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

Diagnosis: Breast cancer, incontinence
Treatment: Personal Care Services (PCS) - 24 hours/day, 7 days/week (split shift)
The insurer denied PCS - 24 hours/day, 7 days/week (split shift).
The health plan's determination is overturned. 

The patient is a female with metastatic triple negative breast cancer, urinary incontinence, bowel incontinence, severe arthritis of bilateral shoulders, recurrent urinary tract infection (UTI), Parkinson's, and obesity who had been hospitalized with hematuria versus vaginal bleeding. The patient was diagnosed with UTI/sepsis, right internal iliac vein thrombosis, and new pathologic fracture of the sacrum. The patient was treated with antibiotics for UTI/sepsis and anticoagulation for deep vein thrombosis (DVT) but had further hematuria and had an inferior vena cava (IVC) filter placed. During the discharge planning process, the patient underwent a telephonic assessment for PCA (personal care aide) services.

Personal Care Services (PCS) - 24 hours/day, 7 days/week (split shift) are medically necessary for this patient.

There is documentation from the patient's medical providers of medical necessity of increased PCA services. There is documentation of the patient's medical records of worsening functional status due to recent hospitalization, anemia, urinary tract infection (UTI), further progression of metastatic breast cancer, and worsening of chest wound. There is specific documentation by the patient's medical provider of the need for incontinence care and turning and repositioning every 2 hours which would not allow a PCA 5 hours of uninterrupted sleep. The patient requires at least maximum assistance with locomotion, transfer toilet, and toilet use all of which are unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. 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 (ADLs) and instrumental activities of daily living (IADLs). The plan incorrectly utilized a tasking tool to calculate PCA services despite the patient having 24-hour care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies as the plan suggested. 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, PCS 24 hours/day, 7 days/week, split-shift are medically necessary for this patient. PCS 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: Overturned

Diagnosis: Acute myeloid leukemia, post allogenic haploidentical peripheral stem cell transplant
Treatment: Prevymis 480 mg tablet
The insurer denied: Prevymis 480 mg tablet
The denial is overturned.

The patient is an adolescent female with a history of acute myeloid leukemia. She underwent a haploidentical peripheral blood stem cell transplant. She has had a negative CMV (cytomegalovirus) PCR (polymerase chain reaction) since transplant and was on viral prophylaxis with acyclovir and valganciclovir. She developed neutropenia, which required stopping the valganciclovir. The provider is recommending prophylaxis with Prevymis (letermovir).

The requested Prevymis is medically necessary.

Universal prophylaxis is the strategy of administering anti-CMV (cytomegalovirus) drug prophylaxis to at-risk recipients prior to the development of CMV (cytomegalovirus) viremia at a pre-defined time point after transplant. Universal prophylaxis is often pursued in patients at higher risk such as recent primary CMV (cytomegalovirus) infection immediately prior to transplant, CMV (cytomegalovirus)-seropositive patients receiving a graft from seronegative donors, those who receive T-cell depleting therapies (e.g., alemtuzumab or antithymocyte globulin) and recipients of T-cell depleted, HLA (human leukocyte antigen)-mismatched, haploidentical or umbilical cord blood allografts.
Potential adverse effects of antiviral medications are an important consideration with use of universal prophylaxis. Ganciclovir and valganciclovir have the undesirable side effect of myelosuppression, which can delay or reverse neutrophil engraftment. The resulting prolonged lymphopenia and/or neutropenia places the patient at risk for other opportunistic bacterial and fungal infections. Foscarnet and cidofovir could also be considered and may be preferred due to less bone marrow toxicity. However, these medications can lead to renal toxicity and/or electrolyte abnormalities. Letermovir has been shown to be safe and effective in preventing CMV (cytomegalovirus) reactivation post-bone marrow transplant in adults and children. Pediatric centers have begun using letermovir in pediatric HSCT (hematopoietic stem cell transplant) patients and have reported promising outcomes.
Since this patient is unable to tolerate oral ganciclovir due to neutropenia and is at high risk for CMV (cytomegalovirus) prophylaxis, the use of Prevymis (letemovir) is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inflammatory Bowel Disease
Treatment: Inpatient emergency admission
The insurer denied coverage for inpatient emergency admission
The denial is upheld

This adult patient has Crohn's disease and an ileostomy and presented with abdominal pain. The patient was afebrile, and the vital signs were stable. There were no peritoneal signs. There was no leukocytosis. The Computed axial tomography (CAT) scan was negative for intestinal obstruction. Solumedrol was given in the emergency room (ER), and the patient was then placed on Prednisone. Pain medications were given. There was a discussion about starting anti-tumor necrosis factor (TNF) therapy. The patient left the hospital Against Medical Advice (AMA). 

