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

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied radiofrequency ablation. 
The denial is overturned. 

The patient is a male with a history of chronic low back pain. Per a letter of medical necessity, it is noted that the patient underwent 2 separate lumbar medial branch blocks in the last 12 months which provided 80% analgesic benefit. The physical exam revealed positive facet loading bilaterally.
Under review is the medical necessity of lumbar facet ablation.

The requested outpatient surgery services (radiofrequency ablation) is medically necessary for this patient.
The optimal patient for radiofrequency medial branch neurotomy is a patient who has chronic pain lasting greater than 3 months, who has failed conservative treatment, and who has had a positive response to facet joint blocks.
Facet joint injections or medial branch blocks have therapeutic utility, in that a positive block predicts a good chance of obtaining complete relief of pain from percutaneous radiofrequency neurotomy. However, control blocks are essential to exclude false positive responses and to maximize the confidence of securing a true-positive response.
The available data on the sensitivity and specificity of comparative blocks were all based on complete relief of pain. There are no equivalent data for 75% relief or 50% relief of pain. Although it might be attractive to believe that the same values apply this is unlikely to be so. Theoretically, one would expect increasingly weaker specificities for criteria with lesser relief of pain.
In this case, it is clear that the patient had an appropriate amount of conservative treatment, made routine follow up visits and unfortunately has persisting pain. Therefore, the requested procedure is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia areata

Treatment: Xeljanz

The insurer denied coverage for Xeljanz
The denial is overturned

The patient is a female who has a diagnosis of alopecia areata that is severe and involves multiple areas of the scalp as well as the eyebrow. The patient has failed therapy with anthralin, steroid, ILK (intralesional kenalog) injections, tacrolimus ointment, topical tofacitinib, clobetasol solution, squaric acid in acetone, and Rogaine treatments without significant improvement. The requested medication is Xeljanz.  

The patient has extensive disease involvement of alopecia which necessitates systemic therapy. Limited systemic options are available for a child. The patient has failed all alternative therapies that are reasonable. No FDA (food and drug administration) approved systemic therapies are available for treating alopecia areata. In this clinical situation Xeljanz is an appropriate treatment option for treatment of alopecia areata. As a result, the denial is overturned and the use of xeljanz is medically necessary for use in the treatment of the patient's condition at the discretion of the prescribing physician's medical judgment. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the Xeljanz is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Evrysdi. 
The denial is upheld in whole. 

The patient is a female with Type 1 spinal muscular atrophy (SMA). She developed symptoms at 8 weeks, and the genetic diagnosis was confirmed at 20 weeks. According to a letter and clinic visit note the patient has 0 copies of survival motor neuron (SMN) 1 and 2 copies of SMN2. She participated in the Ionis CS3B trial of nusinersen (an antisense oligonucleotide). A ClinTrials.gov search identifies this as the Endear trial. [1] This was a Phase 3, randomized, double-blind, sham-procedure controlled study to assess the clinical efficacy and safety of Isis 396443 (nusinersen) administered intrathecally in patients with infantile-onset spinal muscular atrophy. It is not noted in the records whether the patient was on active drug or randomized to placebo. Subsequently she received nusinersen open label on the Shine study. [2] The provider describes that the patient has stabilized or improved on nusinersen. The patient's last dose of nusinersen on the Shine study was in March 2022. Her family and caregivers are requesting transition to risdiplam (Evrysdi), an orally administered SMN2 gene splicing modifier which leads to higher levels of SMN protein [3]
At issue in this review is whether Evrysdi is medically necessary for this patient.

The health plan's determination is upheld.

