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

Diagnosis:  Crohn's disease.
Treatment:  Stelara intravenous (IV) injection.

The insurer denied coverage for Stelara intravenous (IV) injection.  The denial is overturned.

The patient is a teenager with Crohn's disease that was diagnosed several months ago. The patient was having abdominal pain and rectal bleeding. The patient was initially treated with mesalamine and then Entocort. A repeat colonoscopy was performed after the patient failed to respond to treatment. Colitis and enteritis of the terminal ileum were found. A capsule endoscopy showed ulcerations in the small bowel. Her physician is now requesting to start Stelara, 

The physician has submitted an article from The Journal of Pediatric Gastroenterology and Nutrition 2019 Jul;69(1):61-67 titled "Real World Experience with Ustekinumab in Children and Young Adults at a Tertiary Care Pediatric Inflammatory Bowel Disease Center." The conclusions were that greater than 50% (percent) of pediatric patients achieved clinical remission on ustekinumab by week 52. There were higher remission rates in bio-naive patients versus patients who were previously exposed to biologic therapy. Over 90% of patients maintained good ustekinumab concentrations at 52 weeks. It was advised that ustekinumab is efficacious and safe in pediatric irritable bowel disease (IBD) patients for both Crohn's disease and ulcerative colitis. 

Clinical Gastroenterology and Hepatolgy 2023;21 :2359-2369 has an article titled "Comparative Safety and Effectiveness of Biologic Therapy for Crohn's Disease: a CA- IBD Cohort Study." In this study, the safety and effectiveness of tumor necrosis factor (TNF) antagonists were compared to vedolizumab and ustekinumab. The conclusion was that ustekinumab was associated with a lower risk of serious infections compared to TNF antagonists. 

This patient has IBD, and the physician now feels that the patient requires biologic therapy. Ustekinumab (Stelara) has been shown to be safe and effective in the pediatric population. The recent article from Clinical Gastroenterology has shown that there is less risk of infection with ustekinumab while still being as effective as the TNF antagonists. 

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 Stelara intravenous (IV) injection is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Brain cancer. 
Treatment: 5 fraction(s) (treatment sessions) of Multi-Fraction Cranial Stereotactic Radiosurgery (SRS). 
The health plan denied: 5 fraction(s) (treatment sessions) of Multi-Fraction Cranial Stereotactic Radiosurgery (SRS). 
The determination is upheld. 

The patient is a female with a history of stage four lung cancer with metastasis to her brain. Her magnetic resonance imaging (MRI) scan shows between 10-20 enhancing brain lesions. She has been recommended to proceed with a course of external beam radiotherapy with palliative intent. 
At issue is the medical necessity of 5 fraction(s) (treatment sessions) of Multi-Fraction Cranial Stereotactic Radiosurgery (SRS). 
The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of 5 fraction(s) (treatment sessions) of Multi-Fraction Cranial Stereotactic Radiosurgery (SRS) is not medically necessary given the large number of lesions to be treated. SRS has not been proven to be safe and effective as compared to standard of care, which is whole brain radiation, in the patient's setting. The use of SRS to treat 10-20 brain lesions is not supported per the current literature and is not supported by any expert consensus guideline found.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate cancer
Treatment: Eligard 22.5 milligram (mg) injection
The insurer denied coverage for Eligard 22.5 milligram (mg) injection.
The denial is upheld.

This patient had a history of prostate cancer, status post radical prostatectomy many years ago. Prostate specific antigen (PSA) was monitored, found to be rising. Computed tomography scan/ bone scan was negative. Patient given Eligard injection (22.5 milligram) and the Prostate specific antigen was then (less than) <0.08. The insurer has denied Eligard as not medically necessary. Eligard is a Luteinizing Hormone Releasing Hormone (LHRH) agonist, along with Lupron. It is generally indicated for advanced prostate cancer, although it can be used along with radiation therapy for treatment of high-grade localized prostate cancer. This patient had radical prostatectomy. Ideally salvage radiation is considered when the PSA after radical prostate surgery rises to level of 0.2 or greater. If this patient had salvage radiation prior to the Eligard therapy, then the only treatment for his rising Prostate specific antigen would be hormonal therapy or androgen deprivation therapy (ADT), such as Eligard, Lupron etc. If this patient has not had prior salvage radiation; and his imaging studies are negative, as in this case, he could be considered for local salvage radiation therapy, prior to the initiation of hormonal therapy or androgen deprivation therapy (ADT). It should be noted that the best imaging study for this patient now would be a prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scan, not the computed tomography/bone scan, which are considered conventional imaging, whereas the PSMA-PET scan is considered NGI (Next generation imaging). This patient is considered to have biochemical recurrence of PSA (Prostate specific antigen) after his surgery, not necessarily advanced prostate cancer. His imaging studies showed no evidence of metastases.

