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

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

This is the case of a female with a history of osteoarthritis, anemia, glaucoma, pre-diabetes, hypertension, morbid obesity, and visual impairment. She presented to the hospital for a left total knee replacement. She was admitted to the hospital. She received intravenous pain medication, wound monitoring, and physical therapy. She was discharged.

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

The records show there were co morbidities with an associated complicated post-surgical course. The patient had a BMI (body mass index) of 43. This by itself (ie. Morbid obesity) placed her at increased risk. The records showed "moderate drainage" with subsequent dressing change and monitoring recommended. She also had an episode of tachycardia which required additional testing of cardiac enzymes and EKG (electrocardiogram). She required parenteral pain medications. Taking all these events and conditions (morbid obesity, drainage and cardiac complaints) it would be important to monitor her status in an inpatient setting. Observation status would not be applicable nor appropriate. 

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumothorax, multiple left sided rib fractures

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

This patient was admitted to the hospital after a fall from a tree from a height of about 20 feet. The patient presented to the emergency department (ED) with complaint of severe left sided rib pain and pleuritic pain with breathing. Imaging studies revealed a moderate left pneumothorax (PTX), multiple left sided rib fractures and possible contusions of the lung. Computed tomography (CT) head also was showing a possible small subarachnoid hematoma (SAH).  

The patient was evaluated by the Trauma service and Neurosurgery service. A chest tube was placed on the left side. Neurosurgery did not recommend any acute intervention but recommended a repeat CT head in 6 hours. The patient was admitted to Telemetry. The patient was placed on Keppra intravenous (IV). Frequent Neuro Checks were also ordered. The patient had a chest tube placed on water seal and suction.

The patient was in severe pain and was placed on IV Narcotics and other pain meds. The patient had a repeat CT which was stable. Chest tube was continued on suction to help with re-expansion of the lung.

The patient was re-evaluated by neurosurgery. Initially the patient switched to oral (PO) Keppra, and subsequently as repeat CT did not show any changes Keppra was discontinued. Patient remained stable after admission. By discharge, the patient's lung had fully expanded. There was no more air leak. No worsening of SAH on follow up CT head seen. The patient's neurological status remained stable, and his rib pain was controlled with oral meds. The patient then subsequently discharged.

Based on the patient's presentation it was appropriate to admit this patient for close observation and treatment. This could not have been safely done in a lower level of care.

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperbilirubinemia.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is overturned.

This is the case of a female baby. The mother was B positive, Coombs negative. Prior to her initial discharge, there was a total bilirubin of 7.9 mg (milligrams)/dL (deciliter). Fluids and nutrition were provided via breast feeding and formula. Upon follow-up with her primary care provider, she was referred for jaundice to the ED (emergency department) where her total/direct bilirubin were 21.1/0.3 mg/dL on 11/4/2021. Her hemoglobin was 21.3 g (grams)/dL (> 95%percentile) and the reticulocyte count was 0.6 %. She was deemed high-risk and admitted for intensive (quadruple) phototherapy. The total bilirubin was 14.6 mg/dL. Phototherapy was discontinued. A repeat total bilirubin was 12.4 mg/dL. This was followed by discharge home.  

The insurer's denial of coverage is on the basis that it considered the care rendered to meet observation and not an in-patient level of care. According to AAP (American Academy of Pediatrics) Guidelines for Hyperbilirubinemia (Management of Hyperbilirubinemia in the Newborn Infant 35 or More weeks of Gestation, 2004), the infant's bilirubin of 21.1 mg/dL was in the high-risk zone. For >= 38 weeks gestation, and otherwise well, the approximate threshold for phototherapy is 21 mg/dl with the option to provide phototherapy at total bilirubin levels 2-3 mg/dL below. According to MCG (Milliman Care Guidelines) 25th Edition, Page-265, Neonatal Jaundice, admission is indicated for a total serum bilirubin at 96 hours or more of 14 mg/dL in a higher-risk infant, 17 mg/dl in a medium risk infant and 20 mg/dL in a low-risk infant. 

