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

Diagnosis: Chest Pain
Treatment: Inpatient Admission
The health plan denied the inpatient hospital stay as not medically necessary. The health plan's determination is upheld.

The patient is a male with diabetes who presented to the emergency department (ED) with complaints of chest pain. The pain was present for four days, described as a 5 out of 10 pressure sensation to the middle of the chest, radiating to the left arm. The pain was exacerbated by exertion, particularly by climbing stairs or lifting heavy objects. He saw a new cardiologist as an outpatient and was referred for an assessment. Assessment in the ED with cardiac enzymes showed normal values. At admission, he appeared comfortable, with only 2 out of 10 left-sided chest pain. Cardiology was contacted, who recommended a left heart catheterization.
The temperature was normal; the heart rate was 59 beats per minute (bpm), and the blood pressure was 124/80 millimeters of mercury (mmHg), all completely normal. Oxygenation was also normal. A cardiac examination revealed a regular rate and rhythm, no murmurs, and no pedal edema. The lungs were clear. The rest of the labs showed stable electrolytes, normal renal function, and normal liver function tests (LFTs). The hemoglobin was 15.2.
A twelve-lead electrocardiogram (EKG) showed sinus bradycardia, with T wave inversions. A bedside echocardiogram revealed a preserved ejection fraction with no segmental wall motion abnormalities.
The next day, laboratory studies remained stable, with normal electrolytes, renal function, and repeat LFTs. The cardiac markers remained unremarkable. The medical team documented unstable angina as the diagnosis. A stress test was completed, which was completely normal. The heart catheterization plan was canceled. The patient was released home.
At issue is the medical necessity of the inpatient admission.

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

The requested inpatient admission was not medically necessary for this patient. This was a chest pain rule-out presentation, with some typical concerning angina features; however, there were no signs of the acute coronary syndrome. The echocardiogram and stress test were normal. Therefore, there was no indication of inpatient admission. The clinical guidelines on chest pain evaluation, established by the American Heart Association support this. Inpatient admission is indicated in the setting of a true acute coronary syndrome, non-ST elevation myocardial infarction (MI), and ST elevation MI that requires treatment with an urgent heart catheterization and parenteral administration of heparin. However, this hospitalization did not reach the severity of illness typical of the acute coronary syndrome. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Osteoarthritis
Treatment: Personal Care Aide (PCA) Level 2: 7 hours per day - 7 days per week - for a total of 49 hours per week
The insurer denied: Personal Care Aide (PCA) Level 2: 7 hours per day - 7 days per week - for a total of 49 hours per week
The denial is: Overturned in part

The patient is a female with medical history notable for osteoarthritis, inflammatory arthritis, and heart disease. The patient is approved for 5 hours per day, 4 days per week and 4 hours per day, 2 days per week (total of 28 hours per week) of level 2 personal care services. The patient requested an increase to 7 hours per day, 7 days per week (49 hours per week). This request was denied by the insurance company, and this denial is the subject under review.

The health plan's determination is overturned in part. 

The requested Personal Care Aide (PCA) Level 2: 7 hours per day - 7 days per week - for a total of 49 hours per week is not medically necessary for this patient.
The patient has severe limitations in mobility due to arthritis that impact her ability to perform Instrumental activities of daily living (IADLs) and activities of daily living (ADL's). This is clearly documented in the UAS assessment. She demonstrated worsening in functional status in the most recent functional assessment and should have a commensurate increase in personal care hours. The task tool recommends 33 hours per week as a minimum to address her personal care needs. It would seem appropriate to provide her with this level at a minimum. Given her needs, she should receive personal care 7 days per week.
Personal Care Aide at 5 hours per day, 7 days per week is medically necessary for this patient. This would meet the minimum set forth by the task tool and should account for her personal care needs as described by both the patient and the Uniform Assessment System (UAS).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intramural Leiomyoma of Uterus.
Treatment: transcervical RF ablation.
The insurer denied transcervical RF ablation. 
The health plan's determination is upheld.

In this case, the patient is a female with painful and heavy menses. She was noted to have two fibroids on ultrasound measuring 4 centimeter (cm) each in diameter. The patient is under consideration of a transcervical, radio frequency ablation via the Sonata system. Ultrasound has diagnosed her with two fibroids of 4.6 x 4.3 x 4.3 cm and 4.3 x 3.5 x 3.6 cm. The endometrium is 4 millimeter (mm) on exam. The patient has a Mirena intrauterine device (IUD) for contraception. She has also considered D&C (Dilation and curettage) or hysterectomy. Under review is the medical necessity of Transcervical Radiofrequency (RF).

