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

Diagnosis:  Psoriasis.
Treatment:  Skyrizi 150 Dose Injection.

The insurer denied Skyrizi 150 Dose Injection.  The determination is overturned.

This a patient with psoriasis treated in the past with Humira, which caused injection site reactions.  The patient has also tried Stelara, Otezla, Cosentyx, methotrexate and topicals.  Formulary alternatives are Siliq and Enbrel.  The provider is requesting Skyrizi. At issue is the medical necessity of Skyrizi.

The Skyrizi is medically necessary.  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.  It is considered standard of care to switch to a different class of biologics after failure of one agent within a class.  It is acceptable practice, therefore, to avoid further anti-tumor necrosis factor (TNF) agents in this patient.  Skyrizi has shown extremely favorable efficacy and side effect profile.  Enbrel is an additional anti-tumor necrosis factor (TNF) agent, and the patient has already tried and failed one anti-TNF therapy.  Siliq is a newly approved anti-interleukin (IL)-17 agent.  The patient has no specific contraindications to any biologics, and there are no guidelines or recommendations to provide physicians with appropriate first and next-line therapies for each patient.  Therefore, the requested Skyrizi is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Osteoarthritis.
Treatment:  Increased personal care aide services, 9 hours per day  7 days a week for total of 63 hours per week.

The insurer denied increased personal care aide services, 9 hours per day  7 days a week for total of 63 hours per week.  The determination is upheld.

The patient has a past medical history significant for hypertension, a brain aneurysm, depression, hepatitis C, asthma, obesity and osteoarthritis.

Increased Personal Care Aide Services were denied based upon medical necessity, with the denial stating the following:  An increase in personal care services is not medically necessary.  Patient does not meet criteria.  That determination is being appealed.  This review is for the medical necessity of increased personal care services, 9 hours per day  7 days a week for total of 63 hours per week.

The requested health service, an increase in personal care aide hours from 42 hours a week to 63 hours a week is not medically necessary for this patient.

She has multiple medical problems as listed above.  She needs help with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs).  The patient's most recent evaluation with a Uniform Assessment System (UAS) was by telephonic survey secondary to the coronavirus pandemic.  She had a previous evaluation within the last year.  The evaluation noted that the patient required 42 hours of services a week.  This is similar to the previous evaluation.

A letter from her personal physician states the following: patient is able to ambulate with a roller walker but is unable to walk for more than one block without experiencing pain and fatigue.  The patient is noted to have memory issues from her brain aneurysm causing her difficulty with her personal care.  A letter from the patient's physician notes that she needs more help at home, with bathing, grooming and getting dressed along with meal preparation, cooking, shopping, laundry and transportation to medical appointments.

Based on a recent assessment, medical needs can be met with 42 hours a week of personal care service hours.  Additional hours are not provided for safety monitoring and supervision.

The patient is currently receiving 6 hours a day  7 days a week, which according to the documentation provided is sufficient to provide for her medical needs.  Her needs, which were listed according to documentation in the letter from her physician, can be provided in the allotted time.  The patient does have transportation to medical appointments provided separately.  Additional service hours are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Inpatient Hospital

Diagnosis: altered mental status
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a woman with a history of hypertension, diabetes, cerebrovascular accident (CVA) and right sided hemiparesis who presented to the emergency department. She presented by ambulance accompanied by her daughter with decreased food intake, generalized weakness, dizziness, and altered mental status. Vital signs showed blood pressure 143/64, heart rate 77, temperature 99.8 Fahrenheit, and respiratory rate 16. On exam, heart was regular, breath sounds were normal, and there was right sided hemiparesis that was mild. Labs showed white blood cell count (WBC) 13.0, hemoglobin 11.9, magnesium 1.4, lactate 3.2, Troponin negative, and hemoglobin 6.5. Analysis of urine was negative for infection. Head computed tomography (CT) was negative for an acute stroke. Chest x-ray showed a mild right basilar opacity but no other acute abnormalities were seen. The patient was admitted for altered mental status with concern for delirium and infection.

The inpatient admission was medically necessary.
The patient had altered mental status of unclear cause, with suspicion for infection including pneumonia, and she also had hypertensive urgency. Because the source of her altered mental status was unclear, and she had multiple potential sources for infection and delirium, she required a higher intensity of care. Hypertensive urgency can also cause altered mental status leading to hypertensive emergency due to hypertensive encephalopathy. Overall, the uncertainty about her diagnosis and the intensity of her treatment plan increased the complexity of her care.
An elderly patient with altered mental status for unclear reasons and a history of prior stroke, along with ongoing concerns for infection and hypertensive urgency, would not typically be managed at a lower level of care. The reason is that patients like this are more complex and require more intensive monitoring, diagnostic work up and treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, osteoporosis, hypotension
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with hypertension, diabetes, and osteoporosis who was directed to the hospital after a blood pressure of 70's over 50's was noted in a podiatry clinic. The patient's daughter noted that the patient had not been eating well for the prior two days. 

