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

Diagnosis: Short Stature.
Treatment: Growth Hormone- Norditropin.
The insurer denied Growth Hormone- Norditropin.
The determination is overturned.

The patient is seeking growth hormone (GH) treatment for the diagnosis of growth hormone deficiency (GHD). The patient's mother's height is 62 inches and father's height is 66 inches. The patient's growth chart shows their height below the third percentile since several years ago. They were initially evaluated in the pediatric endocrinology clinic. At that time, their height was 100.4 centimeter (cm) (-2.4 SD) while their weight was 16 kilograms (-1.7 standard deviation (SD). The patient's evaluation was unremarkable except for low normal insulin-like growth factor 1 (IGF-1). 

At a follow up visit, the patient's height was 117.6 centimeter (cm) (-2.4 standard deviation (SD) while their weight was 22.7 kilograms (-1.4 standard deviation (SD).  Based on the bone age, their predicted adult height was calculated as 64 inches which was less than their genetics. The patient underwent growth hormone (GH) stimulation testing and their peak growth hormone (GH) response was 7.6 nanograms/milliliter (ng/ml). A magnetic resonance imaging (MRI) of the pituitary gland was normal. The diagnosis of growth hormone deficiency (GHD) was made and treatment with growth hormone (GH) was recommended. The patient started growth hormone (GH) last year. The patient's insurance changed, and new insurance has denied the continued coverage of growth hormone (GH) treatment. At issue is the medical necessity of the requested health service/treatment of Norditropin.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gross Hematuria
Treatment: Lab Work/Blood Tests- Oncology Gene Expression Lab Work
The insurer denied Lab Work/Blood Tests- Oncology Gene Expression Lab Work.
The determination is upheld.

This patient has microscopic hematuria status/post (s/p) Cxbladder Detect test performed on 5/2/22. At issue is the medical necessity of the requested health service/treatment of Oncology Gene Expression Lab Work.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease. 
Treatment: Stelara every 4 weeks. 

The insurer denied coverage for Stelara every 4 weeks. 

The denial is overturned. 

The patient has ileocolonic fistulizing Crohn's disease. The patient was diagnosed and had previously been on Remicade and Humira. The patient had active disease and was switched to Stelara. There was symptom improvement, but a recent colonoscopy showed active disease. The treating physician is now advising to increase the Stelara dose to every 4 weeks. 

Clinical Gastroenterology and Hepatology 2021 Jan 19 (1): 104-110 has an article titled "Effectiveness of Ustekinumab Dose Escalation in Patients with Crohn's Disease." Data was studied from patients who initially received ustekinumab every 8 weeks and then had their interval shortened to every 4 weeks. The conclusion was that shortening the ustekinumab dose to every 4 weeks, in patients who did not respond to dosing every 8 weeks, improved clinical and biological indices of disease activity. It was noted that dose interval shortening was effective and safe. 

This patient has Crohn's disease that is not adequately controlled on the current Stelara dose. Dose escalation of Stelara is supported in the medical literature. Giving Stelara every 4 weeks has been shown to be both effective and safe. The health care plan did not act reasonably or with sound medical judgment. Treatment with Stelara every 4 weeks is medically necessary for this patient. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Stelara every 4 weeks is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Amyotrophic lateral sclerosis (ALS)

Treatment: Relyvrio 3-1gm (gram) pak (pack)

The insurer denied coverage for Relyvrio 3-1gm pak

The denial is overturned

 
According to the medical records, the patient is an adult whose magnetic resonance imaging (MRI) of the brain showed findings consistent with motor neuron disease. There was an Electromyography (EMG) which showed findings consistent with motor neuron disease. There was a tele-visit conducted by the physician for follow up regarding amyotrophic lateral sclerosis (ALS). The physician noted that the patient was on Riluzole with a stable liver enzyme. The physician noted that Radicava and Relyvrio were denied. In the impression the ALS was noted with quadriplegia and respiratory insufficiency. The physician noted that the plan was to continue with Riluzole and start Tauroursodeoxycholic acid (TUDCA). The physician noted that the plan was to appeal for Relyvrio coverage. The physician noted that the patient symptoms started with right hand weakness, that the ALS diagnosis was made, that the patient diagnosis was clinically definite ALS, that the patient was on Riluzole, and that the plan was to start Relyvrio when available. There was a letter stating that Relyvrio was denied as the patient's vital capacity was less than 60%.

