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

Diagnosis: History of prostate cancer, duodenal ulcer,
chronic blood loss anemia

Treatment: 84 Hours of personal care assistance per week (12 hours x 7 days) Plan approved 30 hours weekly
The insurer denied the 84 Hours of personal care assistance per week (12 hours x 7 days) Plan approved 30 hours weekly

The denial is overturned. 

The patient is a male with a history of prostate cancer, duodenal ulcer, chronic blood loss anemia, benign prostatic hypertrophy, chronic kidney disease, hypertension, glaucoma and cataracts. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Appeal review requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 84 hours/week Personal Assistance Services is deemed medically necessary. 

This is a male with a history of prostate cancer, duodenal ulcer, chronic blood loss anemia, benign prostatic hypertrophy, chronic kidney disease, hypertension, glaucoma and cataracts. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent documentation from the patient's provider indicates that due to progressively worsening functional decline including worsening gait ataxia and increased need for assistance with ADLs (activities of daily living) toileting and emptying his urinary catheter bags, the currently approved plan of 30 hours/week Personal Assistance Services is no longer sufficient to meet the patient's current needs. For these reasons, the proposed treatment 84 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain.
Treatment:  Inpatient Hospital Stay.

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

The patient has a past medical history (PMHx) significant for hypertension (HTN) and gastroesophageal reflux disease (GERD), who presented to the emergency room (ER) with complaints of abdominal pain.  Her vital signs were stable.  Lab results revealed leukocytosis with an elevated white blood cell count (WBC).  An ultrasound revealed gallstones and common bile duct (CBD) dilatation.  A computed tomography (CT) scan revealed gallbladder wall thickening.  The patient was made nothing by mouth (NPO) and was supported with intravenous fluids (IVF) and pain medication.  A hepatobiliary iminodiacetic acid (HIDA) scan was ordered, which was negative.  The patient had improvement in the pain and was transitioned to by mouth (PO) and PO pain medication and discharged home.  At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary.

The patient presented with symptomatic cholelithiasis.  She was ruled out for acute cholecystitis with a negative HIDA scan and was discharged home.  There was no decision to proceed with surgery.  The patient met standard discharge criteria with stable vital signs, ability to tolerate PO and PO pain medications within a 23-hour period.  Care could have been provided at a lower level than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Foreign Body Ingestion. 
Treatment:  Inpatient Hospital Stay. 

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

The patient has a medical history of hypertension, hyperlipidemia, atrial fibrillation, hemorrhagic stroke with left hemiparesis, and anxiety.  He presented to the emergency department after accidentally swallowing a metal bottle cap, which was lodged in his throat.  He reported slurred speech and left-sided weakness.  Vital signs were notable for bilateral lower extremity edema.  The physical examination was notable for tachycardia with a pulse rate of 114 beats/minute.  Lab results showed an ethanol level of 38.5 milligrams per deciliter (mg/dL).  A chest x-ray showed a foreign body just beyond the thoracic inlet.  He was maintained nil per os (NPO).  An esophagogastroduodenoscopy showed a normal-appearing oropharynx, and a metal bottle cap at approximately 20 centimeters (cm) from the incisors; an attempt to grasp the cap with a basket was unsuccessful; a biopsy forceps was used to grasp the cap, which was pulled up from the esophagus into the oropharynx; the anesthesiologist then used a Magill forceps to grasp the bottle cap from the oropharynx and remove it.  There was slight non-bleeding excoriation in the upper esophagus from trauma due to the bottle cap, but the esophagus, stomach, and duodenum otherwise appeared normal.  He was treated with intravenous fluids, famotidine, ascorbic acid, and omeprazole.  He denied dysphagia, throat pain, and abdominal pain.  Later in the morning, he had a bit of sore throat, but was able to drink water.  He was discharged on omeprazole, with a plan for Primary Care follow-up.  At issue is the medical necessity of an inpatient stay. 

The inpatient stay was not medically necessary.  The patient presented with a clear history of foreign body ingestion, confirmed on x-ray; he did not have signs or symptoms of airway compromise, esophageal perforation, or of gastrointestinal bleeding.  The esophagogastroduodenoscopy confirmed foreign body ingestion, and rapid removal was successful, without any evidence of bleeding or perforation [1].  Post-procedure monitoring was warranted to watch for complications such as pneumonia and mediastinitis, but as the patient was tolerating a diet without any concerning signs or symptoms the next day, the inpatient level of care was not medically necessary [2-4].  The monitoring, labs, gastroenterology consultation, famotidine therapy, and esophagogastroduodenoscopy could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lymphocytic Colitis.
Treatment:  Entyvio.