Coronavirus disease (COVID) testing was negative. Computed tomography of the brain demonstrated no acute process; computed tomography of the chest demonstrated no pulmonary embolism. The urinalysis was negative. Labs were notable for a white blood cell count 7.6, potassium 4.9, blood urea nitrogen (BUN) 74, bicarbonate 23, and creatinine 3.2. In the emergency department the patient was afebrile with the blood pressure 95 over 78 and pulse 74. Lower extremity Dopplers showed no deep venous thrombosis and a ventilation perfusion scan showed no pulmonary embolism. Intravenous fluids were provided, and antihypertensive agents were held. The creatinine dropped to 1.7 and then 1.3. The blood pressure normalized.

No, the proposed inpatient admission was not medically necessary.

The patient's hypotension was not accompanied by evidence of septic shock, cardiogenic shock, hypovolemic shock, or anaphylactic shock. Vasopressors were not required. The patient's acute kidney injury was not accompanied by hyperkalemia, acidosis, volume overload, or uremia. Dialysis was not required. Renal function improved promptly with administration of intravenous fluids, with rapid drops in creatinine to 1.7 and then 1.3 on follow-up days. There was no evidence of acute cerebrovascular accident or pulmonary embolism. In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male whose inpatient admission is under review. The patient has a history of hypertension (HTN), hyperlipidemia (HLD), lymphedema, and necrotizing fasciitis. He presented with two days left lower extremity (LLE) pain and erythema. He had a fever.

In the emergency room (ER) temperature (T) was 98.9, pulse was 94, respiratory rate was 18, and blood pressure was 176/81. Musculoskeletal assessment revealed left lower extremity (LLE) erythema, lateral aspect, non-tender, with an area on the left foot with a healing skin graft. Erythrocyte sedimentation rate (ESR) was 38 and C-reactive protein (CRP) was 10.5.

The patient was suspected to have necrotizing fasciitis, was admitted and was started on intravenous (IV) vancomycin, Zosyn, and clindamycin. The patient remained stable during hospitalization and was discharged home shortly thereafter.

Yes, the proposed inpatient admission was medically necessary.

This patient meets criteria for admission according the Infectious Diseases Society of America (IDSA) guidelines as "Hospitalization is recommended if there is concern for a deeper or necrotizing infection." (1) 

In addition, given history of necrotizing fasciitis, and how difficult it can be to diagnose early during presentation, standard of care would require admission, intravenous (IV) treatment, and close observation in such a patient. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Failing preexisting fixed bridge.

Treatment: False-tooth shaped cap for #13 and tooth-shaped cap for bridge (crown) for teeth #'s 12 and 14. 

The insurer denied coverage for false-tooth shaped cap for #13 and tooth-shaped cap for bridge (crown) for teeth #'s 12 and 14.

The denial is overturned. 

This is a female patient who presented for dental care with a failing preexisting fixed bridge that had been present for many years. The insurer has denied service for false-tooth shaped cap for #13 and tooth-shaped cap for bridge (crown) for teeth #'s 12 and 14  stating that the medical necessity criteria are not met as the notes and radiographs do not indicate a need for replacement of this bridge.

Upon review of the documentation, in particular the radiographs, it is evident that the preexisting bridge was failing. To restore function to the left maxillary dentition, in this case since the patient has pre-existing fixed bridge, replacement with a fixed prosthesis spanning #12-14 site is the standard of care dental treatment in general dental practice, as recommended. As the dentition is already restored with a fixed bridge prosthesis the only treatment that would be considered appropriate would be for replacement of the fixed bridge.

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

The false tooth shaped cap for #13 and tooth shaped cap for bridge (crown) for teeth #'s 12 and 14 is considered medically necessary for this patient.

Based on the above, the medical necessity for false-tooth shaped cap for #13 and tooth-shaped cap for bridge (crown) for teeth #'s 12 and 14 is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Durable medical equipment (DME).

The insurer denied: Functional Electrical Simulator upper leg. The denial is upheld in whole.

The patient is a female with multiple sclerosis. According to a letter from the provider she has had bilateral hip replacements and a left knee replacement. The patient wears an ankle foot orthosis on her right foot. A Bioness L 300 system (functional electrical stimulation) is requested for treatment of thigh weakness and foot drop.
The subject under review is whether the requested system is medically necessary.

