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

Diagnosis: Alcohol Abuse/Addiction
Treatment: Inpatient emergency admission
The insurer denied the inpatient emergency admission. The health plan's determination is overturned. 

The patient is a male with a medical history of alcohol use disorder and prior pancreatitis. He presented to the emergency department with alcohol intoxication and concern for alcohol withdrawal, epigastric pain, nausea, vomiting, and a fall (he hit his head). Vital signs were unremarkable. His physical examination was notable for epigastric tenderness. Labs showed a low hematocrit of 38.5 percent (%), low sodium of 117 millimoles (mmol)/liter (L), low potassium of 2.8 mmol/L, low chloride of 62 mmol/L, elevated blood urea nitrogen of 27 milligrams (mg)/deciliter (dL), elevated creatinine of 2.2 mg/dL, elevated glucose of 185 mg/dL, increased anion gap of 27 milliequivalents (mEq)/L, elevated aspartate aminotransferase of 195 units (U)/L, elevated alanine aminotransferase of 84 U/L, elevated lactic acid of 7.1 mmol/L, elevated potential hydrogen (pH) of 7.6, elevated ethanol of 235 mg/dL, and positive test for coronavirus 2019 (COVID-19).
A chest x-ray showed no acute findings. A computed tomography scan of the head showed no acute intracranial process. Computed tomography scan of the abdomen and pelvis showed no evidence of acute cryptitis, a small sliding hiatal hernia with mild thickening of the distal esophagus suggesting esophagitis, mild gastroesophageal reflux, and hepatic steatosis.
He was treated with intravenous fluids, ondansetron, famotidine, metoclopramide, potassium, oral folic acid, thiamine, Librium, and multivitamin. He was made nil per os. He was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol. He was discharged with a plan for Gastroenterology, Primary Care, and Chemical Dependency follow-up.
At issue is the medical necessity of inpatient emergency admission.

The requested health service/treatment of inpatient emergency admission was medically necessary for this patient.
The patient presented with a significant electrolyte derangement in the setting of alcohol intoxication. There was risk for alcohol withdrawal, as well as complications of severe hyponatremia and hypokalemia including cardiac arrhythmias and death. [1-5] Both close clinical monitoring and telemetry monitoring were warranted, and there was the potential need for frequent administration of intravenous benzodiazepines. [6,7] He was appropriately treated for electrolyte derangement with gradual sodium correction using intravenous fluids and maintained on a CIWA protocol. [1-7] Given the patient's electrolyte abnormalities, the inpatient emergency admission was appropriate. Additionally, he tested positive for COVID-19, increasing the risk for complications. [4,5] His electrolytes became closer to normal and the risk for alcohol withdrawal had decreased; for these reasons, the inpatient level of care is supported until the patient was stable to be treated in the outpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Skin
Pharmacy/Prescription Drugs

Diagnosis: Psoriatic Arthritis
Treatment: Tremfya 100 milligrams per milliliter (mg/ml) auto injector (one (1) every eight (8) weeks.

The insurer denied the request for Tremfya 100 mg/ml auto injector (one (1) every eight (8) weeks.

The health plan's determination is overturned. 

The patient is a male with severe psoriatic arthritis and plaque psoriasis. The issue in this case is Tremfya is being denied by the health plan. The reason for denial is the patient is also taking Otezla. Per a letter from the patient's provider, the patient had been stable on Otezla and Taltz combination therapy. He was previously on Taltz monotherapy, but it was not adequate in resolving his skin disease, so Otezla was added. He is also on Sulfasalazine (SSz) 2000 milligrams (mg) daily. He had been doing well up until earlier this year when he started to experience a flare consisting of diffuse skin disease as well as joint pain and swelling. Prior treatment: Methotrexate (MTX), Enbrel, Humira and Cosentyx.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of Tremfya 100 mg/ml auto injector (one (1) every eight (8) weeks is medically necessary. Otezla used in combination with Tremfya is medically necessary for this patient. He has tried multiple therapies and still has very active disease. He had been doing well on combination therapy with Otezla, Taltz and SSz up until very recently but is having a major flare up. Switching Taltz to Tremfya is medically necessary at this time and there is ample safety and efficacy data on combination therapy to support this treatment strategy for patients with severe psoriatic arthritis (PsA).

