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

Diagnosis: Cholelithiasis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department with epigastric pain. The pain radiated to the right upper quadrant. The patient had associated vomiting. Her vital signs were unremarkable. Lab results demonstrated an alanine aminotransferase (ALT) of 799 and aspartate aminotransferase (AST) 729, and total bilirubin of 2. The white blood cell count (WBC) was 5.48. A computed tomography (CT) scan demonstrated mild intrahepatic and extrahepatic biliary ductal dilation. An ultrasound demonstrated cholelithiasis and common bile duct dilation. Surgery was consulted. The patient underwent a laparoscopic cholecystectomy with intraoperative cholangiogram. The intraoperative cholangiogram was negative for stones or blockages of the common duct. The patient was doing well and was readied for discharge. The patient was discharged home.
At issue is the medical necessity of an inpatient stay.

The patient's admission was not medically necessary at the inpatient level of care for the entire admission.
The patient did not demonstrate signs of a systemic infection in association with the cholecystitis. The patient also did not demonstrate significant concern for cholangitis other than liver function test (LFT) changes. The patient did not demonstrate hemodynamic instability. She did not have severe or persistent pain that would require high dose medication administration and monitoring. The patient did not demonstrate significant vomiting. The patient did not have signs of sepsis or bacteremia. The documentation does not suggest that the patient's care could not have been performed at a lower level care. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The provided documentation does not support the medical necessity of an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Progressive gait dysfunction.
Treatment: 88184 - Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker; 88185 x 11 - Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker and 88188 flow cytometry, interpretation.

The insurer denied the 88184 - Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker; 88185 x 11 - Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker and 88188 flow cytometry, interpretation.

The denial is upheld

The patient is a male with a history of tremor, diagnosed with essential tremor, and treated with deep brain stimulation. He presented with the complaint of gait instability and leg weakness. MRI (magnetic resonance imaging) showed non-specific changes. A lumbar puncture was performed for cytology and paraneoplastic evaluation.

No, the requested health service was not medically necessary.
The patient presented with progressive gait dysfunction. There was no indication to perform lumbar puncture for cytology. Specifically, there was no evidence of an occult hematological malignancy affecting the central nervous system that could be detected on cytology evaluation. Evaluating for CNS (central nervous system) inflammation using CSF (cerebrospinal fluid) cytology is not a standard of care diagnostic study for this patient's condition. CSF (cerebrospinal fluid) studies are not necessary for the diagnosis of paraneoplastic conditions.

The standard of care in situations such as the patient's involves completion of a serum paraneoplastic antibody panel. There are no clinical studies or guidelines to support the preferential use of CSF (cerebrospinal fluid) for this test in this clinical context (Rosenfeld and Dalmau).

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer Of The Esophagus.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. The patient in this case was diagnosed with esophageal cancer after presenting with a several month history of dysphagia and weight loss.

Given his significant weight loss, the patient was admitted to the hospital for gastrostomy tube placement.  His gastrostomy tube was placed and he also had additional biopsies performed. He was able to take a full liquid diet at the time of admission and it was noted that he was admitted for tube placement due to failure to thrive.  PET/CT (positron emission tomography/computed tomography) had been done around the time of admission and revealed metastatic disease. He was started on tube feeds the following day and chemotherapy treatment was recommended with port placement.  However, the patient opted against port placement.  Liver enzymes had been elevated at the time of admission but they were improving spontaneously.  Following that it was decided to proceed with chemotherapy on an outpatient basis.  The patient continued on tube feeds and also was able to take liquids and a soft diet.  He had the port placed and was discharged to home.

No, the Inpatient admission was not medically necessary.
This patient was admitted to the hospital for placement of a gastrostomy tube.  Following tube placement he was started on tube feeds.  He was able to take liquids at the time of admission.  Records do not document any significant complications related to tube placement or tube feeds.  Chemotherapy treatment was recommended and planned but not given.  He had elevated liver enzymes at the time of admission but they improved spontaneously.  None of the interventions performed during this hospital stay required acute care inpatient hospitalization.  He was hemodynamically stable.  He had anemia but was not actively bleeding.  Anemia was attributed to his underlying malignancy. There was no documentation of significant electrolyte disturbance or active infection. Given these considerations, this acute care inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal/Digestive System. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Remicade. 
The denial is overturned.