The transcervical RF (radiofrequency) ablation is not medically necessary for this patient.
After review of the medical documentation, there is no medical necessity for performance of the requested procedure for fibroids. The patient has two small fibroids and no prior trial of medical management for this and the bleeding.
In this case, the patient is under consideration of the Sonata procedure (radiofrequency ablation guided by ultrasound) for treatment of fibroids. The Sonata procedure utilizes real-time intrauterine ultrasound guidance with targeted radiofrequency ablation to treat symptomatic uterine fibroids. This therapy is Food and Drug Administration (FDA) cleared at this time. The procedure in this case for a patient with fibroids in the wall of the uterus that are small as described in the clinical material would not be standard of care and would not be a recommended therapy for management of leiomyomas in the uterus.
There are short term studies of this technology - a 12 month trial of Sonata among 147 patients who were treated in a single arm interventional trial. The bleeding was noted to decrease but not totally abate with the therapy. There was a reduction in bleeding. Satisfaction was noted with the procedure. However, this was a short term followup trial without long term outcomes. There was a second study also accessed at clinicaltrials.gov that noted an increased risk for intrauterine adhesions following the procedure which would be associated with abnormal bleeding and pain. Unfortunately, this was a smaller study of 34 evaluable patients with 6 having the outcome of adhesions in the uterus. A study of 125 patients noted a low surgical reintervention rate at 12 months after the Sonata procedure. However, again, long term outcomes from randomized controlled trials are missing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status Post Gastric Bypass Surgery.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female with BMI (body mass index) of 52. She presented to the ED (emergency department) with the complaint of abdominal pain and fever. Of note, she had undergone laparoscopic removal of a lap band with conversion to single anastomosis duodenal switch for the condition of refractory morbid obesity. Her surgical drain placed at the time of surgery on had been removed 8 days later. Vital signs at the 
time of presentation were notable normal temperature, heart rate and blood pressure. Examination revealed tenderness in the area of the drain site on the right side of the abdomen. The WBC (white blood cell) count was elevated at 13.2 K (thousand). Abdominal CT (computed tomography) was obtained and was interpreted as showing normal and expected post-surgical changes of recent bariatric surgery. The patient was initially treated with NPO (nothing by mouth) status, IV (intravenous) fluid and follow up lab data. On day #2 the records indicate that the patient was clinically stable with normal vital signs. A CT (computed tomography) scan with oral contrast was performed that showed no evidence for enteric leak. The WBC (white blood cell) count had normalized to 9.9 K (thousand). On the following day the patient was comfortable and the WBC (white blood cell) count was normal at 6.9 K (thousand). The patient was deemed stable for discharge from the hospital. She was prescribed a course of oral antibiotics..The health plan rationale for denial of inpatient care was based on InterQual Acute Adult General Medical 2022. The denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

The care and treatment provided during this time could have been rendered with a lower level of care and did not require an inpatient designation. This lower level of care would have provided for surgical assessment, IV (intravenous) fluid, follow up, labs/imaging, and overnight monitoring over a period of 48-hours. This patient was clinically stable at the time of presentation. She was nine days status post revisional bariatric surgery. She was appropriately monitored for her complaints of abdominal pain and fever. She remained clinically stable and was without a diagnosed complication of her recent surgery that required acute surgical intervention. She responded appropriately to the treatment provided with normalization of the WBC (white blood cell) count and was able to be discharged 
from the hospital 2 days later.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric Pain. 
Treatment: Inpatient Admission. 

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

The patient is a female with medical history of diabetes mellitus type 2, hyperlipidemia, and hypertension. She presented to the emergency department with epigastric pain since the night before. Vital signs were unremarkable. Physical examination was notable for appearance of acute distress, soft abdomen with moderate epigastric tenderness, negative Murphy sign, and lack of guarding or rebound abdominal tenderness. 