The patient has a progressive lethal disease and should not be deprived of any chance or medication that slows the progression of his condition. It is medically necessary, and Food and Drug Administration (FDA) approved. Therefore, Relyvrio 3-1gm pak is considered medically necessary for this patient.

"Coformulated sodium phenylbutyrate/taurursodiol (Relyvrio) (PB-TURSO) was shown to prolong survival and slow functional decline in amyotrophic lateral sclerosis (ALS)." (Paganoni, S. et al. 2022).

"Sodium phenylbutyrate-taurursodiol resulted in slower functional decline than placebo as measured by the Revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) score over a period of 24 weeks. Secondary outcomes were not significantly different between the two groups. Longer and larger trials are necessary to evaluate the efficacy and safety of sodium phenylbutyrate-taurursodiol in persons with ALS." (Paganoni, S. et al. 2020).

Recently, Up to Date concluded that "We now suggest use of PB-TURSO (Relyvrio) for all patients with ALS."

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Relyvrio 3-1gm pak is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Knee Osteoarthritis
Treatment: Gel-One 30 milligrams (mg)/3 milliliter (ml) syringe
The insurer denied the Gel-One 30 mg/3 ml syringe.
The denial is upheld.

The patient is a female with advanced bilateral knee osteoarthritis. Her orthopedic provider has proposed performing Gel-One injections for both of her knees. The patient's health plan denied coverage of these injections with a determination that they were not medically necessary. At issue in this case is whether the proposed Gel-One injections are medically necessary for this patient.

The requested treatment of Gel-One 30mg/3 ml syringe is not medically necessary for this patient. The records document that this patient suffers from bilateral knee osteoarthritis. The patient ultimately will undergo total knee replacement surgery once she reaches the appropriate body mass index with continued weight loss. The provider has proposed Gel-One injections in the interim. These injections are not medically necessary because they will not provide adequate relief for the patient.

The current, peer-reviewed literature, including articles by Jevsevar and colleagues in the Journal of Bone and Joint Surgery and by Tammachote and associates in the same journal found that viscosupplmentation injections like Gel-One are not an effective treatment for advanced knee osteoarthritis. In his peer-reviewed article, Jevsevar and his co-authors concluded that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid treatment over placebo." Tammachote and colleagues performs a prospective, randomized study which compared a corticosteroid injection to a single injection of Hylan G-F 20 and found that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with Hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." Thus, based upon these peer-reviewed articles, the proposed Gel-One injections in this case are not medically necessary in this case. This determination is based on the documentation and medical records and the recommendations of the current peer reviewed literature on the topic of viscosupplementation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: anxiety, gastroesophageal reflux disease, COVID

Treatment: personal care assistance, total of 63 hours per week

The insurer denied coverage for personal care assistance, total of 63 hours per week

The denial is overturned

The patient is an elderly patient with anxiety, gastroesophageal reflux disease (GERD) who was recently admitted to the hospital for upper respiratory tract infection (URI) symptoms and was Coronavirus (COVID) positive. The patient lives alone in a 2-bedroom apartment. Physical therapy and increased Home Health Aide (HHA) were recommended upon discharge. The patient recently fell and sustained a head laceration. The insurer approved personal care assistant (PCA) services 31 hours per week and the request is for 63 hours per week. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as modified independent. However, the patient requires maximal assistance for much of the Instrumental Activities of Daily Living (IADL) tasks including meal preparation (meals are delivered), ordinary housework and shopping. The patient requires extensive assistance for bathing, personal hygiene, dressing, locomotion, and ambulation. The patient also requires extensive assistance for toilet transfer/use. The patient is frequently incontinent of bladder and continent of bowel. The patient is independent with bed mobility and eating. The patient's condition and functional ability continue to decline, are at a level and unpredictable as to require the requested PCA services 63 hours per week. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing PCA services to 63 hours per week. 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  
From a physical medicine and rehabilitation perspective, an increase in PCA services: 63 hours per week are medically necessary.
Based on the above, the insurer's denial must be overturned to allow personal care assistance, total of 63 hours per week (PCS), per 15 minutes. The medical necessity of personal care assistance, total of 63 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

This adult male patient was admitted to the hospital with a chief complaint of dizziness. He had recently (under 30 days) undergone coronary and left subclavian artery stent placement. During his time in the emergency room, the patient also complained of chest pain as well as left upper extremity swelling. Physical exam demonstrated left upper extremity edema. 