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Cosentyx SensoReady Pen 300mg, dose two in 28 days, pre-service
The insurer denied the Cosentyx SensoReady Pen 300mg, dose two in 28 days, pre-service
The denial is overturned

The patient is a female with psoriasis to the hands, treated with topicals, Humira, Otezla and Cosentyx.  Patient is clear on Cosentyx.  The health plan denied the request due to required formulary agents Humira, Otezla, Skyrizi, Stelara, Taltz and Tremfya.

Yes, the proposed treatment is medically necessary.
The health plan denied the request due to required formulary agents Humira, Otezla, Skyrizi, Stelara, Taltz and Tremfya.

Cosentyx is an approved, appropriate and effective medication for psoriasis.  A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis. 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. 

Cosentyx is an interleukin (IL)-17 inhibitor, which have been shown to be among the most economically effective therapies according to current peer-reviewed literature.  Cosentyx has been compared to Stelara in trials but not extensively to other agents.  The meta-analysis published (Loos et al) concluded that the interleukin 17A inhibitors are more effective in achieving clearance than ustekinumab, and they are generally more effective than etanercept, adalimumab, and apremilast.  

It is generally considered medically necessary to continue a patient on a therapy to which they have favorably responded.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Cosentyx 300 mg (milligram) dose - 2 pens.
The insurer denied coverage for Cosentyx 300 mg (milligram) dose - 2 pens.
The denial is overturned.

The patient is a female receiving therapy for latent tuberculosis (TB), who has psoriasis which has failed topical steroid therapy. The requested medication is Cosentyx.  

Based on the submitted documentation Cosentyx is medically necessary for the treatment of this patient's psoriasis. The available treatment options for systemic therapy are complicated by the presence of latent TB infection which is actively being treated. The medical literature is consistent that the use of TNF (tumor necrosis factor) inhibitors is more likely to cause reactivation of latent TB. Multiple smaller studies failed to show reactivation of latent TB in patient's treated with IL-17A (interleukin 17A) inhibitors, such as secukinumab. In this clinical scenario, the treatment options are limited and thus the use of Cosentyx under the close medical supervision of the managing physicians is within the standard of care. 

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

The insurer's denial of coverage for the Cosentyx 300 mg (milligram) dose - 2 pens is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment: Lab tests - blood draw to determine levels of vedolizumab
The insurer denied blood draw to determine levels of vedolizumab.
The health plan's determination is overturned. 

The patient is a female with Ulcerative Colitis. She presented with concern for Ulcerative Colitis flare including abdominal pain and loose bowel movements. She required a prednisone taper. She had testing for Entyvio (vedolizumab) level and anti-Entyvio antibodies, prior to the next Entyvio infusion. The test showed Entyvio level of 19 ug/mL (micrograms per milliliter) and lack of anti-Entyvio antibodies. The coverage is requested for testing for Entyvio level and anti-Entyvio antibodies.

Blood draw to determine levels of vedolizumab 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 was on Entyvio, with signs and symptoms of active Ulcerative Colitis, as well as a need for prednisone. According to the American Gastroenterological Association (AGA) Guideline on Therapeutic Drug Monitoring in Inflammatory Bowel Disease, reactive therapeutic drug monitoring is recommended to guide treatment changes. Studies have shown that Entyvio level is associated with response, and higher levels are associated with histologic healing. In this case, active disease has been documented while on Entyvio, after initial good response to Entyvio. Therefore, the requested testing is indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment: Lab tests - blood draw to determine levels of vedolizumab
The insurer denied blood draw to determine levels of vedolizumab.
The health plan's determination is upheld. 

The patient is a female with ulcerative colitis. In the spring and summer, the patient was experiencing a flare of symptoms including increased abdominal pain, urgency, cramps and diarrhea. A note indicates she was doing well on vedolizumab. The patient was on vedolizumab but required prednisone for disease control. The patient started vedolizumab and is also on Lialda.