The requested Evrysdi is not medically necessary for this patient. Risdiplam (Evrysdi) is the only orally administered drug approved for the treatment of SMA. The drug was Food and Drug Administration (FDA) approved in 2020 for use in patients two months of age and older. Its mechanism of action is as an SMN2 gene splicing modifier leading to higher levels of SMN protein.
There is a lack of documentation that the patient stabilized or had improvement in either her motor function or respiratory function while on nusinersen, an intrathecally administered antisense oligonucleotide. She is tracheostomy and ventilator dependent, with minimal voluntary motor function, and a Children's Hospital of Philadelphia Infant test of Neuromuscular Disorders (CHOP-INTEND) score of 20/64. It is unlikely that the patient would benefit from Evrysdi. The requested health service/treatment of Evrysdi is not medically necessary for this patient.
This reviewer was unable to find any published reports describing stabilization or improvement in function following the introduction of risdiplam (Evrysdi) in children with SMA Type 1 who are already so severely affected that they are ventilator dependent and have a very low baseline CHOP-INTEND score.
A short report on respiratory function in children with SMA Type 1 treated with nusinersen describes that most children in the cohort (84/109) remained stable, but there is limited detail regarding baseline and later pulmonary function. [4]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has moderate, persistent asthma and a history of prior related intubations, atrial fibrillation, polysubstance abuse, heart failure with reduced ejection fraction [HFrEF] (EF 40%), attention deficit disorder (ADD) / attention deficit hyperactivity disorder (ADHD) presented with 2-3 days of shortness of breath (SOB) and wheeze, likely beginning with an upper respiratory infection (URI) after an admission 1 week prior for similar symptoms (but was not on prednisone when discharged). 
In the emergency department (ED), the temperature was 98.2 degrees Fahrenheit, blood pressure (BP) 108/62, heart rate (HR) 99, respiratory rate (RR) 20, peripheral capillary oxygen saturation (SpO2) 95% on room air (RA). He was in no distress, heart was regular, he was breathing comfortably with wheezing, and was alert and oriented. The white blood cell count (WBC) was 5.7, sodium (Na) 140, bicarbonate 25, blood urea nitrogen (BUN)/creatinine (Cr) 19/0.96, troponin (Tn) less than (<) 0.01. Coronavirus disease (COVID) testing was negative. A chest x-ray (CXR) was clear. He felt much better after a nebulizer treatment in the emergency department (ED). He was admitted, diagnosed with acute asthma exacerbation, and started on prednisone and as needed (PRN) albuterol. 

The next day, he still had some wheezing but wanted to leave against medical advice (AMA) and was discharged on a prednisone taper. At issue is the medical necessity of an inpatient stay. 

An inpatient admission was not medically necessary. 

The patient had been recently discharged with an asthma flare, was not discharged on prednisone, and re-developed wheezing at home. At presentation, he was wheezy but otherwise not severely ill with no encephalopathy, hemodynamic instability, respiratory distress or gas exchange abnormality, or acute kidney injury or marked electrolyte abnormality. While he was a high-risk patient (with prior intubation, co-existing cardiac disease), he was not severely ill and improved quickly with nebulizers in the ED. Given the low severity at presentation, improvement over an ED stay, and lack of additional or alternative diagnoses, an inpatient admission was not medically necessary as he did not require inpatient only testing, monitoring, or treatment. Care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Vascular Accident (CVA).
Treatment: Home health care.
The insurer denied Personal Care Aide Service Hours: 7 Days per Week, Two 12-Hour Shifts per Day "Split Shift". 
The health plan's determination is overturned. 

The patient is a female with past medical history of depression, diabetes mellitus, cerebrovascular accident (CVA) with hemiplegia, Parkinson's disease, coronary artery disease (CAD), bedbound status, dysphagia, thrombocythemia, hypertension, urinary incontinence, bowel incontinence, chronic back pain, osteoarthritis, insomnia, hyperlipidemia, and vascular dementia who had an assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, phone use, and shopping while maximum assistance with tasks of managing medication, stairs, transportation, bathing, dressing lower body, and toilet use. With tasks of personal hygiene, dressing upper body, walking, locomotion, and transfer toilet the patient was assessed at extensive assistance while limited assistance with tasks of bed mobility and eating. 

Personal Care Aide Service Hours: 7 Days per Week, Two 12-Hour Shifts per Day "Split Shift" are medically necessary for this patient.
The patient had two 12 x 12-hour, split shift services, 7 days/week following the assessment 5/4/2020. The plan recommended reduction of PCA services to 24 hours/day, live-in, 7 days/week. The patient had worsening in assistance needs with bed mobility and eating when comparing the recent assessments. The patient had a documented cognitive and physical decline. The patient's medical provider documented medical necessity of two 12 x 12-hour shifts, 7 days/week. The patient's medical provider documented a need for turning and repositioning as well as diaper changes every 2-3 hours which would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Aide Service Hours: 7 Days per Week, Two 12-Hour Shifts per Day "Split Shift are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection.
Treatment: Inpatient admission. 
The insurer denied coverage for an inpatient admission.
The denial is upheld.