This patient is a male with a history of Crohn's disease, diagnosed on the endoscopy and colonoscopy.  His disease is complicated by growth failure, pain and diarrhea. His inflammatory markers are very high, and his albumin is low. His weight is approximately (~) 25 kilograms (kg). The subject under review is the medical necessity for Remicade.

The health plan's determination is overturned in whole. 

Anti-tumor necrosis factor alpha (TNF-a) (such as infliximab) are considered the standard treatment for pediatric Crohn's disease. The clinical practice guidelines recommend early biologic therapy for selected children with high risk for poor outcome such as patients with upper gastrointestinal (GI) involvement, growth delay, pan-enteric disease or stricturing diseases (Ruemmele FM et al.).
Furthermore, there is growing scientific evidence supporting the early use of biologics in the treatment of pediatric Crohn's disease. Many peer reviewed literature reports showed superior efficacy and less disease complications when biologics are used early in the disease course.
Yun Seok Lee et al., showed that early anti-tumor necrosis factor (TNF) use led to decrease relapse rate compared to conventional therapies in pediatric Crohn's disease. Thomas D. Walters et al., showed improved effectiveness with early use of Anti-Tumor Necrosis Factor-a in pediatric Crohn`s and improved growth parameters. Other studies showed that early use of biologics can delay disease progression to stricturing and/or penetrating disease when compared to conventional therapy (Basavaraj Kerur et al.).
Finally, infliximab is Food and Drug Administration (FDA) approved for pediatric Crohn's disease. However, the proposed "conventional therapies", such as azathioprine and methotrexate, are not FDA approved for pediatric Crohn's disease and are associated with major side effects.
This child has severe Crohn's disease associated with deep ulcers, anemia and growth failure. He is considered at high risk of poor outcome. Therefore, the early use of infliximab is appropriate and medically necessary despite not trying and failing conventional therapy.
 
According to the clinical practice guidelines: "Intravenous administration of infliximab (Remicade) is usually at 5 milligrams per kilogram (mg/kg) with three induction doses over 6 weeks [weeks 0-2-6], followed by maintenance therapy of 5 mg/kg every 8 weeks. However, there is ample evidence that children less than 30 kg, and those with extensive disease and low serum albumin levels, require higher induction doses up to 10 mg/kg, shorter dosing intervals, or both, to reach target trough levels" (Van Rheenen, et al.). This patient is low albumin, and his weight is 25 kg. Using a higher dose for induction the maintenance is appropriate and consistent with the generally accepted practices.
Therefore, the requested service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis

Treatment: Otezla

The insurer denied coverage for Otezla

The denial is upheld 

The patient is a female with mild psoriasis affecting 1% TBSA (total body surface area) involving the mid back and scalp. The patient has been treated with clobetasol, betamethasone, and calcipotriene. The requested medication is Otezla.  

Based on the documentation provided Otezla is not medically necessary. There is insufficient medical documentation that the patient's psoriasis is not adequately controlled on topical therapy. The progress notes indicate the patient has minimal residual disease and that she is improving. The affected surface area appears minimal.  There is no medical documentation to indicate that the patient has a contraindication to light therapy or other systemic agents which could potentially benefit her psoriasis.  According to the "national physician specialty society recommendations" for psoriasis- the American Academy of Dermatology Psoriasis Guidelines- and dermatology literature, phototherapy is an effective treatment for the management of psoriasis (1-3). Within the peer-reviewed literature, Racz writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks" (4).  Mehta writes "Ultraviolet (UV) B (middle energy between the tanning rays) phototherapy is most appropriate for patients with >10 % affected body surface area who have not responded to topical treatments...NB (narrowband)-UVB. Effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile" (5)

Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Otezla is not necessary. There is no documentation provided that the patient has tried and/or failed phototherapy or alternate therapies to warrant the use of Otezla specifically. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Otezla medically more appropriate than the other options. Therefore, the administration of Otezla is not supported for this patient, and Otezla is not medically necessary for this patient based on the current evidence-based medical literature. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Otezla 30 milligrams for use in the treatment of psoriasis vulgaris is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: asthma.
Treatment: Tezspire.
The insurer denied Tezspire. 
The health plan's determination is overturned. 