Clinical indications for admission for Inflammatory Bowel Disease (Milliman Care Guidelines M-565) include hemodynamic instability, abdominal abscess, active fistulas, toxic megacolon, intestinal perforation, intestinal obstruction, severe dehydration, severe anemia, acute renal failure, and bacteremia. The patient did not have these conditions. 

This patient had Crohn's disease and was having ongoing abdominal pain. The patient was given steroids in the ER and then switched to Prednisone. The patient likely would also have benefited from giving an anti-TNF agent. However, the patient was stable to had been treated on an outpatient basis with oral steroids and pain medications. The patient did not meet Milliman Care Guidelines (MCG) criteria for admission for Inflammatory Bowel Disease. An inpatient admission was not medically necessary. 

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 emergency admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: growth hormone deficiency 
Treatment: Skytrofa
The insurer denied Skytrofa. The health plan's determination is upheld. 

This is a male diagnosed with growth hormone deficiency (GHD). His growth hormone (GH) stimulation test peaked at 4.8. His height velocity on therapy is reported to be improved from 2.3 cm/yr (centimeters/years) to 9.6 cm/yr. 

Skytrofa Injection, 11 milligrams (mg), Four per 28 Days is not medically necessary for this patient.
This patient does meet biochemical criteria for growth hormone deficiency (GHD). Growth hormone (GH) stimulation testing peaked at less than 10. The patient met height criterion 4 as his height velocity is more than 2 standard deviation (SD) below the mean. The patient met both height and height velocity and biochemical criteria for the diagnosis of GH deficiency.

However, Skytrofa is not medically necessary. The standard of care in this case would be daily growth hormone (GH). Per the literature, there may be a slight advantage of the Skytrofa over daily GH but the study only went for 1 year and did not show improved final height. It has the advantage of being a weekly medication. However, other than the convenience of weekly administration, Skytrofa is not superior to daily growth hormone. Daily growth hormone would be the standard of care for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thyroid eye disease

Treatment: Tepezza 500 milligram (mg) injection

The insurer denied coverage for Tepezza 500 mg injection

The denial is overturned

This case involves a patient seeking authorization for Tepezza (teprotumumab) 500mg injection. The patient has a history of thyroid eye disease. The patient presented for an eye examination. The patient had exposure keratopathy, eyelid retraction, and proptosis. A recommendation was made for Tepezza 500 mg.

In an undated appeal, the provider recommended reconsideration for the patient's Tepezza. The patient had a history of thyroid eye disease with subsequent proptosis, exposure keratopathy, and eyelid retraction. The patient had tried and failed a course of oral corticosteroids. The regimen did not alter her disease and resulted in considerable side effects. It was unlikely that she would achieve any significant relief with another round of corticosteroids. Literature strongly supported the role of re-treatment for recurrent and recalcitrant thyroid eye disease. The provider cited 2022 literature that demonstrated clear benefit with the intervention in the patient's specific clinical setting. Another recent article was referenced which suggested re-treatment. The Food and Drug Administration's (FDA) approval for the medication was based on an indication of thyroid eye disease. Initial and repeat treatments were not considered in the ruling. 

As the patient had thyroid eye disease, she met criteria for treatment with the medication. Additionally, the patient's situation was quite severe. At her last examination her clinical activity score was 7. The extent of her disease suggested that therapy with the only FDA approved medication for her condition was appropriate. She initially benefited from infusions of Tepezza. However, her condition had rebounded and resulted in considerable pain, blurred vision, and interference with activities of daily living. Based on the findings, the provider recommended authorization for the infusions.

In this case, the patient has severe thyroid disease and is at risk of loss of sight if she is not appropriately managed. The patient has a paucity of treatments available and has already failed oral corticosteroids. The patient was noted to have benefit with Tepezza. Current literature notes that the requested medication can be considered for flares to address the patient's clinical presentation. Given the lack of alternative treatments, prior benefit with treatment, and risk of decompensation without the treatment, proceeding with the request is medically necessary based on current literature and standards of care. As such, the Tepezza 500mg injection is medically necessary.

Based on the above, the insurer's denial must be overturned. 

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

The medical necessity for Tepezza 500 mg injection is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ulcerative colitis
Treatment: Stelara
The insurer denied Stelara. 
The health plan's determination is overturned. 

