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

Diagnosis: Psoriasis
Issue under review: Skyrizi

Determination:
The Skyrizi is medically necessary.

The patient is an adult male with psoriasis.  He has been treated with topicals, phototherapy, and Otezla.  His provider is requesting Skyrizi.  The patient has 15-20 alcoholic beverages per week.

A traditional immunosuppressant would not be appropriate in this case due to the patient's alcohol intake.  Methotrexate is also far inferior to newer biologic agents.  Currently, the selection of an initial and subsequent agents is made using a limited evidence base.  Skyrizi is an approved, safe and effective therapy and has demonstrated superior efficacy in clearance of psoriasis.  Therefore, it is medically necessary according to standard of care.  Remicade is used less commonly for plaque psoriasis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System / Neuromuscular Disorder 
Treatment: Inpatient Hospital 

The patient is a male with past medical history of multiple sclerosis with right eye blindness, seizure disorder, hypertension, bipolar disorder, kidney stones, post-traumatic stress disorder (PTSD) and traumatic brain injury who presented to the emergency department with altered mental status. The patient felt like he was going to have a seizure. He complained of headache, dizziness, nausea and "scrambled thoughts". The patient had infusion of Ocrevus and Solumedrol prior to onset of symptoms. The patient's vital signs were stable except for a heart rate of 111. Physical exam was without significant findings except the patient could not give a meaningful history of present illness. Electrocardiogram (EKG) showed sinus tachycardia. Computed tomography (CT) of the head was without acute findings and laboratory data was normal except for mild elevation of liver function tests and blood sugar of 229. The patient was seen by psychiatry while in the emergency department and was not felt to require inpatient psychiatric admission, having recently been admitted. The patient was admitted to inpatient level of care. The admission history and physical stated "agree with neurology to admit the patient and establish his baseline mental status." The patient was seen by the neurology provider and ongoing psychiatric follow up was recommended as well as updating vitamin B12 and thyroid stimulating hormone (TSH) on labs. The patient's mental status improved, and it was felt his symptoms were related to steroid psychosis from Solumedrol received with Ocrevus prior to initiation of symptoms. The patient's vital signs and laboratory data remained stable and patient was discharged to home with further outpatient follow up. 

The health plan's determination is upheld. 

The patient presented to the emergency room with symptoms that started just after infusion of Ocrevus and Solumedrol for treatment of underlying MS. The patient felt like he was going to have a seizure. He was alert and awake but was not able to provide meaningful history. CT imaging of the brain was normal. The patient had no other focal neurological findings on exam. Labs were stable and vital signs were stable except for mild tachycardia. The psychiatry consultants that saw the patient in the ED didn't feel he needed inpatient psychiatric admission. The neurologists felt the patient should be observed to sort out psychiatric versus neurological symptoms. The patient did not have severe symptoms, abnormal vital signs or concerning data in the emergency room that would have made inpatient admission medically necessary. The Neurologist felt the patient's symptoms were likely explained by a psychiatric cause. The patient didn't have persistent altered mental status beyond the observation period of care. At the time of admission there was no mention of concern for acute stroke or TIA. The severity of illness at the time of admission was appropriate at a lower level of care status. The intensity of care did not require an inpatient level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Goiter 
Treatment: Inpatient Admission 

The inpatient admission was not medically necessary. 

The patient is a female. The patient underwent total thyroidectomy for symptomatic goiter. Surgery and recovery were uncomplicated. However, "Patient was admitted overnight and monitored for airway distress and signs of hypocalcemia." 

The next day, having returned to her baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up. 

According to peer-reviewed medical literature and professional societies, in the absence of significant co-morbidities or complications, thyroidectomy does not require admission at an acute inpatient level of care [Hessman et al; Perera et al; Stack et al; Sun et al; Terris et al]. It can be performed safely at a lower level of care -- "Outpatient thyroidectomy performed by an experienced surgeon is safe and feasible." 