The patient is a male with severe persistent asthma who is dependent on oral corticosteroids (OCS) for symptom relief. He had 5 hospitalizations for asthma. He has severe obstructive lung disease by spirometry with a FEV1 (forced expiratory volume in one second) of 0.76L (liters) which is 24% of predicted. He has positive allergen tests to molds, a total IgE (immunoglobulin E) level of 1146, an absolute eosinophil count of 3200, and a chest computed tomography (CT) without evidence of allergic bronchopulmonary aspergillosis. He takes Trelegy Ellipta (a long-acting beta agonist/inhaled corticosteroid/long-acting muscarinic antagonist combination inhaler) at the maximum dose, montelukast, prednisone, and as needed albuterol. He was started on monthly Tezspire injections. By the patient's report his symptoms improved significantly, with elimination of wheezing and the need for albuterol use.

A formulary exception is indicated. The patient would be expected to have adverse effects from switching from the prescribed Tezspire to one of the formulary alternatives. Tezspire [tezepelumab] is a biologic therapy for asthma that uses a unique mechanism of action compared to the formulary alternatives. It was Food and Drug Administration (FDA) -approved in December 2021 for severe asthma, which this patient has. It has been shown to reduce acute exacerbations of asthma by 71% compared to placebo, which is a great improvement compared to the formulary alternatives of Xolair [omalizumab] (25% reduction in acute asthma exacerbations), Nucala [mepolizumab] (approximately 50% reduction in acute asthma exacerbations), Fasenra [benralizumab] (49% reduction in acute asthma exacerbations), or Dupixent [dupilumab] (47% reduction in acute asthma exacerbations). The patient has had 5 acute asthma exacerbations requiring hospitalization in the previous year, and switching his medication to a less efficacious formulary alternative would increase the risk of hospitalization for acute asthma exacerbation. Switching to a formulary alternative would be switching to a less effective medication, and poses a risk of a life-threatening exacerbation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Skilled Nursing Facility. 
The insurer denied Continued Stay in Skilled Nursing Facility. 
The denial is upheld. 

The patient is a female who has a diagnosis of leptomeningeal disease and breast cancer. Per the medical records the patient became paralyzed from the waist down after leptomeningeal disease which was a complication of her breast cancer. Based on her medical records this is not expected to be a reversible paralysis. Physical and occupational therapy indicated that the patient is unable to walk or use stairs, has zero muscle strength in her legs, needs maximum assistance with transfer from wheelchair to bed and vice versa and is totally dependent for activities of daily living. The patient received necessary durable medical equipment (DME) prior to discharge including hospital bed, wheelchair, Hoyer lift, sliding board, commode which per records were delivered.
At issue is the medical necessity of Continued Stay in Skilled Nursing Facility.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Continued Stay in Skilled Nursing Facility is not medically necessary for this patient.
For inpatient skilled nursing a patient must show active participation in physical, occupational, or speech therapy for a minimum of 1 hour per day and 5 days per week. In addition, documentation must demonstrate sustained gains, progress towards pre-established goals, improvement in function, and reduction in limitations. For the time period in question, the patient did not meet these criteria as she was not making functional gains. For this time period, the patient did not have complex skilled nursing needs. She did not require intravenous (IV) or intramuscular (IM) medication management. She was not dependent on parenteral nutrition. She did not have complex wound care needs. The patient remains maximum assistance for transfers, bed mobility, and toileting. She is nonambulatory. A continued stay at a Skilled Nursing Facility (SNF) would not be expected to improve her strength or independence.
The patient received necessary durable medical equipment (DME) prior to discharge including hospital bed, wheelchair, Hoyer lift, sliding board, and commode. Construction of an exterior ramp and modification of interior living spaces at the patient's home are not included in the assessment of medical necessity for discharge from a SNF.
Therefore, the requested health service/treatment of Continued Stay in Skilled Nursing Facility is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: congestive heart failure.
Treatment: home health care.
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 7 Days x 12 Hours. 
The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, polymyalgia rheumatica, urinary incontinence, dementia, hearing loss, osteoporosis, chronic kidney disease, gastroesophageal reflux disease (GERD), mild asthma, and congestive heart failure who had been assigned CDPAS (Consumer Directed Personal Assistance Services). Recently, the patient underwent another assessment, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, shopping, and transportation while maximum assistance with tasks of managing finances, managing medication, stairs, equipment management, and dressing lower body. With tasks of bathing, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility, the patient was assessed at extensive assistance while limited assistance with task of personal hygiene. The patient was assessed at set up with phone use and independent with task of eating.