This is a female with no significant past medical history. She presented to the emergency department with complaint of fever and right flank pain. The patient was given intravenous (IV) fluids and Tylenol. Her urine was cultured. A computed tomography scan of the A(abdomen)/P(pelvis) showed uterine fibroids. The patient was admitted to medicine service for further treatment. The patient was given intravenous Rocephin once daily then changed to intravenous Cipro. Her condition improved with treatment. The patient was discharged with a one-week treatment course of oral Cipro. The insurer has denied coverage for the inpatient admission as not medically necessary. They noted the patient presented to the hospital with a urinary tract infection. There were no unstable vital signs or other findings that warranted an inpatient admission. The appeal on behalf of the hospital is noted and read in detail. Per MCG (Milliman Care Guidelines) Health (25th) Urinary Tract Infection (UTI) -RRG, the patient does not meet clinical indications for an admission to inpatient care. These include, but are not limited to:

I-	Hemodynamic Instability
II-	Altered mental status - severe or persistent
III-	Persistent or worsening of clinical findings fever, pain, dehydration) despite observation care treatment
IV-	Pregnancy > 24 weeks gestation
V.	Immunocompromised states (AIDS (acquired immunodeficiency syndrome), chronic steroids)
VI.	Ureteral obstruction (stone)
VII.	Bladder outlet obstruction
VIII.	Renal or perinephric abscess
IX.	Pyonephrosis
X.	Acute renal failure (Stage 3 AKI (acute kidney injury))
XI.	Needs for intravenous hydration support despite observation care

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

The inpatient admission is not considered medically necessary for this patient.
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's 
Treatment: Humira
The insurer denied Humira 40 milligrams (mg) every week. 
The health plan's determination is overturned. 

This female patient has severe ileocolonic Crohn's disease and has had prior bowel resection following a bowel perforation. She was started on Humira at standard dosing but had a recent hospitalization for a flare of her Crohn's disease.

Humira Pen is medically necessary for this patient. Dose escalation is the standard of care in patients with inflammatory bowel disease (IBD) who are on a biological medication and not responding to standard dose of the medication. Dose escalation in biological therapy used to treat inflammatory bowel disease is a well accepted practice and supported by literature in patients who are not responding to standard dosing of the medication. Therefore, Humira dose escalation to weekly in this patient who failed standard dosing of Humira is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Central nervous system
Treatment: home health care
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split Shift). 
The health plan's determination is upheld. 

The patient is a female with a past medical history significant for cerebrovascular disease, dementia, stroke, chronic obstructive pulmonary disease (COPD), hypertension, hyperlipidemia, anemia, gastroesophageal reflux disease, constipation, blindness, nephrolithiasis, history of aspiration pneumonia and generalized medical decline.

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split Shift) medically necessary for this patient.
The patient currently has 24 hour a day live-in services which are sufficient to meet the patient's functional needs for activities of daily living (ADL) and Instrumental activities of daily living (IADL). Additional services beyond 24 hour live-in services, specifically split shift services are not medically necessary. The personal care hours are currently authorized in the amount, duration scope necessary to meet the members personal care needs.
The patient is an elderly female with multiple medical problems who is currently on hospice and bedbound with total care for her medical problems. The daughter requests additional services at night for providing her mother a drink of water and changing diapers along with repositioning. The question is whether the patient meets medical necessity for these services during the nocturnal hours and if the services can or cannot be provided by the aide who was already there. The patient has no active bedsores as noted. Prevention of bedsores can be provided through other means such as alternating mattress. Medical necessity is not met for the services in the nocturnal hours. It is not unreasonable for the patient to be left alone for 5 hours in bed during the nocturnal hours. The patient is in bed for the rest of the 19 hours of the 24 hour day. There is no documentation to why the live-in aide could not provide the services as noted. There is no documentation that the aide could not get at least 5 hours of uninterrupted sleep. No nocturnal log was provided for review. This is determining factor whether or not patient would require split shift services versus 24-hour aid live-in services. Therefore, the additional services are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sensorineural Hearing Loss. 
Treatment: Surgery to insert a hearing device (cochlear implant) in the left ear.
The insurer denied coverage for surgery to insert a hearing device (cochlear implant) in the left ear.  
The denial is overturned.