The patient is a female with Ulcerative Colitis. She had initial response to infliximab. She was on high-dose infliximab (Renflexis 10 mg/kg [milligrams/kilogram] every 4 weeks) with undetectable infliximab level and high anti-infliximab antibody level (20.9). She has had elevated C-reactive protein and fecal calprotectin. Coverage is being requested for Stelara for the treatment of Ulcerative Colitis. 

Stelara is medically necessary for this patient.
Stelara is indicated over the formulary alternatives Humira and Entyvio, and Xeljanz would not be recommended. Stelara is recommended by American Gastroenterological Association (AGA) guidelines for the induction of remission of moderate to severe Ulcerative Colitis. The guidelines state that "In adult outpatients with moderate to severe Ulcerative Colitis who have previously been exposed to infliximab...the AGA suggests using Stelara (ustekinumab) or Xeljanz (tofacitinib) rather than Entyvio (vedolizumab) or Humira (adalimumab) for induction of remission". Both Stelara and Xeljanz are recommended by American College of Gastroenterology guidelines for patients who have experienced anti-tumor-necrosis factor (TNF) therapy. However, the patient will be of childbearing age for many years, and the use of Xeljanz is not recommended in females of childbearing age. Because Xeljanz is a small molecule, "tofacitinib is likely to cross the placental barrier, studies have shown teratogenic and feticidal effects...ofacitinib is not currently approved for use in pregnancy or breastfeeding". Additionally, "Tofacitinib therapy in females of reproductive age may cause a possible risk to a developing fetus during pregnancy and may also impair infertility in women of reproductive potential". These concerns do not apply to Stelara. Additionally, Stelara has shown efficacy for the treatment of Ulcerative Colitis in a Phase III trial, UNIFI. This trial demonstrated that a single intravenous dose of Stelara induced clinical remission in a significantly greater proportion of patients than placebo did, as measured by both clinical response and endoscopic response; this result was attained in a patient population which was 50% biologic-refractory. For these reasons, Stelara is supported as medically necessary for the treatment of this patient's Ulcerative Colitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis right knee
Treatment: Knee surgery (27447 x 1) - Total knee arthroplasty
The insurer denied coverage for Knee surgery (27447 x 1) - Total knee arthroplasty.
The denial is overturned.

The patient presented to the orthopedic physician's assistant, with the chief complaint of follow-up for osteoarthritis of the right knee. On examination, the right knee revealed range of motion (ROM) grossly limited and with pain. Right knee effusion was noted, and right quadriceps strength was four. Right hamstring strength was four. Right knee patellar grind test was positive, and the patient was diagnosed with knee osteoarthritis, right. The recommendation for the patient included knee surgery (27447 x 1).

Based on the provided documentation, the patient was recommended for a right total knee replacement, and it was previously denied. The patient was diagnosed with right knee osteoarthritis. The examination of the right knee revealed right knee grossly limited and painful range of motion. The patellar grind test was positive. Previous in-office x-rays of the bilateral knees showed moderate to advanced arthritis in the medial compartment of the right knee. In this case, the patient has been treated with conservative management to include injections, bracing and a home exercise program over the last three months. Body mass index was discussed with the patient, and he was advised on a weight loss plan, with the recommendation to consult with a nutritionist. Further, it was noted the patient has been smoke-free for nine months. 

"Total knee arthroplasty (TKA) is a well-described treatment option for patients suffering from knee pain secondary to osteoarthritis who have failed conservative treatment measures. It is a reliable procedure that provides pain relief and improves the patient's functional status.[2] Furthermore, the need for correction of a significant or progressive deformity at the knee with evidence of osteoarthritis can also be an indication for a TKA. A patient with persistent knee pain without radiographic evidence of knee osteoarthritis should have further workup to exclude other possible sources of their pain." (Hsu & Siwiec, 2022)

"Total knee arthroplasty (TKA) is one of the most consistently successful surgeries performed in orthopedics. Patient-reported outcomes are shown to improve dramatically with respect to pain relief, functional restoration, and improved quality of life. TKA provides reliable outcomes for patients suffering from end-stage, tri-compartmental, degenerative osteoarthritis (OA). While OA affects millions of Americans, the knee is the most commonly affected joint plagued by this progressive condition which is hallmarked by a gradual degeneration and loss of articular cartilage." (Varacallo et al., 2022)