The patient's provider recommended assessing vedolizumab levels and antibodies to vedolizumab at a commercial laboratory.

The proposed test to determine the level of Vedolizumab was not likely to be more beneficial than any standard treatment for the patient's ulcerative colitis. The major societal guidelines do not advocate for clinical testing for vedolizumab levels as the data to support this practice is very weak. Unlike anti-tumor necrosis factor (TNF) drugs like Remicade, there are no high-quality clinical studies to show what drug level is optimal for vedolizumab. The estimates are primarily derived from retrospective observational studies. In a recent landmark study which compared the efficacy of vedolizumab to Humira, assessment of drug levels were not part of the study design because measuring these levels is not considered standard of care at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment: Lab tests - blood draw to determine levels of vedolizumab
The insurer denied blood draw to determine levels of vedolizumab.
The health plan's determination is overturned. 

The patient is a female who has ulcerative colitis managed with Entyvio. The attending provider was concerned that this patient may have developed antibodies to vedolizumab or had low vedolizumab trough levels since she had symptoms suggestive of a flare of ulcerative colitis (UC) despite being on adequate dosing of Entyvio and required a course of steroids to treat her flare. Rather than empirically increase the dose of vedolizumab or switch to another agent, the attending provider ordered antibodies to vedolizumab and vedolizumab trough levels since a dose increase would have been futile if this patient had antibodies to vedolizumab.

Blood draw to determine levels of vedolizumab was likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Since this patient had a flare of her UC and required steroids, it was important to determine if she had adequate levels of vedolizumab or had developed antibodies. If she had low levels a dose escalation would have been appropriate or if she had antibodies then switching to a different biological medication may have been appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional-Growth Hormone Deficiency.
Treatment: Pharmacy/Prescription Drugs - Humatrope.
The health plan denied the prescription drug Humatrope as not medically necessary for this patient. 
The reviewer has overturned in whole the health plan's determination.

This patient's annualized height velocity is reported to be 1.9 centimeters (cm) per year. Bone age was 2 years delayed. The patient failed growth hormone (GH) stimulation testing with glucagon and clonidine with a peak growth hormone of 5.8. A magnetic resonance imaging (MRI) scan of the brain was normal. His height is less than the 3rd (third) percentile. His weight gain has been normal along the 10th (tenth) percentile. His height declined from the 5th-10th percentile to below the 3rd percentile. Mid-parental target height is 71 inches or 180.5 cm +0.51 standard deviation (SD). His height was 120.2 cm,  2.3% (percent), -2 SD. Height velocity over 2.7 years was approximately 4.8 cm per year.  Insulin like growth factor (IGF-I) was 105 (62 - 347). Height velocity over 1.7 years was 4.2 cm per year, -1.8 SD. 

The requested Humatrope is medically necessary for this patient. The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2, 3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 years of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 years. The biochemical criteria include low IGF1 or insulin-like growth factor binding protein 3 (IGFBP3) or GH stimulation testing with a peak GH less than 10 nanograms/milliliter (ng/ml).

This patient met biochemical criteria. GH stimulation testing peaked at less than 10 ng/ml. The patient met height criterion 2 as his height is more than 1.5 SD below target height SD. The patient met both height and height velocity and biochemical criteria for the diagnosis of GH deficiency. GH in the treatment of GH deficiency is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg pain
Treatment: Diclofenac 1.3%
The insurer denied the Diclofenac 1.3%.
The determination is upheld.

The patient is female requesting coverage for Diclofenac patches. There are no medical records available for review.  In a prior authorization, the rationale for an expedited review was "patient experiencing acute leg pain." It was indicated that the patient tried naproxen, ibuprofen, diclofenac, Voltaren gel, and lidocaine ointment; all either caused gastrointestinal (GI) distress or were ineffective. However, in the Appeal Request for Denial of Services form, the patient stipulated that the previously tried medications were "not able to relieve my acute lower back pain due to minor strain." Records were requested but not received. At issue is the medical necessity of Diclofenac 1.3%.