The patient has severe plaque psoriasis and PsA. He had been stable on Otezla, Taltz and SSz up until earlier this year. His provider is requesting to switch Taltz with Tremfya but Tremfya is being denied as it is going to be used in combination with Otezla (Apremilast). However, there is a myriad data on the safety of a phosphodiesterase-4 inhibitor (PDE4 inhibitor) (e.g., Otezla) used in combination with a biologic. For example, a study published in Curr Rheumatol Review in 2019 concluded that 'apremilast can be safely combined with all biologic agents in patients with plaque psoriasis or psoriatic arthritis not responding adequately to biologics alone'. Moreover, an abstract published in the Journal of the American Academy of Dermatology in 2020 found that 'Apremilast could be safely and effectively combined with biologic agents in patients with psoriasis and psoriatic arthritis non responders to biologic drugs. Apremilast could provide additional control of the activity of each domain without affecting safety. No adverse events and major side-effects such as cancer or infection were reported'.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: difficulty breathing
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a boy who presented with difficulty breathing. He was well until 3 days prior to presentation when he developed a cough and fussiness. He was given a saline nebulized treatment with limited response. He saw his primary doctor who prescribed albuterol. He also developed a fever to 102o F (Fahrenheit). He then started to breathe fast and his parents noticed a change in his voice. Due to continued difficulty breathing, he was brought to the emergency department for care.

The Inpatient Hospital Stay was medically necessary for this patient.

Indications for hospitalization for bronchiolitis include continued respiratory distress with retractions and hypoxemia, which were present in this patient.
 
This is a young boy who presented with tachypnea, increased work of breathing, and hypoxia. He received appropriate and aggressive treatment at home and in the emergency department, but continued to have respiratory distress and a requirement for supplemental oxygen. He therefore required inpatient hospital admission for continued treatment, initially with albuterol every 2 (Two) hours, along with close monitoring and supplemental oxygen as needed.

The decision making at the time of admission for this patient was consistent with his young age, the presence of respiratory distress that persisted despite appropriate therapy, and the need for ongoing intensive treatments along with close monitoring for potential deterioration of clinical status.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: tinea unguium onychomycosis

Treatment: Kerydin (tavaborole)

The insurer denied coverage for Kerydin (tavaborole).

The denial is overturned.
 

The patient is an adult male with a diagnosis of tinea unguium onychomycosis with subsequent nail dystrophy.  The patient has failed therapy with oral terbinafine as well as econazole cream.  The request is a formulary exception for Kerydin topical.  

The patient has a diagnosis of onychomycosis and tinea unguium which has resulted in nail dystrophy.  

Failed formulary alternatives include both oral terbinafine and topical econazole.  The failure of both an oral and topical agent is reasonable and sufficient to warrant a trial of Kerydin. 

Kerydin would not be expected to result in any significant side effects compared to formulary alternatives.  

The requested medication, Kerydin, is likely to be more effective than other topical formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Kerydin (tavaborole) is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tonsil cancer.

Treatment: J9060 (Cisplatin), J9171 (Docetaxel), J9271 (Pembrolizumab)

The insurer denied coverage for J9060 (Cisplatin), J9171 (Docetaxel), J9271 (Pembrolizumab).

The denial is overturned.
 

According to the medical records, this is an adult male patient with the diagnosis of stage IV tonsil cancer whose treating medical doctor (MD) would like to use Cisplatin, Docetaxel and Pembrolizumab.

The use of the proposed regimen is a standard of care.  Pembrolizumab plus carboplatin and paclitaxel is active in clinical studies of recurrent and metastatic head and neck cancer. In addition, regimens that contain platinum with a taxane are similarly effective and better tolerated than regimens containing platinum plus fluorouracil.      

Pembrolizumab plus carboplatin and paclitaxel is active in clinical studies of recurrent and metastatic head and neck cancer. In addition, regimens that contain platinum with a taxane are similarly effective and better tolerated than regimens containing platinum plus fluorouracil. While there are other regimens, many consider this an optimal regimen.

"In summary, current frontline standard of care systemic therapy options for cancer of the oral cavity, oropharynx, larynx, and hypopharynx include pembrolizumab monotherapy or platinum/5FU plus pembrolizumab or platinum/5FU plus pembrolizumab for all patients. While this change in frontline systemic therapy has limited the applicability of nivolumab and pembrolizumab monotherapy for platinum failure patients." (Hsieh, R. W. et al.).