The insurer denied the Entyvio.  The denial is upheld. 

The patient is a female with lymphocytic colitis.  She has failed anti-diarrheals, antibiotics, pancreatic enzymes and steroids.  Her provider is requesting treatment with Entyvio. 

No, the treatment with Entyvio is not medically necessary.

The patient has lymphocytic colitis and has failed steroids.  The planned preferred agents
are 6-MP (mercaptopurine) and azathioprine. 

Munch showed that in the majority of chronic, active lymphocytic colitis patients azathioprine did not work and led to cessation of treatment.  He concluded that further studies were needed to explore the efficacy, acceptance, tolerance and safety of 6-MP (mercaptopurine) in such patients. (2)

There are only isolated case reports showing that Entyvio can be beneficial in the treatment of lymphocytic colitis.  As there are no randomized clinical trials or non-randomized clinical trials with a significant number of subjects, the requested Entyvio is not professionally accepted as a usual and customary way to treat lymphocytic colitis.  There is no literature to support that Entyvio is more effective than 6-MP for the treatment of lymphocytic colitis.  Therefore, the proposed Entyvio, instead of the plan-preferred 6-MP (mercaptopurine) is not medically necessary, and the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She presented for evaluation to the emergency department of the facility filing the appeal. The patient reported right lower quadrant abdominal pain, nausea, emesis, and several days of melena worsening the day prior to arrival. The abdominal pain was described as severe and continuous as well as spasmodic, with an intensity of 8 out of a possible 10. The pain started in the right lower quadrant and then involved the right upper abdomen as well. The patient noted a 30-pound weight loss, fevers, dysphagia to solids, and early satiety. A fever to 101 was reported in a facility the day prior to presentation. The patient noted hoarseness and reported she was diagnosed with a vocal cord mass. 

An ENT (otolaryngologist) subsequently noted this was Reinke's edema rather than a mass. The patient noted noncompliance with her Synthroid medication. The patient expressed a desire to start outpatient naltrexone treatment. The patient had abdominal pain and was admitted for this a week prior but had signed out AMA (against medical advice) prior to the performance of an endoscopy. The patient had received PPI (proton pump inhibitor) therapy. 

On ER (emergency room) evaluation, bradycardia and generalized abdominal pain were noted. A CT (computed tomography) scan showed dilation of the common bile duct. A GI (gastroenterology) consultation recommended an EGD (esophagogastroduodenoscopy) and EUS (endoscopic ultrasound). No further melena was noted. 

The patient was admitted and received IV (intravenous) fluids and supportive care. The patient was not tolerant of waiting for testing and signed out against medical advice before the endoscopy could be performed.  The patient had a history of polysubstance abuse, hypertension, a prior CVA (cerebrovascular accident), hypothyroidism, PID (pelvic inflammatory disease) and COPD (chronic obstructive pulmonary disease). 

No, the Inpatient admission was not medically necessary. The medical treatment as provided was medically appropriate, but the level at which the care was provided was not medically necessary, as explained below.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had reports of abdominal pain and vague symptoms; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for prolonged NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  There was no evidence of an active bleeding and no blood products were required. 

As such the care, including an endoscopy, could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain.
Treatment:  Inpatient Hospital Stay.

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

The patient presented to the emergency room for acute onset abdominal pain associated with diarrhea and vomiting. The symptoms were thought to be related to food poisoning (seafood salad).  He was seen in the emergency room one week earlier for similar symptoms and had a computed tomography (CT scan) that showed ileitis.  In the emergency room, his vital signs were not concerning.  He was described as well appearing and well hydrated.  He was admitted for further management and received intravenous fluids and antacids.  He tolerated diet advancement and his pain improved.  At issue is the medical necessity of an inpatient admission.

The admission to acute level of care was not medically necessary.

The patient had a week's history of abdominal pain associated with diarrhea and vomiting.  He was described as well hydrated and well appearing on presentation.  His vital signs were unremarkable, and he was hemodynamically stable.  He did not have signs of dehydration, bowel obstruction or mental status changes.  His laboratory studies were reassuring and without severe abnormalities that would require inpatient management.  His history (food poisoning), symptoms, clinical picture and previous CT scan suggested infectious gastroenteritis as the underlying etiology.  His pain improved with the emergency room treatments, and his vital sign remained stable.