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Professional Services, knee surgery (27447 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary emboli
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient is a young adult who presented to the hospital on with complaints of chest pain and shortness of breath (SOB). The patient was alert and oriented and ambulating. The patient had significant history of frequent air travel. At presentation to the emergency department (ED) vital signs were Temperature 99.6 degrees Fahrenheit, Blood Pressure 146/83, Heart Rate 77, Respiratory Rate 20 and oxygen saturation 98 percent (%) on room air. Lungs were clear, heart sounds normal and there was no acute distress. The patient had an electrocardiogram (EKG) which revealed premature ventricular contractions (PVCs) but no acute ST-T (interval on an EKG) changes. The patient had a computed tomography angiogram (CTA) which revealed multiple bilateral segmental and subsegmental pulmonary emboli and some left lower lobe infarct. No right heart strain was noted. A deep vein thrombosis (DVT) study was negative.

This patient was seen by Hematology. Workup for hypercoagulable state was initiated. The patient was started initially on Lovenox and then switched to oral Apixaban. This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hours.

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

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

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

The patient is young adult who came to the emergency room with reports of marijuana use and a seizure episode at home. He suffered a laceration to his eyelid after falling off his bed due to a second seizure, which was witnessed by his wife. He reported hitting his head and biting his tongue. He denied headache, weakness, numbness, tingling, lightheadedness, nausea/vomiting, diarrhea, constipation, blurry vision, chest pain, palpitations, diaphoresis, shortness of breath, epigastric, abdominal pain, urinary symptoms, or joint pain. Upon assessment in the emergency department (ED), the patient had mild swelling associated with the left upper eyelid laceration with no signs of facial fractures. Vital signs were stable. His wound was cleaned, and Steri-Strips and bacitracin were applied. Initial laboratory report noted elevated glucose at 121. In the ED, the patient suffered another seizure that lasted approximately 30 seconds. Neurology recommended a loading dose of Keppra 3500 milligrams (mg) intravenous (IV) with continuation of Keppra 1000 mg twice a day. He was subsequently admitted at that time for further care.

The Milliman Care Guidelines (MCG) state that for patients with reports of seizures, admission to inpatient care is indicated for 1 more the following to include those who have recurrent seizure (during ED or observation care) with 1 more the following to include that the patient has no known seizure disorder, has recurrent seizure of a different seizure types and previously known seizure disorder, or the patient was with baseline of infrequent seizures and recurrence was not thought to be due to readily modifiable etiology.  

In the case of this patient, the information provided for the review stated that following the seizure at home, he had another seizure in the ED. He also had no known seizure disorder before the episodes on that date. It was therefore determined that he met the criteria for inpatient admission for further work-up and care. As such, the inpatient admission was medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Renal Failure; Stage V Chronic Kidney Disease due to Polycystic Kidney Disease
Treatment: Kidney Transplant
The health plan denied the requested kidney transplant as not medically necessary.
The health plan's determination is upheld.

The patient is a male with end stage renal disease (ESRD) on dialysis secondary to polycystic kidney disease who is being requesting to be placed on kidney transplant waitlist. 

The denial letter states that patient does not have necessary testing including Hepatitis C, Hepatitis B, human immunodeficiency virus (HIV), Tuberculosis (TB) testing, rapid plasma regain (RPR), cytomegalovirus (CMV), Epstein-Barr virus (EBV) and Varicella testing within the past 12 months; a history and physical within the past 6 months, including basic blood work (complete blood count (CBC), comprehensive metabolic panel (CMP)); cardiology testing and clearance showing his heart is strong enough for transplant.; drug testing within 90 days; and a psychosocial evaluation within the last 6 months. 

Blood work was supplied including a CMP, CBC, a tuberculosis gold QuantiFERON (pending). A social work assessment was performed.

At issue is the medical necessity for the requested service/treatment of a kidney transplant.

I uphold, in full, the health plan's determination of medical necessity.

A kidney transplant is the best option of treatment for the individual in this case. Based on the documentation provided, he does not meet the health care plan's criteria for listing for a kidney transplant, as he is lacking necessary testing and clearance, including Hepatitis C, Hepatitis B, HIV, Tuberculosis testing, RPR, CMV, EBV and Varicella testing within the past 12 months; a history and physical within the past 6 months; cardiology testing and clearance showing his heart is strong enough for transplant; drug testing within 90 days; and a psychosocial evaluation within the last 6 months.

If this testing and clearance has been obtained, then forwarding these documents could allow for appropriate transplant listing.