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

Diagnosis: Leg pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay
The determination is upheld.

The patient is a female who presented with lower extremity (LE) pain and swelling. The review of systems was positive for myalgias.
The patient was afebrile and was not in acute distress. The physical examination was remarkable for bilateral (BL) lower extremity (LE) tenderness, swelling, warmth and edema.
The patient was admitted for BL LE pain and swelling. An ultrasound was negative for thrombosis. An echocardiogram showed normal left ventricular ejection fraction (LVEF). A chest x-ray showed no congestion. The patient was started on Lasix and was sent for autoimmune workup with rheumatology. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital admission was not medically necessary. The care could have been safely rendered at a lower level of care.
The patient was admitted for lower extremity swelling. There was no hypoxia or respiratory distress, and chest. An x-ray did not show pulmonary vascular congestion. The documentation supports a lower level of care for isolated lower extremity edema. This can be managed with transition to outpatient care for workup and echocardiogram. The patient was not short of breath and did not have symptoms of respiratory or heart failure. As such, lower extremity edema can be worked up as an outpatient.
In patients with congestive heart failure (congestive heart failure (CHF), age is associated with an increased risk of cardiovascular events and mortality during short- and long-term follow-up. Congestion, or fluid overload, is a classic clinical feature of patients presenting with heart failure patients. Diuretics are the mainstay of management for patients with congestion. The beneficial effects of a loop diuretic on jugular venous pressure (JVP), pulmonary congestion, peripheral oedema and body weight have been known for years; diuretics also improve cardiac function, symptoms, and exercise tolerance in patients with heart failure (HF). In this case, the indication for Lasix was for isolated lower extremity edema and there was no evidence of a clinical exacerbation of heart failure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Continued subacute rehabilitation or skilled nursing facility stay.
The insurer denied continued subacute rehabilitation or skilled nursing facility stay.
The determination is upheld.

This is a patient who was referred for skilled services secondary to decreased mobility and functional ability after hospitalization for coronary artery disease. The past medical history is significant for a previous head injury, hypertension and coronary artery disease. The patient needs help with transfers, ambulation and bed mobility skills requiring the use of extensive assistance. Admission was for to increase his functional ability. Services were denied by the patient's insurance stating the following: Your condition has not gotten much better. He does not need continued skilled services. The patient was mainly admitted for skilled services for rehabilitation. No other specific skilled services were noted such as complex wound care, intravenous medicine or other therapies. This review is for the medical necessity of continued subacute rehabilitation or skilled nursing facility stay.
The requested services are not medically necessary.
The patient has plateaued and there has been very limited improvement.
The patient has a past medical history significant for head injury, coronary artery disease and hypertension. On admission, physical therapy and occupational therapy notes state that the patient requires significant help, with total dependence for some services maximal assistance for other services. The patient had therapeutic services with both physical therapy and occupational therapy for well over a month. On reevaluation there was minimal improvement in that month in regards to the patient's progress.
No other specific skilled services were noted such as complex wound care, intravenous medicine or other therapies.
The patient may continue with skilled services which may benefit him in the future, however,continued admission for inpatient skilled nursing is not medically necessary due to the noted lack of progress in his functional ability. Services could be provided an alternate location.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arm Pain
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male patient with a history of polycystic kidney disease, end stage renal disease (ESRD) status/post (s/p) kidney transplant, gout, transient ischemic attack (TIA), iron deficiency anemia, gastric bypass, hypertension (HTN) and mitral valve repair who presented to the hospital with bilateral arm pain, left greater than right. He denied fevers, chills, shortness of breath, chest pain, nausea, vomiting, diarrhea, abdominal pain, decreased urine output, dysuria, hematuria or other complaints.  On exam, he was not in any acute distress, he had left forearm ecchymosis at prior intravenous (IV) sites, right upper extremity (RUE) increased warmth with mild erythema and tenderness.  A chest x-ray did not have any acute cardiopulmonary findings. He was admitted for further workup, given 1 gram (g) of intravenous (IV) ceftriaxone and an ultrasound (US) of the right elbow was ordered in addition to a left elbow x-ray. A renal transplant ultrasound did not show any hydronephrosis. Bilateral upper extremity x-rays were unremarkable. A bilateral doppler venous ultrasound of the upper extremities did not show any deep vein thrombosis (DVT), but did show bilateral thrombophlebitis. He was found to have thrombophlebitis on his bilateral upper arm veins. He was discharged home in stable condition. At issue is the medical necessity of an inpatient stay.