Most gastroenteritis cases do not require inpatient care.  However, a small percent of patients develop severe dehydration and require intravenous rehydration and hospital care.

Per Banyai, K., et al. "For treatment of dehydration caused by gastroenteritis viruses, the administration of reduced-osmolality oral-rehydration solutions (5060 millimoles per liter (mmol/L) sodium) is the first line of therapy.  Profuse vomiting, worsening dehydration with altered consciousness, or severe acidosis, hypovolaemic shock, abdominal distension, and ileus are indications for intravenous rehydration".

The care provided during the admission was minimal and included antacids and diet advancement.  No surgical intervention was needed.  No advanced imaging was required.  The care could have been provided safely and effectively at a lower level than inpatient.  Therefore, the admission to inpatient was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ischemic Stroke
Treatment: Myoelectric Arm Brace
The insurer denied the Myoelectric Arm Brace
The determination is upheld.

The patient had a right middle cerebral artery ischemic stroke with partial involvement of right anterior cerebral artery. She received tissue plasminogen activator (TPA). She had resultant deficits of left sided weakness and left arm spasticity. She has received static bracing, electrical stimulation (e-stim), and botulinum toxin injections. Her left arm remains non-functional for activities of daily living due to weakness and spasticity. Her arm strength is 1-2/5 throughout. She ambulates with a cane and has had some falls due to imbalance and inability to catch herself due to her left arm impairment. Her upper extremity impairment is severe and this is supported by her DASH (Disabilities of the Arm Shoulder and Hand) questionnaire which she filled out. At issue is whether a myoelectric arm brace is likely to be more beneficial than any standard treatments.
It is not likely to be more beneficial than standard treatments. Per the history and physical exam review, the expected outcome of a myoelectric orthosis is that it will, "restore her left arm function and range of motion." This expected outcome is not supported by published literature studying myoelectric orthoses. Restoration of left arm function is not a reasonable outcome for a patient with the level of impairment of an upper extremity in the chronic phase of stroke, which this patient has per the documentation submitted, regardless of the treatment that is provided. The proposed myoelectric arm brace is not likely to be more beneficial than standard treatment for patient's upper extremity impairment. The botulinum toxin injections, occupational therapy, static bracing, and e-stim that patient has received are appropriate standard treatment for her condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ischemic Stroke
Treatment: Myoelectric Arm Brace
The insurer denied the Myoelectric Arm Brace
The determination is upheld.

The patient has a past medical history significant for a right middle cerebral artery and partial involvement of right anterior cerebral artery ischemic stroke resulting in residual left spastic hemiparesis. At issue is whether the proposed myoelectric arm brace is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The proposed treatment with myoelectric arm brace is not likely to be more beneficial than any standard treatment or treatments for the insured's disabling condition. There is not enough data to support that this type of therapy is more beneficial than standard therapy.  The research consists of small studies with larger studies outside the United States.  Without additional information from more recent, larger studies in the United States there is not any data to support that such a device would be more beneficial than standard therapy.  For example, "Giving Them a Hand: Wearing a Myoelectric Elbow-Wrist-Hand Orthosis Reduces Upper Extremity Impairment in Chronic Stroke" did show that use of such a device increased gross manual dexterity and performance of certain functional tasks the study was limited by its small size (#18) and while there was "significant difference in time required to" complete multiple tasks (including to grasp a cup, decrease time taken on lifting the laundry basket and self-feeding) it was not statistically significant. Similarly, there was "a significant difference in the quality with which subjects performed feeding and drinking tasks with and without" the device "but these differences were not statistically significant." Also, "Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature" concluded that "We found that when the duration/intensity of conventional therapy (CT) is matched with that of the robot-assisted therapy (RT), no difference exists between the intensive CT and RT groups in terms of motor recovery, activities of daily living, strength, and motor control" and while "extra sessions of RT in addition to regular CT are more beneficial than regular CT alone in motor recovery of the hemiparetic shoulder and elbow of patients with stroke; gains are similar to those that have been observed in intensive CT." Finally, the larger studies, such as "Three-dimensional, task-specific robot therapy of the arm after stroke: a multicentre, parallel-group randomised trial" was from Switzerland. At this time, there is not enough data to support that this type of therapy is more beneficial than standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ischemic Stroke
Treatment: Myoelectric Arm Brace
The insurer denied the Myoelectric Arm Brace
The determination is overturned.

