L (lumbar) 2 superior endplate and L1 inferior endplate, L3/4 disc bulges with annular tears, and L4/5 disc bulges with annular tears and facet hypertrophy.

The Intraosseous Basivertebral Nerve Ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The Intraosseous nerve ablation procedure (INTRACEPT) was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient's persistent back symptomatology is consistent with vertebrogenic pain. He had tried epidural steroid injections, medial nerve branch blocks, chiropractic manipulation, and heat and ice therapies without adequate pain relief. Further interventions are indicated to improve his pain. Other potential treatment options are long-term use of medications (opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario, the requested Intraosseous Basivertebral Nerve Ablation is indicated as the next step intervention.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Back pain.
Treatment:  Intraosseous Basivertebral Nerve Ablation.

The insurer denied Intraosseous Basivertebral Nerve Ablation. The health plan's determination is upheld.

The patient is a male with a history of chronic low back pain. An magnetic resonance imaging (MRI) of the lumbar spine revealed Modic changes. He was treated with chiropractic care, epidural injections and facet blocks. The treating provider recommended Intraosseous Basivertebral Nerve Ablation (Intracept procedure). 

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.

Intracept is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. However, the evidence is insufficient to determine that the technology results in an improvement in the net health outcome. While a recent study has shown promising results, the limitation of most of the studies performed include unavailable long-term comparative data, lack of a sham controls and short duration of follow-up.

In this case, the proposed treatment of the Intracept procedure is not supported by the literature to offer long term relief, and the treating provider does not offer any specific rationale on how this intervention would offer any long term relief for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Upheld

The patient is a female with anxiety and depression who presented to the emergency department with depression. The family reported poor appetite, a quiet demeanor, and not getting out of bed for four days. The patient was alert and oriented x (times) 3 on assessment and had dry, cracked lips. She refused to drink anything. She denied any psychiatric issues. The vital signs showed blood pressure of 116/78, pulse rate of 78, and normal temperature. On examination, other than dry mucous membranes, no abnormalities were noted.

Upon admission, the psychiatrist assessed the patient and documented depression with auditory hallucinations, paranoia, and passive suicidal ideation. They concluded the patient could not care for herself and would benefit from inpatient psychiatric care.
The patient's liver function tests (LFTs) improved. The medical team had ordered a hepatitis panel and concluded the elevation was likely due to fasting. The uncomplicated urinary tract infection (UTI) was treated with oral antibiotics for an additional four days. The patient did not become symptomatic with coronavirus 2019 (COVID-19). The psychiatrist rescinded the plan for inpatient admission and recommended outpatient psychiatric counseling. The patient was safely released home in stable condition.
The subject under review is the medical necessity for an inpatient admission.

Inpatient admission is not indicated. This is a young patient with what appears to be depression, a urinary tract infection, and mildly elevated liver enzymes due to no oral intake in 4 days. The patient is hemodynamically stable, without evidence of sepsis. The urinary tract infection was uncomplicated. The patient tested positive for COVID-19 infection but was completely asymptomatic with no evidence of hypoxemia, respiratory failure, or sepsis. Advanced therapies were not warranted.
From a psychiatric standpoint, the patient did not exhibit active suicidal or homicidal ideation and was subsequently cleared by psychiatry for outpatient treatment.
The liver enzymes were only mildly elevated and can be attributed to 4 days of not eating. There is no evidence of acute liver failure, synthetic dysfunction of the liver, increased risk of bleeding, or severe hepatic encephalopathy.
The patient could have been safely managed at a lower level of care status.