 Consumer Directed Personal Assistance Services (CDPAS): 7 Days x 12 Hours are medically necessary for this patient.
There is documentation of functional and cognitive decline following the patient's multiple hospitalizations and rehabilitation stays by the patient's medical provider, the patient's caregiver, the patient's care manager, and even on the recent assessment with certain tasks. The patient requires at least extensive assistance with walking, locomotion, transfer toilet, and toilet use. The patient has unpredictable and unscheduled care needs and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The plan incorrectly assumed that the patient has informal help outside of the assigned CDPAS service hours. It is a hardship for the patient's family to provide informal help all of the time outside of CDPAS service hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 12 hours/day, 7 days/week, are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Back Pain.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

This is a case of a female admitted for a diagnosis of acute back pain. The patient presented with a chief complaint of back pain and vomiting. The back pain started the Thursday prior to admission. She was prescribed a Prednisone taper on an outpatient basis, but the pain continued to worsen. Vital signs demonstrated temperature of 98F (degrees Fahrenheit), a pulse of 91 beats per minute (bpm), a respiratory rate of 18/minute, a blood pressure of 138/75 millimeters of mercury (mmHg) and an oxygen saturation of 100% (percent). Physical exam showed no altered mental status with normal strength and a negative straight leg test bilaterally. A chest x ray showed no acute infiltrate and the lumbar x-ray showed normal height and alignment. The white blood cell count was 11.6 with a sodium of 130. The elevated white blood cell count was thought to be secondary to steroid use. A magnetic resonance imaging (MRI) of the lumbar spine was performed which showed multilevel disc herniations from (lumbar-sacral) L2-S1. She was seen by pain management who recommended a pain regimen of a Lidocaine patch, Cyclobenzaprine, Lyrica, Tylenol and Dilaudid. The patient underwent an epidural steroid injection and physical therapy was provided daily. The mild hyponatremia resolved during the hospital stay and she was able to be discharged.
At issue is the medical necessity for the inpatient stay.

The health plan's determination of medical necessity is upheld, in whole.

No, the medical necessity of admission has not been established.
According to the documentation submitted, the patient was treated for acute back pain but did not have etiology considered to be serious such as cauda equina compression, metastatic malignancy, epidural abscess, osteomyelitis, motor weakness, fever or hemodynamic instability. A magnetic resonance imaging (MRI) of the lumbar spine was performed which showed multilevel disc herniations from (lumbar-sacral) L2-S1. She was seen by pain management who recommended a pain regimen of a Lidocaine patch, Cyclobenzaprine, Lyrica, Tylenol and Dilaudid. The patient underwent an epidural steroid injection and physical therapy was provided daily.
Although the patient had needs best addressed in the hospital setting the monitoring, diagnostic workup and therapeutic interventions prescribed could have been safely administered at an alternate level of care. Therefore, medical necessity of admission has not been established.
Also, according to Milliman Care Guidelines (MCG) Health Back Pain 25th Edition and the documentation submitted the patient did not have acute neurological deficit, severe pain requiring inpatient management, aortic dissection, spinal instability, or need for urgent inpatient surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth decay.
Treatment:  White Glass With Crown for Teeth 7, 8 and  9.
The insurer denied the  White Glass With Crown for Teeth 7, 8 and  9.
The denial is upheld.

The patient is a female. Teeth 7, 8 and 9 have composite restorations in them. They have all been endodontically treated. Prior denial was for lack of missing tooth structure necessitating crowns.

No, the White Glass With Crown for Teeth 7, 8 and  9 is not medically necessary.
Teeth 7, 8 and 9 have conservative composite restorations in them already. There is no recurrent decay in the teeth and there are no fractured off pieces of tooth structure seen on the x-rays. The teeth are evidenced to be very sound and intact and not in need of any crowns to restore them.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.