According to peer-reviewed medical literature and professional societies, in the absence of significant co-morbidities or complications, thyroidectomy does not require admission at an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism Spectrum Disorder - Autistic Disorder 
Treatment: Physical Therapy 

The patient is a young male with a diagnosis of autism. Records available include health plan documents that outline the requirements for substantiating medical necessity and information regarding covered services. Available clinical records include therapy notes and an occupational therapy (OT) evaluation and reassessment. The goals on the notes are essentially unchanged and no documentation regarding progress towards goals or any short-term goals achieved is provided. The health plan has denied the physical therapy as not medically necessary. The health plan's determination is upheld. 

The health care plan's requirements for documentation of therapy services requires all of the following: adequate documentation of a detailed description of the services, the area of application, the required time component for the service, the requirement for one on one professional supervision to perform the intervention. These are not provided in the clinical notes documentation for this patient. Efficacy of ongoing care was not supported by the documentation submitted and the service/treatment of physical therapy is not medically necessary for this patient based on the documentation provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation
Treatment: Inpatient admission
The insurer denied the inpatient admissio0n.
The denial is upheld.

The proposed treatment was not medically necessary.

The patient is a male.  At the time of admission to the hospital, he had a past medical history significant for hypertension (HTN).  The patient presented to the ER for new onset palpitations. The patient was found to have atrial fibrillation on electrocardiogram (ECG) in his cardiologist's office and was referred to the ER. He was again noted to have atrial fibrillation with rapid ventricular response. 

The patient was treated with intravenous (IV) Cardizem and was started on oral Cardizem for rate control. The blood pressure was stable. ECG revealed atrial fibrillation with rapid ventricular response. Cardiac troponin was negative. The patient was admitted to telemetry for atrial fibrillation. He was started on anticoagulation with Eliquis. An echocardiogram revealed normal left ventricular (LV) function. The patient spontaneously converted to normal sinus rhythm and was discharged home with a plan for outpatient follow-up.

The patient presented for evaluation of palpitations and was diagnosed with paroxysmal atrial fibrillation. The patient was hemodynamically stable, with no evidence of hypotension. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), or ventricular arrhythmia. The heart rate was increased on arrival to ER and was controlled with Cardizem IV push and subsequently orally, given in the ED. Echocardiogram revealed normal ventricular function. The patient converted to normal sinus rhythm. Thus, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was hospitalized secondary to the presence of worsening pain and swelling of the right upper extremity after being bitten by 2 dogs two days previously.  Initial laboratory data was notable for leukocytosis (white blood cell count 13,140) and mild hyperlactatemia (serum lactate 2.6). An x-ray of the affected area demonstrated soft tissue swelling and possible 3 millimeter (mm) linear foreign body in the right proximal forearm. An ultrasound did not reveal a thrombus. Blood cultures were obtained and were ultimately without growth. Treatment included the provision of intravenous fluids, intravenous antibiotic therapy (Unasyn), oral pain medication, and rabies immunoglobulin. Clinical improvement was noted and the patient was discharged with prescribed oral antibiotic therapy (Augmentin). At issue is the medical necessity of an inpatient stay. 

The health plan's determination is upheld. The patient was afebrile and hemodynamically stable. He was initially noted to have mild tachycardia (HR 101) which improved quickly. He was tolerating oral intake. His laboratory data was notable for leukocytosis and mildly elevated serum lactate but no evidence of metabolic acidosis or renal insufficiency. He had not received or failed prior outpatient treatment. Clinical improvement was noted in less than 24 hours with the provision of intravenous fluids and antibiotic therapy. Acute inpatient care was not medically necessary for this patient. The medical care provided could have safely and effectively been delivered at a lower level of care. The patient improved rapidly with the provision of intravenous fluids and antibiotic therapy and was discharged within 24 hours.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with psoriasis, treated with topicals and phototherapy.  Her provider is requesting Cimzia as the patient is planning pregnancy.  The health plan denied the requested Cimzia and lists medications on the preferred drug list: Humira, Otezla, Stelara, Skyrizi and Talz in the Final Adverse Determination letter.  At issue is the medical necessity of Cimzia.