The inpatient hospital admission was not medically necessary. The patient presented with concern for symptomatic cholelithiasis and cholecystitis. However, there was no persistent hemodynamic instability or other complications such as ascending cholangitis, hepatic abscess, active gastrointestinal bleeding, peritonitis, fistula, or sepsis, which would require a higher level of care. Laparoscopic cholecystectomy was not complicated by postoperative pneumonia, bile leak, bleeding, sepsis, or other complications. Although liver enzymes (transaminases) were elevated, there was no evidence of biliary obstruction, or intervention such as endoscopic retrograde cholangiopancreatography to diagnose or address biliary obstruction. The care provided, including monitoring, labs, imaging, specialist consultations, and cholecystectomy could have been performed at a lower level of care. For these reasons, the inpatient level of care is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pre-exposure prophylaxis for HIV
Treatment: Descovy 200 milligrams (mg) - 25mg tablet 
The health plan denied the requested Descovy 200 mg - 25 mg tablet as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with bipolar disorder, anxiety, hypertension (HTN), and attention deficit disorder (ADD). He is taking Lithium, Wellbutrin, Adderall XR, Ativan, and is also on human immunodeficiency virus (HIV) prevention medications (PrEP). He had been taking Descovy for PrEP. Labs showed a serum creatinine of 0.8. The provider ordered Descovy. A letter from the provider states the patient cannot be changed to Truvada because "he is anxious of starting a new medication" and that this "will negatively affect adherence" which "will result in high-risk HIV exposure."

The health plan clearly states that Descovy is considered medically necessary when ONE of the following criteria are met:

1) Documentation of estimated glomerular filtration rate (eGFR) less than (<) 60 milliliters/minute (ml/min)/1.73 millimeters (mm) squared. 2) One of the following: a) Diagnosis of osteoporosis, per definitions provided. b) Diagnosis of osteopenia, per definitions provided. c) Documentation of a prior low-trauma or non-traumatic fracture. d) Documented history of clinical risk factors for osteoporosis. 3) Documentation of a history of adverse event or intolerance to Truvada, or otherwise medically inappropriate.

At issue is the medical necessity for the requested health service/treatment of Descovy 200 milligrams (mg) - 25 mg tablet.

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

The requested health service/treatment of Descovy 200 mg - 25 mg tablet is not medically necessary for this patient.

Although the provider states patient will have anxiety about changing from Descovy to Truvada, and as a result will not be adherent to the PrEP, this appears to be a highly subjective determination and with nothing in the record to indicate this patient has had adherence issues with any of his medications. Medically, there is no contraindication to this patient taking Truvada, and any concerns he may have might be allayed by discussion with the provider and ongoing monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Myeloma
Treatment: Chemotherapy and related admission
The insurer denied the chemotherapy and related admission.
The denial is upheld.

The patient is a male with relapsed lambda light chain multiple myeloma. The patient was previously treated with induction bortezomib + (plus) Doxil + dexamethasone and achieved a complete remission (CR). He went on to an auto blood and marrow transplant (BMT) and was on lenalidomide maintenance therapy. He relapsed 8 years later and was treated with CyBorD followed by carfilzomib + dexamethasone + lenalidomide. Upon progression, he received daratumumab + pomalidomide + dexamethasone and subsequently had progressive disease. The patient was admitted for chimeric antigen receptor T (CAR-T) therapy on a clinical trial (membrane associated RING-CH [MCARH109], a G protein coupled receptor family C [GPRC5D] targeted CAR-T therapy). Treatment and related admission is under review for medical necessity.

The requested treatment and related admission is not medically necessary. It should be noted that b cell maturation antigen (BCMA)-targeted CAR-T therapy is the treatment of choice for penta-refractory patients with myeloma, as this patient is. However, this patient was treated with a different type of CAR-T therapy (GPRC5D targeted) within the context of a clinical trial. By definition, this therapy is not medically necessary as it is not known to be effective nor safe. The primary endpoint of the study this patient was treated on (National Clinical Trial [NCT] 04555551) is maximum tolerated dose and the secondary outcome of this trial is response rate. For these reasons, medical necessity cannot be established for this service and associated admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza A and parainfluenza Type 3.
Treatment: Infectious agent detection by nucleic acid.
The insurer denied: Infectious agent detection by nucleic acid.
The denial is: Upheld.

The patient is a male that presented for medical care with two and a half days of fever of 103 degrees Fahrenheit (F) at had resolved by the morning of presentation as well as a rash on his upper back that developed when his fever resolved and runny nose. On exam, he was in no acute distress, with temperature was 38.0 degrees Celsius (C), non-pruritic non-tender maculopapular rash on the upper back, clear oropharynx, clear lungs, and non-focal neurologic exam. A respiratory pathogen panel was obtained, and he was discharged with instructions to continue supportive care. The panel returned positive for influenza A H3 (virus) and parainfluenza type 3.

The health plan's determination is upheld.