This patient with a history of sudden hearing loss in the left ear, which failed medical management, presented to the Otolaryngologist's office for a follow-up visit for hearing loss. The patient had a sudden left-sided hearing loss after having a virus. He took steroids without improvement. An audiogram performed showed profound sensorineural hearing loss without improvement. The physician recommended a cochlear implant in the left ear to treat sensorineural hearing loss.

This patient has sensorineural hearing loss (SNHL) to the left ear. Hearing aids are not appropriate for this type of hearing loss.

"Persons with severe or total sensorineural hearing loss do not typically benefit from hearing aids, since inner-ear hair cells are not able to stimulate the auditory nerve in response to sound. In such cases, cochlear implants, which are surgically implanted devices that bypass the cochlear hair cells to electrically stimulate the auditory nerve, permit partial restoration of hearing and have been shown to improve speech perception and vocational, social, and psychological functioning, as well as the quality of life for adults, including older adults. Details of the function and use of cochlear implants can be found at nidcd.nih.gov" (Cunningham et al., 2017).

The patient suffers from left (L) profound SNHL and is a candidate for L cochlear implant. Bilateral hearing is necessary in order to determine the directionality of sound, for communication, and in order to participate in full activities of daily living (ADLs). A traditional hearing aid will not be of benefit to the L ear; therefore, a cochlear implant is medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for surgery to insert a hearing device (cochlear implant) in the left ear is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric Pain
Treatment: Esophagogastroduodenoscopy (EGD)
The insurer denied the Esophagogastroduodenoscopy (EGD).
The determination is upheld.


The patient has a history of pancreatitis and epigastric abdominal pain. The attending provider did an esophagogastroduodenoscopy (EGD) to evaluate his abdominal pain. The medical records provided do not indicate that the patient has gastroesophageal reflux disease (GERD) and had been on an adequate trial of an acid suppressive medication or had alarm symptoms. At issue is the medical necessity of the EGD.

No, the requested health service/treatment of EGD was not medically necessary for this patient. Dyspepsia is a poorly characterized syndrome thought to originate from anatomic or functional disorders of the upper gastrointestinal (GI) tract. Dyspepsia encompasses a variety of symptoms including epigastric discomfort, bloating, anorexia, early satiety, belching or regurgitation, nausea, and heartburn. Dyspepsia symptoms overlap significantly with those associated with peptic ulcer disease, gastroesophageal reflux disease (GERD), other functional disorders such as epigastric pain syndrome and irritable bowel syndrome, malignancy, adverse effects of medications, pancreatitis, biliary tract disease, vascular disease, and motility disorders. Alarm symptoms that may be associated with dyspepsia are unintended weight loss, iron deficiency anemia, gastrointestinal (GI) bleeding, dysphagia, odynophagia, persistent vomiting, a family history of upper GI malignancy in a first-degree relative or abnormal imaging showing structural disease. According to current guidelines, dyspeptic patients older than 50 years of age or those with alarm features should undergo upper endoscopy. Endoscopy should be considered for patients in whom there is a clinical suspicion of malignancy even in the absence of alarm features.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders/Psoriasis
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested medication, Tremfya, as not medically necessary. 
The health plan's determination is overturned.

The patient is a male with psoriasis, 8% body surface area (BSA) including scalp involvement, who has been treated with topicals. His provider is requesting Tremfya.
At issue is the medical necessity for the requested medication, Tremfya 100mg/ml Auto Injector.

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

According to the meta-analysis by Sbidian et al., compared to placebo, the biologics infliximab, ixekizumab (Taltz), risankizumab (Skyrizi), bimekizumab, secukinumab (Cosentyx), guselkumab (Tremfya) and brodalumab were the most effective treatments for achieving psoriasis area and severity index (PASI) 90 in people with moderate-to-severe psoriasis on the basis of moderate- to high-certainty evidence. Phototherapy would not be appropriate due to scalp involvement. Systemic immunosuppressants can be used but are far less effective than Tremfya. Tremfya is also a safer alternative in the current COVID pandemic, due to reduction in vaccine efficacy with systemic immunousppressants.