The health plan's determination is overturned.  Cimzia is medically necessary for this patient as it is known to be the preferred agent in females of childbearing potential.
 The formulary alternatives are either category C or "caution advised" in pregnancy as no data is available.  Cimzia would be the most appropriate therapy as there is little concern for use of Cimzia in pregnancy since it does not cross the placenta.  This would allow for continuation of therapy for this patient during pregnancy.  Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems: Other
Inpatient hospital

The patient is a female with a past medical history significant for anxiety who presented to the emergency department with complaints of near syncope.  The patient reported 2 episodes that happened prior to the admission.  Apparently, the first episode happened several days before the day of admission, and at that time, the patient went to urgent care first.  At the urgent care, the patient was found to have an elevated creatine phosphokinase (CPK) level of 5000.  She was admitted to a different hospital and received treatment with intravenous fluids.  Subsequently, the patient's CPK level came down to 2000 and she was discharged from the hospital.  Apparently, the patient's rhabdomyolysis was attributed to an intense workout that the patient had several days before her previous admission.

The health plan's determination is upheld.  The inpatient stay is not medically necessary.  The patient's near syncopal episodes were not associated with any high-risk features.  There was no evidence that the patient had any serious underlying problem.  The patient's hypokalemia was transient and corrected very quickly.  The previously diagnosed rhabdomyolysis continued to improve.  There was no evidence that the patient had acute kidney failure associated with rhabdomyolysis.  The patient has several episodes of diarrhea that were self-limiting and did not cause significant dehydration and kidney failure.

In general, the patient remained in stable clinical condition and the admission was primarily for observation purposes.  The review of the medical records did not reveal any legitimate reason for admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting
 
Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission.  The denial is upheld. 

This patient is a female patient with a past medical history of hypertension, coronary artery disease, a myocardial infarction several years ago and status post a percutaneous coronary intervention on aspirin and Plavix who presented to the Emergency Department (ED) with complaints of non-bilious non-bloody emesis with approximately 20 episodes.  

The patient had a mastectomy two days prior to admission.  She developed multiple episodes of nausea and vomiting.  She had not yet started chemotherapy.  She was afebrile and the vital signs were stable.  The abdominal exam was benign.  An abdominal x-ray was negative for obstruction.  The renal function was normal.  It was felt that the vomiting was a secondary reaction to opioid use.  By the following day, the progress note states that there was no further nausea or vomiting.  The blood pressure was 121/70 and the pulse was 60.  She was given laxatives for constipation.  The plan was to use non-steroidal anti-inflammatory drugs (NSAIDs) for pain if needed.

Clinical indications for admission for vomiting (M-370) include intestinal obstruction, a significant metabolic derangement, hemodynamic instability, severe electrolyte abnormalities, high fevers, and acute renal failure.  The patient did not have these conditions.  The patient did have persistent vomiting prior to the hospitalization.  However, after receiving treatment her nausea and vomiting resolved.

This patient had vomiting that was attributed to a side effect from the narcotics.  She received treatment in the Emergency Room (ER) and by the following day was feeling better.  Intravenous (IV) hydration and antiemetics could have been given with observation status.  She did not meet MCG criteria for admission for vomiting.  The healthcare plan acted reasonably and with sound medical judgment.  An inpatient admission was not medically necessary.  The denial is upheld.

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

Diagnosis: Testosterone deficiency
Treatment: Stendra
The insurer denied the Stendra.  The denial is overturned.

The proposed Stendra is medically necessary.


This male with erectile dysfunction has requested coverage for Stendra.  He had used Cialis ten milligrams (MG) tablets.  According to the appeal documents, the "Patient is not currently taking phosphodiesterase 5 enzyme inhibitor.  Patient has tried and failed alternatives Cialis, Viagra and Levitra."

Stendra use as a monotherapy for erectile dysfunction is an accepted standard of care for the treatment of erectile dysfunction.

In addition, the Plan criteria were met:

The appeal letter indicates that the patient is not using Cialis; therefore, this criterion in question was met - "Patient is not concurrently receiving an alternative phosphodiesterase-5 enzyme inhibitor (e.g. Cialis, Levitra, Staxyn, Stendra, or Viagra)."