Electrocardiogram (EKG) demonstrated right bundle branch block. The emergency room physician had a differential diagnosis of acute coronary syndrome, deep venous thrombosis /pulmonary embolus, and sepsis. The entire admission was denied as not being medically necessary. 

The proposed treatment was medically necessary. 

It is true that some cases of dizziness can be safely managed on an outpatient basis. However, this patient had significant risk factors for an acute condition mandating hospitalization. He had recently undergone coronary stenting and also subclavian stenting. Because of this recent history, the patient was an elevated risk for acute coronary syndrome or subclavian stent occlusion. Moreover, he had left arm swelling, which raised appropriate concern for deep vein thrombosis and pulmonary embolus. All of these conditions require inpatient evaluation then the treatment. For these reasons, the admission under review was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Skyrizi Pen 150MG/ML (milligrams per millimeter).
The insurer denied: Skyrizi Pen 150MG/ML (milligrams per millimeter).
The denial is upheld.

The patient is an adult female diagnosed with moderate to severe psoriasis. The patient has tried methotrexate, Enbrel, Humira and topical steroids, and is now being prescribed Skyrizi. 
The request was denied by the health plan, so the treating provider is appealing the denial. The patient also has a seizure disorder and thyroid disease. The plan requires a trial of the alternative Cosentyx prior to approval of Skyrizi.

The proposed treatment is not medically necessary.

The plan requires a trial of the alternative Cosentyx prior to approval of Skyrizi. However, there is insufficient documentation of why the patient is not a candidate for the alternative Cosentyx. 
Frieder J, et al (2018) writes "Cosentyx (secukinumab) is an efficacious anti-interleukin (IL)-17A biologic agent for the treatment of moderate to severe plaque psoriasis. It has demonstrated superiority to placebo in a number of phase II and III clinical trials, as well as superiority to etanercept and ustekinumab. Specifically, secukinumab is associated with a rapid rate of clinical response, with Psoriasis Area and Severity Index (PASI) 50/75 responses observed by 4 weeks and maintained or improved responses documented through week 52.38,48. Furthermore, a greater proportion of patients on secukinumab achieve higher clinical responses of PASI 90 and 
100 compared with other biologics." 
Per Brownstone et al (2021), "Secukinumab has excellent efficacy in the treatment of several disease domains. Dedicated studies for difficult to treat areas such as scalp, nail and 
palmoplantar psoriasis has been completed with data showing sustained efficacy for greater than 2 years for the latter two conditions. Secukinumab possesses higher efficacy versus several other subcutaneous biologic agents, showing superiority in head-to-head trials against both etanercept and ustekinumab".
There is insufficient documentation of why the patient is not a candidate for the alternative, Cosentyx. The provider did document concerns for the alternatives. The provider states that 
cases of inflammatory bowel disease were noted in clinical trials with Cosentyx. Standard of care would be to avoid interleukin (IL)-17 inhibitors such as Cosentyx if possible, in patients with a 
history of inflammatory bowel disease. However, the patient's records do not show a history of inflammatory bowel disease; thus, there is no evidence to support avoidance of Cosentyx in this patient. Since the patient is naive to both medications (Skyrizi and Cosentyx) there is no indication that the patient could not have a positive response to the preferred alternative of 
Cosentyx.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Temporal Mandibular Joint (TMJ)/Jaw, joint pain
Treatment: Botulinum (Botox) Shots
The health plan denied the requested Botulinum (Botox) Shots as not medically necessary.
The health plan's determination is overturned.

This is a male with a history of temporomandibular joint (TMJ) Dysfunction. The patient has been treated in the past with medication, trigger point injections, massage therapy and physical therapy. The only treatment that has been successful is Botox injections.
At issue is the medical necessity for the requested health service/treatment of Botulinum (Botox) Shots.

The health plan's determination is overturned, in whole.