Inpatient admission was not medically necessary based on the documentation provided. The patient presented with bilateral arm pain after a recent kidney transplant surgery. He was hemodynamically stable and afebrile. He did not have leukocytosis. He did not have clinical signs of sepsis. He did not have severe electrolyte or metabolic abnormalities. He did not have severe pain requiring inpatient admission. His exam and imaging studies did not reveal acute DVT, compartment syndrome, abscess, fractures, or limb ischemia. He was diagnosed with superficial thrombophlebitis and was discharged home in stable condition. He could have been managed at a lower level of care with subsequent transition to outpatient follow up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma, Difficulty Breathing
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male child with a medical history significant for mild intermittent asthma who presented to the emergency department (ED) with a two-day history of a cough and difficulty breathing. His mother began treatment with nebulized albuterol when the cough started and took him to the ED when he did not improve. Examination was significant for non-toxic appearance, moist mucous membranes, retractions with accessory muscle use, nasal flaring, prolonged expiratory phase, decreased air movement, wheezing, rash, and non-focal neurologic exam.
He was treated with DuoNebs and dexamethasone followed by parenteral magnesium. He was given two more nebulized albuterol treatments and normal saline bolus. His work of breathing improved significantly but he was still wheezing, so admission was attempted to the pediatric floor. Because he was requiring more frequent treatments than could be accommodated on the floor, the Pediatric Intensive Care Unit (PICU) was contacted for admission. In the interim, he was treated with second and third doses of magnesium and albuterol every two hours. Rapid viral testing returned negative. 
Admission orders included albuterol every two hours, parenteral steroids every six hours, Pulmonology consultation, asthma action plan and education, continuous hemodynamic monitoring, maintenance intravenous (IV) fluids, nothing by mouth pending improvement, and parenteral famotidine for gastrointestinal (GI) protection. Pulmonology recommendations included Symbicort twice daily, Zyrtec daily, albuterol every four to six hours pending resolution of exacerbation, and avoidance of allergens. He remained afebrile throughout his hospital stay, with no supplemental oxygen requirement. He tolerated spacing albuterol to every three hours and then every four hours. He received a total of three days of parenteral steroids. He continued to improve and was deemed stable for discharge. At issue is the medical necessity of an inpatient stay.

Full hospital admission was not medically necessary for this patient.

This male child with a history of prematurity and mild intermittent asthma presented to the ED with a cough and wheezing refractory to nebulized albuterol at home. He was treated aggressively in the emergency department with persistent wheezing. He was admitted to the PICU because of the frequency of his albuterol treatments. While it was medically necessary to monitor this patient in the hospital for improvement, he was overall hemodynamically stable with no supplemental oxygen requirement and no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Psoriasis Arthritis
Treatment: Otezla 30mg (milligram) Tablet
The insurer denied: Otezla 30mg (milligram) Tablet
The denial is overturned.

The patient is an elderly male with history of psoriasis and psoriatic arthritis. He has failed acitretin, phototherapy, and Taltz. The patient was previously on Otezla (apremilast). The 
requesting is for continuation of treatment. Of note, the patient has had a history of four melanomas and monoclonal gammopathy of undetermined significance (MGUS).

The health plan should cover the requested health service.

Due to the patient's history of melanoma and monoclonal gammopathy of undetermined significance (MGUS), it would not be advisable to use other biologics. Furthermore, the patient 
has already failed treatment with an oral systemic (acitretin) and phototherapy, so there is no need to require the use of another oral systemic.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Psoriasis Arthritis
Treatment: Otezla 30mg (milligram) Tablet
The insurer denied: Otezla 30mg (milligram) Tablet
The denial is overturned.

The patient is an elderly male with severe psoriasis and psoriatic arthritis. He has failed acitretin and phototherapy in the past. His psoriasis has been well controlled with Taltz for the past two to three years, but his arthritis was not responding. Otezla (apremilast) was added 3 years ago with significant improvement of his psoriatic arthritis. This is a request for continuation of 
treatment with Otezla.

The health plan should cover the Treatment with Otezla. 

The requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease.
Biologics have been shown to constitute a highly effective treatment for patients with psoriasis. However, a number of patients treated with biologics may experience either loss of efficacy over time or efficacy for skin disease without adequate control of the arthritis associated with psoriasis. The evidence for adding small-molecule drugs to an ongoing biologic treatment is accumulating, and combination therapies are evidenced to be advantageous in appropriately selected patients with psoriasis.
Combination therapy of biologics with other agents such as apremilast can be considered as a treatment option in such cases. Apremilast (Otezla) can be safely and effectively combined with phototherapy, systemic, and/or biological agents in patients with plaque psoriasis not responding adequately to these agents alone. There are no contraindications to the use of apremilast with a biologic, such as Taltz, in appropriately selected patients. This is already proving beneficial for the patient, and continuation of therapy is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Psoriasis Arthritis
Treatment: Otezla 30mg (milligram) Tablet
The insurer denied: Otezla 30mg (milligram) Tablet
The denial is overturned.