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient.

Eligard -22.5 mg (milligram) injection is not considered medically necessary for this patient.

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 Eligard 22.5 milligram (mg) injection is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystitis/Inflammation of the Gallbladder
Treatment: Inpatient hospital admission
The insurer denied the Inpatient hospital admission. 
The health plan's determination is overturned.

This patient presented to the emergency room (ER) with complaints of right upper quadrant (RUQ) pain for several weeks. In the ER, the patient had a temperature of 101 with pain and emesis. The patient was found to have mild leukocytosis. A computed tomography (CT) scan showed cholelithiasis with gallbladder wall thickening. An ultrasound revealed cholelithiasis and thickened gallbladder consistent with acute cholecystitis. The patient was started on intravenous fluids (IVF), intravenous (IV) antibiotics and a decision was made to proceed with laparoscopic cholecystectomy. The patient was found to have a necrotic gangrenous gallbladder and a drain was left in place and the patient was continued on antibiotics. Post-operatively, the patient had initial pain control issues, which improved. The patient was discharged home. At issue is the medical necessity of Inpatient hospital admission.

The requested health service/treatment of Inpatient hospital admission was medically necessary for this patient.
Although most elective laparoscopic cholecystectomy for biliary colic or symptomatic cholelithiasis can generally be managed in the ambulatory or outpatient setting, this patient presented with pain for several weeks with findings of tachycardia, fever, and leukocytosis. A decision was made to proceed with surgery where the patient was found to have a necrotic gangrenous gallbladder. The patient was continued with IV antibiotics and downtrending of labs was documented and an improvement in pain control was noted. The patient was discharged home with a Jackson-Pratt (JP) drain in place and an oral antibiotic.
Therefore, the requested Inpatient hospital admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/Neuromuscular
Inpatient Hospital

Diagnosis: Transiently altered mental status
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a medical history significant for hypertension, hyperlipidemia, chronic ischemic stroke, and deep venous thromboembolism on Xarelto who presented to the hospital with transiently altered mental status. The emergency room admitted the patient for evaluation of a transient ischemic attack. No focal neurologic deficits were noted. In the emergency department, the patient underwent a computed tomography (CT) scan of the head that was unremarkable for any acute changes and computed tomography angiography (CTA) of the head and neck that showed mild atherosclerotic disease. After admission, the patient underwent a magnetic resonance imaging (MRI) scan of the brain that showed no stroke or other ischemic pathology. The patient was treated with oral anticoagulants and anti-platelet agents of Xarelto and aspirin. She was treated with a statin. The patient was subsequently discharged home as the altered mental status was transient and imaging was negative. At issue is the medical necessity of an inpatient stay.

An acute hospital admission for evaluation of a transient ischemic attack is not the standard of care. The patient presented to the hospital with transiently altered mental status. There were no focal neurologic deficits demonstrated to support a transient ischemic attack. The initial imaging in the emergency department did not show any acute pathology on the CT scan of the head or CTA of the head and neck. The patient's mental status improved during an observation time frame. The patient underwent a negative MRI of the brain that confirmed that a stroke was not present. During the admission, the patient did have any significant vital sign or laboratory abnormalities. The patient was treated with her usual home medication, which was provided by mouth. The patient did not require any complex rehabilitation or nursing services. Based on all of the above, a lower level of care was the most appropriate status for this patient. She did not meet the level of complexity or intensity required for an acute inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with diabetes mellitus type two who presented to the hospital for evaluation of left-sided numbness and tingling. The patient was admitted to the hospital for further evaluation and underwent a computed tomography angiography (CTA) scan of the head and neck that was unremarkable. The patient declined a magnetic resonance imaging (MRI) scan of the brain due to claustrophobia. The patient's weakness improved early on in the hospitalization. She was treated with aspirin and a high intensity statin after neurologic consultation. The patient was noted by internal medicine to have poorly controlled type two diabetes with a hemoglobin A1C of 8.9 percent (%). She was referred to an outpatient endocrinologist. The patient was discharged home with outpatient follow up. She did not require outpatient physical therapy. At issue is the medical necessity of an inpatient stay.