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

No. The requested functional electrical stimulator is not medically necessary. For this particular device, randomized controlled trials are lacking to show that a functional electrical stimulation (FES) device is effective as compared to conventional means for treatment of leg weakness including physical therapy and bracing. Further studies are needed. For example, some studies show that the Bioness L300+ system when used as an adjunct to standard of care may improve certain outcomes; however, control groups are lacking to show the size of benefit of the device if one exists. This device is not considered the standard of care for treatment of leg weakness or foot drop in the United States. Furthermore, the existing literature is not specific to treatment of foot drop or leg weakness with multiple sclerosis and studies are often performed in stroke patients. It is unclear if the results can be translated to multiple sclerosis patients. Modalities such as physical therapy, assistive devices, and bracing are considered the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Cosentyx Inj 300mg Dose [2-Pack] (secukinumab) 
The insurer denied Cosentyx Inj 300mg Dose [2-Pack] (secukinumab) .
The determination is upheld.

The patient has moderate to severe psoriasis. The patient has tried and failed topical corticosteroids (such as triamcinolone, betamethasone, and halobetasol). It is noted that he tried Humira but it is not clear how he obtained this. Phototherapy was used but stopped due to treatment failure and burning side effects. The patient has elevated liver function tests associated with fatty liver side effects (the patient has a serum glutamic-oxaloacetic transaminase (SGOT) of 40, and a serum glutamic pyruvic transaminase (SGPT) of 59. At issue is the medical necessity of Cosentyx.

The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line oral/systemic therapies such as Cyclosporine. Neither the patient's liver enzymes nor blood pressure are significant medical contraindications based on the documentation provided, and control of these conditions can occur with appropriate monitoring and appropriate medications. Cyclosporine is an appropriate treatment for this patient at this time. The patient has no true contraindication to this therapy and treatment with/ failure of Humira is not sufficiently documented as to confirm and conclude treatment failure with that first-line biologic therapy. Therefore, consistent with modern dermatology literature [1-4], the requested Cosentyx is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Misaligned teeth.
Treatment:  Braces (D8080) and Monthly visit x 12 (D8670).

The insurer denied the Braces (D8080) and Monthly visit x 12 (D8670).  The denial is overturned. 

The patient is a female requesting orthodontic benefits and monthly follow up visits.

Yes, the Braces (D8080) and Monthly visit x 12 (D8670) are medically necessary. 

First, the handicapping index score is 27, which is above the threshold of 26, so the case warrants treatment.  Second, both the upper left canine and the lower right canine are "blocked" out of their proper positions.  Orthodontic treatment is needed to correctly place them in their correct positions.  Without these teeth positioned properly, there can be no "canine guidance" and the patient's teeth will not mesh properly during the chewing cycle.  Trauma and/or fracturing of teeth can result due to this.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cancer - Metastatic Breast Cancer.
Treatment:  Radiation Therapy - Intensity Modulated Radiation Therapy (IMRT).

The health plan denied the IMRT as not medically necessary.  The reviewer upholds in whole the health plan's determination.

This is the case of a patient who presented with pinching in the back and numbness in the right(R) hand.  The patient also had pain in the upper back and was diagnosed with metastatic breast cancer.  The patient was treated with palliative radiation therapy (RT) using intensity modulated radiation therapy (IMRT).

The requested health service/treatment of Intensity Modulated Radiation Therapy (IMRT) is not medically necessary for this patient.

This is first time treatment in this area, and it is a palliative condition with low dose of radiation which can be treated with 3D CRT.  The conventional three-dimensional conformal radiation therapy (3D CRT) is standard of care (SOC) for a case such as this patient's.  This is not retreatment of a same area or overlap with adjacent previous radiation fields where IMRT would be medically appropriate.

There is no overlap with a previous radiation field.  This is not retreatment of the same area or overlap with adjacent previous radiation fields where IMRT will be medically appropriate. This is first time treatment in this area.  It is palliative condition with low dose of radiation.

There are no extenuating circumstances in this case to use IMRT.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Blood Sugar.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial is upheld. 

The patient is a male with type 2 diabetes complicated by right eye blindness, depression, cerebrovascular accident with residual right sided weakness, asthma, chronic obstructive pulmonary disease, hypertension, high cholesterol, status post cervical spinal fusion surgery and wheelchair dependence. He presented to Emergency Department for hyperglycemia, blurry vision, and polyuria. He had been to three other emergency departments with similar complaints.