The patient suffered a right middle cerebral artery (MCA) territory ischemic stroke with partial involvement of the right anterior cerebral artery. This resulted in permanent left sided spastic hemiparesis. The left upper extremity appears to be more affected than left lower extremity. The patient had a course of inpatient and outpatient rehabilitation with only minimal improvement. At issue is whether the myoelectric arm brace is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The proposed health service or treatment myoelectric arm brace is 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 already undergone an extensive course of both inpatient and outpatient rehabilitation for residual functional impairments related to her stroke. She has only shown minimal improvement. A myoelectric orthosis would have the capacity to help restore independent function in terms of her ability to perform activities of daily living such as but not limited to: dressing, grooming, feeding, bathing, and hygiene. Myolectric orthoses have been shown through sound scientific rigor by clinical trials to help improve functional mobility and activities of daily living (ADL) capacity in those who have sustained an insult or injury to the central nervous system. In this particular case, the patient has likely achieved maximum medical improvement regarding all other rehabilitative options to help improve function.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Immunologic-Other/Atopic Dermititis.
Treatment: Pharmacy/Prescription Drugs-Dupixent.
The health plan denied Dupixent as not medically necessary. 
The reviewer has upheld the health plan determination in whole.

The patient has atopic dermatitis of the hands, which is less than 10% body surface area but makes it difficult for the patient to work. Documentation submitted in the form of paid claims show presumed use of halobetasol, triamcinolone, and tacrolimus. The patient's work schedule prevents access to phototherapy. Methotrexate has been avoided because of long-term safety concerns and the COVID-19 pandemic.

Dupixent is only medically necessary when alternative and more time-tested systemic therapies have been tried and failed. Light therapy is among the safest treatments for hand dermatitis and other variants of atopic dermatitis. Neither methotrexate nor other oral/systemic therapies have been proven to confer any greater risk of catching the COVID-19 virus, or to have a greater risk of a more severe course if infection should occur. Some of these aforementioned therapies are indicated and necessary for use in Dupixent patients should that therapy prove insufficient to control a treatment-resistant case of atopic dermatitis.
Modern dermatology literature [1-4] supports use of preferred medications as similarly efficacious to the requested Dupixent, particularly for a patient with a limited history of systemic atopic dermatitis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario.
Atopic dermatitis (AD) is a common chronic inflammatory skin disease that predominantly affects children. However, it can persist in adulthood and/or start at older ages. Due to its chronic nature and frequently occurring relapses, AD has a substantial effect on patients' quality of life, often requiring long-term systemic treatment, especially in adult patients, who are more frequently refractory to adequate topical treatment with mid- to high-potent corticosteroids and/or calcineurin inhibitors. Therefore, treatment with systemic therapies is often needed to take control of the disease, prevent exacerbations, and improve quality of life. However, data regarding systemic treatment effectiveness and long-term safety in adult patients with AD are insufficient. Indeed, standardized international guidelines are lacking, and the treatment approach widely differs among diverse countries.  [2] Additionally, many AD patients respond satisfactorily to topical or systemic treatments, but for those patients who do not respond or have contraindications, new biologic agents appear to be promising therapies. [3]
Therefore, as per current medical standards of care, Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypercalcemia
Treatment: Cinacalcet 30MG Tablet
The insurer denied the Cinacalcet 30MG Tablet.
The denial is overturned. 

The patient is a female with familial hypercalciuric hypocalcemia. She has fatigue and generalized pain. Her calcium was 12.3 mg/dL (milligrams per deciliter). The request for cinacalcet is under review. 

Yes, the treatment with Cinacalcet is medically necessary.

Familial hypocalciuric hypercalcemia is a rare condition with limited information on therapy. Cinacalcet was shown to be effective in three individuals with familial hypocalciuric hypercalcemia in reducing hypercalcemia and improving symptoms [1]. This patient has marked hypercalcemia and symptoms of fatigue and generalized pain. The use of cinacalcet in this clinical situation is supported by Marx [2]. There are no other treatment options available as alternatives to cinacalcet. Without cinacalcet, this patient will be at risk of ongoing hypercalcemia and ongoing symptoms that may impair quality of life. Therefore, yes, the requested cinacalcet is medically necessary and consistent with standard of care.