The acute inpatient hospitalization was not medically necessary for treatment of this patient's transient ischemic attack. The patient was initially admitted to the hospital with complaints of left-sided numbness and weakness. The neurologic deficits were transient and improved during the hospitalization. The patient returned to her neurologic baseline. She did not require any complex neurologic nursing or rehabilitation services. The patient did not have any acute abnormality on imaging. A computed tomography angiography (CTA) of the head and neck was unremarkable. An MRI of the brain was not performed in order to demonstrate a definitive stroke. She did not receive thrombolytic therapy, thrombectomy, parenteral anticoagulation, or other emergent vascular procedure. The patient did not have any significant vital sign abnormalities. All of the abnormal lab work was secondary to chronic conditions such as poorly controlled diabetes mellitus and hyperlipidemia. The patient was treated with oral medications such as aspirin and a statin. The intensity of services was not consistent with inpatient admission and the required services could have been completed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain, rectal bleeding. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is overturned. 

This is an adult female patient with asthma, Crohn's colitis, diabetes mellitus, hypertension, multiple sclerosis, pulmonary embolism and deep vein thrombosis, seizure disorder, and lupus, who presented to the emergency room for urgent evaluation of severe and progressive abdominal and suprapubic pain with intermittent rectal bleeding. The patient had increased frequency of loose blood stools and low-grade fevers. The patient had a poor appetite. On exam, the patient was found to have abdominal tenderness to palpation of the left lower quadrant (LLQ) with guarding. The white blood cell (WBC) count was 12.4. The patient was treated with intravenous antibiotics, intravenous fluids, mesalamine, Protonix, intravenous morphine, loperamide, and intravenous methylprednisolone. The treating physician's clinical impression was acute gastroenteritis likely secondary to acute Crohn's/ulcerative colitis flare. The treating physician's evaluation plan and treatment course for the patient consisted of 
Gastroenterology consultation, Rheumatology consultation, continuation of intravenous fluids, continuation of intravenous antibiotics, intramuscular Dilaudid for pain, and close monitoring of the patient's signs and symptoms. While undergoing proper and expert medical care, the patient eloped leaving the hospital against medical advice (AMA) on day #2. 

The proposed treatment was medically necessary. 

An inpatient level of stay was medically necessary since the patient had an elevated white blood count (WBC) count, required treatment with intravenous fluids, required treatment with intravenous pain medications and required treatment with intravenous steroids. This level of treatment requires inpatient level of care. The medical records do support that the acute inpatient admission was medically necessary. The patient did require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would have been threatened by providing the care given in a lower level of care setting. Therefore, based on review of the submitted medical records, the requested inpatient level of care was medically necessary for the dates of service in question as it required the intensity of level of care necessary to provide safe, adequate and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, Vomiting
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female child with a medical history significant for a urinary tract infection two weeks prior who presented to the emergency department (ED) with a two-day history of abdominal pain, nausea, vomiting, headache, low-grade fever 99-100 degrees Fahrenheit, not tolerating fluids. She had no diarrhea. She was seen by her pediatrician the day prior and was prescribed Zofran, with some relief.  A chest x-ray revealed diffuse peribronchial thickening and cuffing bilaterally mid to upper hila with left greater than right perihilar airspace disease. She was treated with intravenous (IV) fluids and Tylenol. On re-evaluation, she was refusing to drink, with clinical dehydration. At this time, she had no complaints of abdominal pain. She was evaluated again in the ED after being admitted and was complaining of abdominal pain, with mid-abdominal tenderness on exam without guarding or rebound. An abdominal ultrasound was obtained, with no clear explanation for her pain. An abdominal computed tomography (CT) scan was negative.
Admission orders included intravenous (IV) fluids with 6% dehydration correction, regular diet as tolerated, azithromycin for community acquired bronchopneumonia, and routine vital signs. The following day, her appetite had returned, and she was tolerating fluids by mouth. By rounds in the morning she had no complaints of nausea. The headaches had resolved and she was afebrile She was deemed stable for discharge to follow-up in the next 24-48 hours. At issue is the medical necessity of an inpatient stay.

An acute inpatient hospital admission was not medically necessary.
This young female child presented with vomiting and abdominal pain, clinically dehydrated on exam. Evaluation yielded adenovirus infection. She was unable to tolerate fluids in the ED so was admitted. While it was reasonable to monitor her in the hospital while providing intravenous (IV) hydration, she was overall hemodynamically stable with no significant metabolic derangements and no evidence of impending shock. She did not require acute inpatient admission and could have been safely managed at lower level of care.