No, the requested health service/treatment of Diclofenac 1.3% was not medically necessary for this patient. Based on a review of the provided information, the Diclofenac 1.3% patch is not medically necessary for this patient. There are no objective medical records to substantiate the rationalizations stated on the prior authorization form and the Appeal Request form. In addition, the documents show a discrepancy between the cited indications for the medication. It has not been objectively demonstrated that the patient tried and failed all of the usual formulary medications. Therefore, based on the standard of care, and the peer reviewed literature cited in the reference below, the Diclofenac 1.3% was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Athletic Pubalgia 
Treatment: Core Muscle Surgery Repair
The insurer is denied coverage for Core Muscle Surgery Repair
The denial is reversed. 

This was a female with athletic pubalgia. The patient had been treated with core muscle injury repair surgery. The patient's symptoms included bilateral groin pain that did not improve with rest and physical therapy for one year. The patient's magnetic resonance imaging (MRI) showed continued edema and aponeurotic plate injury, Grade 1 left obturator externus muscle strain, and bilateral full thickness labral tears. The surgeon performed bilateral pelvic floor repair (CPTcode49999), bilateral adductor longus and pectineus repairs, and bilateral adductor longus and pectineus compartment decompression.
According to literature review, there are studies that support core muscle surgery for athletic pubalgia. For instance, as per Rossidis et al (2015) study, "Athletic pubalgia is a disease with a multifactorial etiology that can be treated surgically by a laparoscopic totally extraperitoneal hernia repair with synthetic mesh accompanied with an ipsilateral adductor longus tenotomy allowing patients to return to sports-related activity early with minimal complications." And as per Harr & Brody (2017), "In athletes with MRI confirmation of rectus and adductor longus injuries, tenotomies along with a herniorraphy may improve outcomes. A suture repair to reinforce the inguinal floor prevents mesh-related complications, especially in young athletes." However, the studies are small in number, and needs further research to determine whether a net health outcome is supported. Thus, as to date, the core muscle surgery does not have final approval from the appropriate regulatory bodies.
However, based on the review of the medical record, this patient had failed conservative treatment. The patient's condition was non-responsive to physical therapy. Considering that there is no other standard treatment available for this patient, this patient is considered a good candidate for this core muscle surgery. Thus, the requested procedure is likely to be more beneficial than any of the standard treatments/procedures for this patient.
The carrier's denial of Core Muscle Surgery Repair, procedure code 49999, should be reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Short stature.
Treatment: Genotropin.

The insurer denied coverage for Genotropin.  The denial is overturned.

This is a female diagnosed with short stature. This request is for Genotropin. Her GH (growth hormone) stimulation test with arginine and clonidine peaked at 7.9. Her GU (genitourinary) growth was at tanner 1. Her IGF1 (insulin-like growth factor 1) was 128; IGFBP3 (insulin-like growth factor binding protein) was 3127. Her MRI (magnetic resonance imaging) was normal. Her weight was 21.36 kg(kilograms). 

Her height was 109 cm (centimeters) (-3.01 SDS (standard deviation score), and she grew to 116.3 cm (-2.50 SDS) with height velocity over 1 year of 7.1 cm/year.

Her mother's height is 162.56 cm, and father's height is not reported. Mid parental height as per chart is 164 cm (+0.10 SDS). 

The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:

Classic GH deficiency

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2, [3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD (standard deviation) below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 yr (year) more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr in children over 2 yr of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng (nanograms)/ml (milliliter).

This patient met biochemical criteria. GH stimulation testing peaked at less than 10ng/ml. The patient met height criterion 2 as her height is more than 1.5 SD below target height SD. The patient met both height and height velocity and biochemical criteria for the diagnosis of GH deficiency. GH in the treatment of GH deficiency is medically necessary. 

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

The insurer's denial of coverage for the medication Genotropin is overturned. Medical Necessity is substantiated.