"Tonsil cancer is the most common form of oropharyngeal malignancy, and its incidence is sharply rising due to the increasing prevalence of human papillomavirus (HPV)-induced cancers. The presence of HPV can dramatically alter the prognosis of tonsillar cancer, and there have recently been significant changes made to the World Health Organization classification and staging system to reflect this. Tonsil cancer can be managed by both surgical and oncologic approaches, although the optimal treatment regimen remains an area of ongoing research." (Williamson et al.,)                                                         

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 J9060 (Cisplatin), J9171 (Docetaxel), J9271 (Pembrolizumab) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission. The health plan's determination is upheld.

The patient is a male with no significant medical history. He presented to the emergency department with nausea, vomiting, diarrhea, and chills. He had a fever and was vomiting in the emergency department. His vital signs were notable for tachycardia with a heart rate of 101 beats per minute. The physical examination was notable for a soft, nontender, nondistended abdomen with positive bowel sounds. Laboratory studies showed an elevated white blood cell count of 15.6 kilos per microliter (K/uL) with 92.4 percent (%) neutrophils and 7% (percent) bands and an unremarkable comprehensive metabolic panel. The chest x-ray showed no gross pulmonary pathology. A computed tomography scan of the abdomen and pelvis showed a partially visualized and normal-appearing appendix without evidence for acute appendicitis, and was an otherwise unremarkable scan. He was treated with intravenous fluids, ondansetron, famotidine, ketorolac, Zosyn, and oral acetaminophen. He had ongoing diarrhea, but he denied nausea, vomiting, chest pain, and dyspnea; he was assessed to have likely viral gastroenteritis. Laboratory studies showed a normalized white blood cell count. He was discharged with a plan for a Primary Care follow-up.

At issue is the medical necessity for the inpatient admission.
I uphold the health plan's determination, in whole.

The inpatient level of care is not supported as medically necessary.

The patient had symptoms (nausea, vomiting, and diarrhea) consistent with an infection such as gastroenteritis without findings of complications such as an abscess, colitis, or perforation on imaging. The standard of care for the evaluation of viral gastroenteritis was appropriately performed, including intravenous fluids, empiric antibiotic therapy, and supportive care. [1-7] No other cause for the inpatient level of care, such as inflammatory bowel disease flare, peritonitis, toxic megacolon, abscess, fistula, or other complication was documented. He had gradual improvement with conservative therapy. The care which was undertaken, including observation, monitoring, laboratory studies, imaging, and empiric antibiotic therapy, could have been performed without the inpatient level of care, at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thrombocytopenia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient in this case is an adult female with a history of alcohol abuse and cirrhosis. She tripped and fell and had a lip laceration. She went to the emergency department. She complained of 8/10 pain in the lip and smelled of alcohol. On exam, the patient had a contusion and hematoma of the left cheek. There was a left lip laceration going through the vermillion border with active bleeding. This was full thickness. Labs were notable for a platelet count of 12. INR (international normalized ratio) was 1.6. CT (computed tomography) cervical spine and maxillofacial studies were done, and both were unremarkable. She had the laceration repaired in the emergency department. She was started on Rocephin following that laceration repair. She was given a platelet transfusion though had no active bleeding following laceration repair according to the admission note. She was started on the CIWA (clinical institute withdrawal assessment) protocol for alcohol withdrawal. The patient was seen by hematology, who recommended platelet transfusion to keep the platelet count over 10,000, unless she had fever or active bleeding. Neither were present at the time of that consultation 5 months ago. She stayed in the hospital and received intravenous antibiotics, IV (intravenous) fluids and vitamins. She was discharged on day #8, and no acute medical issues arose during her hospital stay.

The Inpatient Hospital Admission was not medically necessary.

This patient fell and sustained a lip laceration. There was no documented loss of consciousness. She was intoxicated. There was no documentation of active alcohol withdrawal. Her platelet count was 12. The laceration was repaired in the emergency department and bleeding stopped at that point. She was seen by hematology, and no platelet transfusion was recommended unless the platelet count was less than 10,000. Following admission hemoglobin dropped to 8.8g/dl (grams per deciliter), though she was not actively bleeding and did not need blood transfusion. There were no other acute medical issues active at the time of admission or during her hospital stay. The acute care inpatient admission in this case was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Vetebrogenic Low Back Pain
Treatment: Intracept Procedure 
The insurer denied the Intracept Procedure.
The health plan's determination is upheld.