The patient's glucometer was reading high. He was afebrile, heart rate 135, blood pressure 154/94, and oxygen saturation of 98%. Fingerstick glucose was 354 mg (milligram)/dL (deciliter). Venous blood pH (potential of hydrogen) was 7.386 (7.31-7.41). Total CO2 (carbon dioxide) was 22.2 (23-29). Creatinine was 1.27. 

The patient was treated with intravenous fluids, diazepam, Toradol, Tylenol, and lispro insulin. He was treated with Lantus daily and lispro three times daily. Endocrinology was consulted. Glucose improved to 142 mg (milligram)/dL (deciliter).  

No, the Inpatient admission was not medically necessary.

This patient presented with hyperglycemia and dehydration in the setting of known type 2 diabetes. He had tachycardia that resolved with hydration. He was hemodynamically stable. He did not have evidence of sepsis or infection. He had hyperglycemia, but his pH (potential of hydrogen) was 7.386. Therefore, he did not have acidosis to support a diagnosis of diabetic ketoacidosis. He did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar state. His glucose improved with hydration and insulin therapy. His glucose improved to 142 mg (milligram)/dL (deciliter). He had an elevated creatinine level that was within his baseline creatinine. The patient was discharged the day after admission and the documentation does not indicate that the patient failed a lower level of care. Therefore, no, the requested inpatient stay  was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Phencyclidine (PCP) induced psychosis.
Treatment:  Inpatient Mental Health Stay.

The insurer denied the inpatient mental health stay.  The health plan's determination is overturned in part. Two additional days were medically necessary. 

The patient is a male with a diagnosis of hallucinogens (phencyclidine) (PCP) induced psychosis.  Case notes document that the patient was admitted via the Emergency Department (ED) because of his aggressive and dangerous behavior in the community.  When he could not be stabilized in the ED, he was admitted.  The patient has a history of substance use disorder, primarily PCP.  He has two prior arrests, one for domestic abuse and one for substance use.  He had functional impairment and high social stressors prior to admission, specifically lack of family support, residing in a shelter, and no college education.

In the ED, he was noted to be responding to internal stimuli.  He was screaming and making inappropriate sexual gestures.  He had poor impulse control, disorganized behavior, paranoid delusions, as well as poor insight and poor judgment.  On the inpatient unit, he was treated with Haldol, Cogentin, risperidone, trazodone, and Ativan as needed (prn).  In addition, he received supportive psychotherapy and discharge planning.

The Adult Inpatient Mental Health Treatment for Adults (AIMHTA) for 2 additional days is medically necessary for this patient. 

Based on a review of hospital progress notes, the patient could not be safely discharged and with good medical judgment on day 2 recommended by the health plan.  The patient had clearly improved in several parameters, but was still experiencing auditory hallucinations as he had also experienced prior.  PCP produces schizophrenia type symptoms.  PCP induces psychotic symptoms and needs to be treated as a psychosis.  PCP psychosis is treated with neuroleptics and anti-anxiety agents, as was done with this patient.  The experience of continuing auditory hallucinations supports the fact that the patient was still under the influence of his PCP use disorder.  This symptom would entail a high probability that he would need to be readmitted, or would be of risk to others, and possibly to himself, if discharged on the date in question.  The lack of new clinical information would support the probability that there was no new adverse symptomatology in the patient.  Therefore, the patient could be safely discharged on the 2nd day with good medical judgment and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient is a male for which a convergent Maze procedure is under review. There was history of two unsuccessful ablations and multiple cardioversions. He was on amiodarone and Cardizem. On these medications he was in normal sinus rhythm. He has a history of a normal left ventricular ejection fraction (LVEF).
The subject under review is whether the proposed treatment is likely to be of greater benefit to the patient for his atrial fibrillation. The health plan's determination is upheld.

There are multiple treatments for atrial fibrillation, both invasive and noninvasive. More invasive treatments are generally reserved for those where clinically significant atrial fibrillation is refractory to more conventional treatments such as rate lowering and antiarrhythmic medical therapy and cardioversion. Invasive treatments include percutaneous and surgical ablations. The convergent MAZE procedure combines both percutaneous and surgical (thoracoscopic) ablations. Both have been demonstrated to be relatively safe and effective. However, there is no definitive evidence (i.e. randomized trials) establishing a convergent procedure as standard of care compared to, for example, percutaneous ablation, towards definitively improved atrial fibrillation outcomes. This individual has had two unsuccessful percutaneous ablations and multiple unsuccessful cardioversions. However, on antiarrhythmic therapy he is in normal sinus rhythm. A convergent maze procedure for an individual in normal sinus rhythm is not been definitively established as standard of care towards improved cardiac outcomes. As such it cannot be considered more beneficial than any standard treatment.