The patient is an elderly male. His relevant diagnoses include psoriasis and psoriatic arthritis. He has been treated with topical steroids, acitretin, phototherapy, and Taltz. His provider is requesting use of Otezla (apremilast) to control the psoriatic arthritis, as Taltz has not worked well for this, but is controlling skin disease. The patient has been stable on this combination for 3 years. The health plan denied the combination as experimental/investigational. The denial is being appealed.

The health plan should cover the requested Otezla.

Otezla has been safely combined with other therapies, and this patient has been established on this combination for 3 years. A retrospective study examined a total of 81 patients with plaque psoriasis who were treated with apremilast in combination with at least one other therapy (narrow band ultraviolet B [NB-UVB], 
methotrexate, acitretin, cyclosporin, etanercept, adalimumab, infliximab, or ustekinumab) (1). Fourteen patients (17%) discontinued treatment before completion of 12 weeks of apremilast therapy. Sixty-seven patients continued on drug past 12 weeks. Of these patients, 81% achieved Psoriasis Area and Severity Index (PASI)-75 at week 12 after apremilast was added to an existing therapy. There are several case reports outlining successful treatment with Humira and Otezla, as well as with Cosentyx. A 2021 review included 17 studies of 617 patients (2). Of those studies, 15 demonstrated beneficial results with excellent safety and efficacy of apremilast combination therapy. The drug's simple dosing schedule with mild side-effect profile makes it a practical option for patients as combination therapy. The remaining two studies did not show the combination to be more effective than apremilast monotherapy. Therefore, given the support for combination therapy in the literature and this patient's documented favorable response to this combination, the requested Otezla is medically appropriate. 
The combination of agents for psoriasis has not been studied extensively in comparative trials with monotherapy. While there are other biologics that could be tried as monotherapy, the patient has been stable on this combination for some time, and its use is supported in current medical literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: obesity
Treatment: bariatric surgery
The insurer denied
The health plan's determination is overturned. 

This patient is a woman under consideration for bariatric surgery. She is 65 inches tall and weighs 230 lbs. This corresponds to a body mass index (BMI) of 38.3. She has comorbid health conditions of hyperlipidemia, anxiety, osteoarthritis, bipolar disorder, and gastroesophageal reflux disease (GERD). The patient has attempted weight loss with conventional diet programs. Unfortunately, she has not been successful with significant sustained weight loss.

The Bariatric Surgery Services (Stomach/Weight Loss Surgery) is medically necessary for this patient.
This patient has a body mass index (BMI) in excess of 35 with weight related comorbid health conditions that include hyperlipidemia, anxiety, osteoarthritis, bipolar disorder, and gastroesophageal reflux disease (GERD). These weight-related health conditions will respond favorably to the sustained weight loss associated with laparoscopic sleeve gastrectomy. She has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has been cleared for bariatric surgery from a mental health standpoint. She has been granted medical clearance. She has participated with a supervised weight loss program with her primary medical doctor and a registered dietitian with refractory medically complicated obesity.
The requested surgery is medically necessary for this patient per widely accepted guidelines as her BMI is in excess of 35 in association with weight related illness of hyperlipidemia, anxiety, osteoarthritis, bipolar disorder, and GERD.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces. 
The determination is overturned.

This is a patient with a Class I occlusion. He has severe maxillary spacing and minor mandibular crowding. Tooth number (#) 10 is missing. He is treatment planned for 24-30 months of orthodontics create space for future prosthetic replacement of (number) #10. At issue is the medical necessity of braces.

Orthodontic treatment is medically necessary. In order to correct his malocclusion, the space either needs to be closed orthodontically, (9,10) or the space need to be managed orthodontically to arrange the space so that the missing tooth can be replaced with a prosthetic, be it an implant (10,11) or a tooth-supported restoration. (12,13) There is no way to address this problem that does not involve orthodontic intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: pneumonia
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male who presented with left-sided chest pain, cough, and sputum with blood streaking that had begun the day prior, associated with fever, chills, diarrhea, and dysuria.
In the emergency department (ED), temperature was 99.5, blood pressure (BP) 93/78, heart rate (HR) 110, respiratory rate (RR) 19, and oxygen saturation 98% on room air (RA). On exam, he was in no distress, heart was regular, breathing comfortably, and he was alert and oriented. Achest x-ray (CXR) showed left-sided pneumonia. He was given ceftriaxone and azithromycin for pneumonia.