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

Diagnosis: Cardiac/Circulatory Problems/ Other/ Cardiac Catheterization with Percutaneous Cardiac Intervention
Treatment: Inpatient Hospital/ Inpatient admission stay
The health plan has denied the requested treatment, inpatient admission stay, as not medically necessary. The health plan's determination is upheld.

This case involves a male with a history of hypertension, hyperlipidemia, active cigarette smoker, and type 2 diabetes mellitus who underwent an outpatient stress test which was abnormal. He was then referred for a left heart catheterization. The patient's vital signs were stable. An electrocardiogram (ECG) demonstrated normal sinus rhythm and an age-indeterminate inferior infarct. The report of catheterization revealed high grade stenosis of the distal left main artery into the proximal left circumflex artery (LCX) and left anterior descending artery (LAD) which required bifurcation stenting of the LAD and LCX. The right coronary artery (RCA) and distal LAD were chronically occluded. Cardiothoracic Surgery was consulted, but the patient was turned down for a coronary artery bypass graft (CABG) due to poor target vessels. Post procedure, the patient reported to nursing staff he was experiencing visual disturbances, floaters in both eyes, which resolved after intravenous fluids (IVF) hydration. The patient was admitted under inpatient level of care post percutaneous coronary intervention (PCI) and was monitored on telemetry overnight. The patient remained hemodynamically stable and asymptomatic without recurrences of visual disturbances. He was subsequently discharged home the following day.

At issue is the medical necessity of an inpatient admission stay.
I recommend that the health plan's determination be upheld, in whole.

The inpatient level of care was not medically necessary post PCI for the following reasons.
The patient presented for an elective cardiac catheterization for evaluation of a recent abnormal stress test. The patient was found to have multivessel PCI requiring bifurcation stenting of the proximal LAD and left circumflex arteries. The patient experienced a brief episode of "floaters" post PCI which resolved. The patient remained otherwise asymptomatic, tolerated the procedure well, and remained hemodynamically stable post PCI. He was monitored on telemetry overnight without events and was discharged home the following day. For these reasons, the inpatient level of care was not medically necessary in this case after an elective PCI. Rather, an overnight alternate level of care would have been medically appropriate and safe in this case supported by expert consensus guidelines on the length of stay post PCI from the Society for Cardiovascular Angiography & Interventions. [1,2]
Appeal type: Medical necessity
Decision: Upheld

cancer
radiation therapy

Diagnosis: cancer
treatment: radiation therapy
The insurer denied Stereotactic Body Radiation Therapy (SBRT). The health plan's determination is upheld. 

This is the case of a patient with metastatic disease to the spine who is being evaluated for Proton beam Stereotactic Body Radiation Therapy (SBRT) to L (lumbar) 2-L4 spine. This is the subject of review.

The requested Stereotactic Body Radiation Therapy (SBRT) is not medically necessary for this patient.
Medically necessary treatment is defined as those which are in accordance with Generally accepted standards of medical practice. The generally accepted standard of medical practice for spine metastasis is photon based intensity modulated radiation therapy (IMRT) in the United States. The National Comprehensive Cancer Network (NCCN) guidelines do not support SBRT for spine metastasis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Wegovy. 
The insurer denied Wegovy. 
The health plan's determination is overturned. 

This is a male diagnosed with obesity and obstructive sleep apnea. His body mass index (BMI) is 26.45; his weight is 88.5 kilograms (kg). His obesity is complicated by elevated glucose, arthritis, and a past BMI of 28. He tried and failed Ozempic due to supply chain issues and being unable to obtain the medication, and nausea. He has been on Wegovy  with a positive response, and his weight went down from 202 pounds (lbs.) to 195 lbs.
At issue is the medical necessity of Wegovy. 

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

The requested health treatment of Wegovy is medically necessary for this patient.
Semaglutide is a glucagon-like peptide 1 receptor (GLP1R) agonist (1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity. (2-4) Recent studies published in peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity. (5-7) This medication is now available for the treatment of obesity in the form of Wegovy. 
The standard of care requires that the patient is participating in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension and hyperlipidemia. The request is for continuation of therapy. The patient has lost seven pounds on the requested medication. The patient had a pretreatment BMI greater than or equal to 27 with comorbidity of obstructive sleep apnea. Continuation of therapy is appropriate. The request meets the standard of care and therefore Wegovy is medically necessary.