The patient is a male who has a long-standing history of low back pain radiating to his bilateral lower extremities (BLE's). He has had this pain for many years. The pain is shooting, worse with standing straight. The pain level is 9 out of 10. He had tried 6 weeks of physical therapy (PT) and Meloxicam with no relief. He had a negative straight leg raise (SLR) and positive facet loading tests. The magnetic resonance imaging (MRI) showed severe spinal stenosis at (L)2/3 and L3/4 from disc bulge, ligament flavum hypertrophy and facet arthropathy with impingement of bilateral L3 and L4 nerve root, mild central canal stenosis with impingement of descending L5 nerve roots and degenerative changes at L5/sacral vertebrae (S)1 with impingement of left S1 nerve root. Difficulty walking and left leg pain were documented in the MRI report. The provider recommended bilateral L4/5 transforaminal epidural steroid injections and Intracept procedure at L3 L4 L5 and S1.

The INTRACEPT system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. The available medical records did not suggest that vertebrogenic pain is the primary pain generator. This patient has low back radiating pain to bilateral lower extremities and difficulty walking. The MRI showed severe spinal stenosis at L2/3 and L3/4 from disc bulge, ligament flavum hypertrophy and facet with impingement of bilateral L3 and L4 nerve root. Truumees's study supported the efficacy of Intracept procedure. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded. (1)
Given this patient's medical history, MRI findings of severe spinal stenosis, and the current clinical evidence, it is unlikely that the proposed Intracept Procedure is more beneficial than any standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Vetebrogenic Low Back Pain
Treatment: Intracept Procedure 
The insurer denied the Intracept Procedure.
The health plan's determination is upheld.

The patient is a male with low back pain. The pain is chronic. Prior treatments have included medications, as well as physical therapy. The pain impacts activities of daily living (ADL's). The pain can be as high as 9 out of 10. The magnetic resonance imaging (MRI) of the lumbar spine demonstrated Modic type I changes that disc spaces lumbar vertebrae (L)3-L4, L4-L5, and L5-sacral vertebrae (S)1.

The proposed health service or treatment Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has complaints of low back pain. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned


The patient presented to the hospital complaining of chest pain on exertion accompanied by dyspnea and diaphoresis.  Symptoms were present for several months but increased in frequency and severity.  Past medical history was significant for hypertension and diabetes mellitus.  On arrival to the hospital, vital signs were stable: blood pressure (BP) 145/68, pulse 100.  Physical examination revealed no major abnormality.  12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave abnormalities. Serum blood testing revealed hyperglycemia of 245 and normal troponin levels - 4. The patient was admitted to the hospital and referred for cardiac catheterization where a severe ostial/mid left main stenosis and severe proximal left anterior descending artery stenosis were noted.  She underwent successful percutaneous intervention of both lesions  and was admitted to the hospital.  Her post operative course was complicated by generalized pruritis and rash as well as hyperglycemia with blood glucose in the 300-400 range.  The patient was successfully treated for iodine contrast allergy and hyperglycemia. She was discharged home on medical therapy with cardiology and endocrine follow up.

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with crescendo typical chest pain accompanied by dyspnea and diaphoresis. Her pretest probability of coronary artery disease is intermediate. 
(Reference 1). 

Although the patient had no elevation of serum troponin and an intermediate HEART (History, ECG, Age, Risk Factors, Troponin) score, careful evaluation for the etiology of crescendo chest pain was indicated (Reference 2). 

Patients requiring circulatory support, multivessel revascularization and left main coronary artery revascularization are considered high risk and cannot be managed at a lower level of care. (Reference 3-7).   

Inpatient admission for work up and treatment was medically necessary. This patient was ultimately diagnosed with severe obstruction of the left main and proximal left anterior descending arteries. Following percutaneous intervention, additional treatment was necessary due to iodine contrast allergy and poorly controlled hyperglycemia.  In conclusion, in patient admission to the hospital was medically necessary.

Based on the above, the insurer's denial is reversed.