An inpatient admission was not medically necessary. He presented with chest pain, cough, and streaky hemoptysis. He was diagnosed with pneumonia. He was not severely ill at presentation with no encephalopathy, hemodynamic instability, respiratory distress or gas exchange abnormality, or acute kidney injury (AKI). Routine scoring systems would all suggest a low risk of poor outcomes. He improved over an observation care time frame. He did also have hypophosphatemia, but this also improved with observation. He had urinary symptoms, but these are usually managed as an outpatient. He had minor hemoptysis, likely related to pneumonia, that resolved over an observation care time frame.
As he was not severely ill at presentation and was unlikely to become so and had no alternative or additional diagnoses that would require inpatient treatment, a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

This patient is an adult female who came to the emergency department (ED) with increased shortness of breath, body pain, and diarrhea. Her past medical history includes chronic obstructive pulmonary disease (COPD) with chronic respiratory failure on home oxygen, bipolar disorder, seizures, stroke, hypertension with congestive heart failure, diabetes mellitus, adrenal insufficiency on steroids, and depression. The patient's initial emergency department vital signs revealed pulse of 104, respiratory rate of 16, blood pressure of 126/75 and pulse oximetry of 97% (percent). Her physical examination was remarkable for diffuse expiratory wheezing and rales. There was no increased work of breathing, and she could speak in full sentences. Clear mentation was noted. The patient's white blood cell count was 9.7 and blood urea nitrogen (BUN)/creatinine was 31/0.8. Arterial blood gas revealed 71/53/7.38 - (partial pressure of oxygen/partial pressure of carbon dioxide/acidity) (PaO2/PaCO2/pH). Her chest x-ray revealed no infiltration.
The patient's breathing was better, but she still had wheezes in the emergency department with Duonebs, doxycycline, and intravenous methylprednisolone. She was admitted to the medicine floor for chronic obstructive pulmonary disease (COPD) exacerbation. Room air pulse oximetry reported 93% (percent). The patient was treated with intravenous albuterol and Atrovent inhaler and intravenous methylprednisolone every eight hours. Home medication was continued. The patient improved and was discharged on day (number) #3.

The requested health service was not medically necessary.

The patient's symptoms improved in the emergency department. She had no high-risk acute comorbidity such as pneumonia, dysrhythmia, decompensated heart failure, or effusion or pneumothorax. She is steroid dependent for adrenal insufficiency and not for chronic obstructive pulmonary disease. She had no respiratory failure - worsening partial pressure of carbon dioxide or partial pressure of oxygen. She did not require invasive or noninvasive ventilation. She did not require any surgical intervention. She had no hemodynamic instability or altered mental status. Therefore, inpatient hospital admission was not necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Psoriasis of the scalp. 
Treatment: Clobetasol shampoo. 
The insurer denied Clobetasol shampoo. 
The determination is upheld. 

This is a male patient with psoriasis of the scalp. The patient has been using clobetasol lotion with some improvement. The patient has also been using calcipotriene ointment and Dermasmoothe/FS scalp oil and over-the-counter (OTC) psoriasis shampoos. The patient is experiencing a flare to his scalp of his psoriasis, and clobetasol shampoo has been prescribed. The health plan formulary only covers clobetasol in a foam or solution formulation. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects. 
Clobetasol foam and solution will be as much if not more effective than clobetasol shampoo, particularly because it will remain on the scalp longer (where the diseased skin is) than clobetasol in a shampoo form. No anticipated adverse effects of any significantly increased incidence are anticipated with clobetasol foam or solution, compared to the requested clobetasol shampoo. 
Current medical literature [1-4] consistently supports greater efficacy of "leave-on" clobetasol or other topical products over shampoos (or any other brief/temporary contact therapy) because of the longer-lasting or ensured access of a "leave-on" medication to the site of a given disease process. 
This greater benefit of "leave-on" medications is true for all dermatoses with respect to efficacy and long-term outcomes. The length of time a shampoo contacts the scalp is as vital as any factor with respect to topical efficacy of a given shampoo, such that it is possible that leaving the patient's OTC shampoos on for as long as 3-5 minutes (sometimes longer) will be of similar benefit (if not greater benefit) than use of clobetasol shampoo.