With the patient's history of hypertension, hypercholesterolemia and hypogonadism, this criterion was also met -- "a. Patient has an organic cause of erectile dysfunction [ie: diabetes mellitus, hypertension, atherosclerosis, drug induced**, hypercholesterolemia, renal insufficiency, neurological disease (stroke, seizure disorder, demyelinating disease, spinal cord injury, tumor), endocrine disorder including hypogonadism, vascular or neurologic disease affecting the genitalia, or history of male genital surgery (including prostatectomy, trauma, or irradiation)]."
Appeal type: Medical necessity
Decision: Overturned

This is a patient  with a past medical history of dementia, Parkinson's disease, diabetes mellitus type 2, hyperthyroidism, hypertension, incontinence, gait and balance impairment, stroke and frequent falls. The patient had been approved for personal care aide (PCA) services at 5 hours/day, 5 days/week to total 25 hours/week based on assessment tool . There was a request to increase PCA service hours to 8 hour/day, 5 days/week to a total of 40 hours/week. At issue is the medical necessity of personal care aide services 8 hours per day, 5 days per week - total of 40 hours a week.
The health plan's determination is overturned.
Tthe requested personal care aide services are medically necessary. The patient had a decline in her chronic medical issues which include Parkinson's disease and dementia causing her to need more help with multiple activities of daily living (ADLs) and AIDL's. The patient's primary care provider noted the medical necessity in an office visit and further documented in a letter to the health plan. The patient was at increased risk for falling due to her medical conditions and needed more than extensive assistance with walking, locomotion and toilet transfer. The patient also needed more than extensive assistance with personal hygiene and toilet use given her incontinence and incontinence care needs.
The patient had another assessment tool  showing only a change in walking, locomotion and transfer toilet from limited assistance to extensive assistance needed. The health plan denied an increase in PCA service hours based on this assessment. An office note from noted the patient attended adult daycare from 9:00 AM to 3:00 PM on Tuesdays and Thursdays and was with an aide from 4:00 PM to 8:00 PM on those days. On the other days of the week, the patient is alone from 3:00 PM to 6 PM. The office visit note also documented the patient needing help with dressing, medication management, toileting, showering, transferring, laundry, food preparation, shopping, incontinence cares and AM and PM personal hygiene. The patient's primary care provider wrote a letter on  noting the medical necessity of the requested increase in PCA service hours. The patient's family submitted a letter indicating the patient was not asked to walk at the assessment but the denial letter indicated the patient is able to walk with the assistance of a walker. The denial letter also noted the son refused a recommended referral to physical therapy (PT) when the patient already had PT services as prescribed by the PCP.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Trauma/Injuries/Laceration.
Treatment:  Inpatient hospital stay.
The insurer denied the inpatient hospital stay.  The denial was upheld.

This patient has a history of alcoholism, who came into the emergency department via Emergency Medical Services (EMS), after being found down on the street, with a laceration on the head.  The patient could not recall the events that led to the injury, woke up in the hospital, slightly disoriented, with a high blood alcohol level.  Because of the confusion initially, the patient was given Haldol and Benadryl intramuscular (IM) in the emergency department.  A 12-lead electrocardiogram (EKG) showed QTC prolongation at 501.  Head computed tomography (CT) was negative for intracranial bleed; cervical spine CT just showed degenerative changes.  The patient was cleared from the cervical collar.  Given the alcohol intoxication, hypokalemia, and QTC prolongation, the patient was admitted to the hospital for monitoring.  The patient denied any history of seizures, denied headache, nausea, or vomiting or chest pain.  Patient was provided with potassium supplementation in the emergency department with both intravenous (IV) and oral potassium.  A neurology evaluation was requested the following day for evaluation of the fall in an alcohol-intoxicated patient.  Alcohol withdrawal evaluation was performed on the patient, with a Clinical Institute Withdrawal Assessment (CIWA) scoring system, with a value of 2.  The patient was given folic acid and thiamine and was monitored for signs of withdrawal.  On the day of discharge, the echocardiogram and the carotid duplex results came available and showed preserved ejection fraction and no hemodynamically significant carotid stenosis.  The health plan's determination of medical necessity is upheld in whole.  The requested health service/treatment of inpatient stay is not medically necessary for this patient.  A lower level of care is more appropriate.  Clinically, there was no reason why the patient could not be evaluated under a lower level of care, with subsequent transition to home.  There is no evidence of persistent confusion, severe cardiac arrhythmias, hemodynamic instability, or intracranial injury.  Episodes of intoxication, with electrolyte abnormalities, can be managed at a lower level of care, with subsequent transition to an outpatient level of care.