The infectious agent detection by nucleic acid panel was not medically necessary.
This patient presented with signs and symptoms consistent with mild viral infection, including fever and runny nose. The rash developed after the fever resolved, which is not uncommon in viral infections. His medical history was unremarkable, with no reported chronic illnesses, no history of asthma, no history of immunodeficiency. His examination was unremarkable except for the rash on his upper back. There was no documented medical indication for testing, no decisions to be made based on the results of the testing. Antibiotics would not have been indicated with or without the viral panel. If the physician was concerned about influenza with the plan to start antiviral therapy, specific testing for influenza would have been reasonable. The respiratory pathogen panel really is most useful for cohorting patients in the hospital setting or in very young children and infants where fever without source might indicate serious bacterial infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Familial hypercholesterolemia.
Treatment: Repatha.
The insurer denied Repatha.
The determination is overturned.


This is a patient with a history of type 2 diabetes, hypertension, hyperlipidemia, coronary artery disease, myocardial infarction and percutaneous coronary intervention. On rousuvastatin 40 milligrams (mg) daily and ezetimibe 10 mg daily, his low density lipoprotein (LDL) cholesterol level was 55 milligrams per deciliter (mg/dl). The medical necessity for Repatha (evolocumab) is at issue.

Based on the documentation provided, Repatha is medically necessary.
This patient has premature atherosclerotic cardiovascular disease as well as diabetes, both of which place him in the "extreme risk" category. Per the American Association of Clinical Endocrinologists an LDL cholesterol level goal of less than 55 mg/dl is recommended for extreme risk patients. This approach has been shown to have a salutary effect on health outcomes. In the 2018 report by Sabatine et al, a meta-analysis of 32 trials showed that patients with LDL cholesterol levels of less than 70 milligrams per deciliter (mg/dl) benefited from further lowering of their levels with statins or nonstatin drugs to the same degree as patients with higher baseline levels did. The risk of major vascular events was significantly reduced by 21 percent (%) for each 1 millimole per liter (mmol/L) (38.7 milligrams per deciliter (mg/dL)) reduction in LDL cholesterol, which was virtually the same magnitude as seen in the overall Cholesterol Treatment Trialists Collaboration analysis in which the starting level was nearly twice as high. These data parallel observational data showing progressively greater coronary atherosclerotic plaque regression and progressively lower adjusted risk of major vascular events with progressively lower levels down to less than 0.2 mmol/L (7 mg/dL).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Crohn's Disease
Treatment: Simponi 100 milligrams/milliliter (mg/ml) syringe
The insurer denied Simponi 100 mg/ml syringe.
The denial is upheld.

The patient is a male with severe Crohn's disease and has had prior bowel resection. He has previously tried and failed therapy with steroids, an anti-tumor necrosis factor (TNF) agent (adalimumab) and an interleukin (IL)12-23 (ustekinumab). He was restarted on Simponi last year and initially responded but recently lost response. Therapeutic drug monitoring revealed low golimumab (Simponi) levels. Therefore, the attending gastroenterologist would like to re-induce Simponi followed by an escalated dose of 100 milligrams (mg) every 2 weeks to treat this patient's Crohn's disease.

The subject under review is whether the requested treatment with Simponi is likely to be more beneficial for this patient's Crohn's disease than any standard treatment.

The proposed Simponi 100 milligrams per milliliter (mg/ml) syringe is not likely to be more beneficial than any standard treatment or treatments for the patient's condition.

Crohn's disease results from a pathological immune response to luminal antigens in genetically predisposed individuals. Since the causes of Crohn's disease are complex and only partially understood, treatment is based on the empiric use of anti-inflammatory drugs. Although multiple therapies for Crohn's disease currently exist, a substantial proportion of patients are unresponsive to conventional agents. Approximately a third of patients fail treatment with TNF antagonists, and up to 40% (percent) of patients who initially benefit subsequently lose response. Early biologic therapy is recommended in patients with inflammatory bowel disease and poor prognostic factors and in those refractory to conventional medications. Anti-TNF agents infliximab and adalimumab currently constitute the major biological therapy in inflammatory bowel disease (IBD).

Simponi is not Food and Drug Administration (FDA) approved in the United States for treatment of Crohn's disease. Small studies and case series done in outside the United States have shown that Simponi can be used in patients with Crohn's disease previously treated with anti-TNF therapy. However, the studies concluded that further studies should be performed in Crohn's disease to formally assess the efficacy of golimumab in a randomized controlled trial and to establish the optimal dosing regimen. There are some data on dose escalation of Simponi for ulcerative colitis (UC) but not for Crohn's disease.

Therefore, unless this patient has failed all FDA approved therapies for Crohn's disease and has documented medically refractory Crohn's disease and has exhausted all classes of biological therapy, Simponi is not likely to be more beneficial than any other standard treatment.