Botox is indicated when standard conservative therapy has failed. It has failed in this case and Botox has been proven to be effective for this patient.
Medically necessary is defined as:
1. Essential for the symptoms and diagnosis or treatment of the Sickness or Injury. MET. The treatment is essential because all standard conservative therapy has failed.
2. Provided for the diagnosis, or the direct care and treatment of the Sickness or Injury. MET. The treatment is being provided for myofascial pain dysfunction.
3. In accordance with the standards of good medical practice. MET. Treatment with Botox is recommended if all standard conservative therapy has failed.
4. Not primarily for the convenience of the Insured, or the Insured's Physician. MET. The treatment is for myofascial pain and not for the convenience of the patient.
5. The most appropriate supply or level of service which can safely be provided to the Insured MET. This is the most appropriate treatment as all standard treatment has failed.
Botox can play a significant role in reducing the pain observed in TMJ Dysfunction, which can be justified if more randomized controlled studies are conducted with larger study sizes. It has been used in similar cases to this and has been effective in many cases. Botox usually has some beneficial effect in improving the symptoms, and should be considered as an alternate treatment for masticatory myofascial pain if conservative methods have failed and it is suggested that Botox therapy be instituted after standard conservative therapy failure and before surgical interventions. This patient has failed conservative treatment; Botox would be indicated, as conservative treatment has failed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal Bleeding/ Bleeding of Intestines
Treatment: Inpatient Hospital Admission
The health plan denied: Inpatient Hospital Stay
The determination is: Upheld

The patient is a male with history of gastrointestinal (GI) bleeds who presented to the emergency room (ER) with bright red blood per rectum. The patient had bright red blood passed with a small amount of stool before being directed to the ER. Guaiac testing was positive. The lab work demonstrated a hemoglobin of 8.9. The colorectal team saw the patient who recommended admission with intravenous (IV) access with large bores at all times. The patient was placed on a clear liquid diet and home meds. The patient was monitored in the hospital for three days. He did have several bloody bowel movements but did not drop his hemoglobin significantly and did not undergo significant interventions or advanced monitoring.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is upheld in whole.
The patient's inpatient admission was not medically necessary. The patient did not have hemodynamic instability, evidence of ongoing active bleeding, failure to control bleeding after colonoscopy, coagulopathy, suspected or known ischemic colitis, or shock index greater than 1. The patient did demonstrate anemia, but he did not have significant tachycardia, orthostatic hypotension, altered mental status, heart failure, chest pain, exertional dyspnea, or other findings of inadequate perfusion. The patient did not have severe pain, signs of intestinal obstruction or peritonitis. The patient did not have a low platelet count. The patient did not have inability to maintain oral hydration. The patient did not have interventions or monitoring that could only be provided at an inpatient level. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Laparoscopic Gastric Bypass Surgery and Laparoscopic Surgical Repair of Paraesophageal Hernia [43644 (Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)) and 43281 (Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh)]
The insurer denied the Laparoscopic Gastric Bypass Surgery and Laparoscopic Surgical Repair of Paraesophageal Hernia [43644 (Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)) and 43281 (Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh)].
The health plan's determination is overturned.

This patient is a woman under consideration for bariatric surgery. The preauthorization request documents that she is 63 inches tall and weighs 206 lbs. This corresponds to a body mass index (BMI) of 36.5. She has comorbid health conditions of sleep apnea, gastroesophageal reflux disease (GERD) with esophagitis, steatohepatitis, hyperlipidemia, and hypertension. The patient has attempted weight loss with conventional weight loss programs without significant sustained weight reduction. She followed a supervised weight loss program with her endocrinologist also. The patient has the support of her primary care physician for the proposed bariatric operation.

Given this patient's diagnosis, her current health condition, and the accepted guidelines for the care and treatment of bariatric surgical patients, the proposed roux en Y gastric bypass and hiatal hernia repair operation is medically necessary.

This patient has a BMI in excess of 35 with reported weight related comorbid health conditions that include sleep apnea, gastroesophageal reflux disease (GERD) with esophagitis, steatohepatitis, hyperlipidemia, and hypertension. She also has a hiatal hernia and esophagitis as documented on recent upper endoscopy. She has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has been cleared for the proposed surgery from a medical and psychological standpoint.

The proposed operation is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the member's disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Personal Care Assistance (PCA) 24 hours per day 7 days per week (Monday through Sunday).

The insurer denied coverage for Personal Care Assistance (PCA) 24 hours per day 7 days per week (Monday through Sunday).  The denial is overturned.

This is an older patient with an extensive medical history of dementia with behavioral disturbances, heart disease, chronic pain, anxiety, incontinence, and falls. The recent Uniform Assessment System (UAS) report noted moderate impairment which had declined. Assistance with activities of daily living is required. This included maximal assistance with bathing, toilet, dressing, walking, and eating. There was high risk for falls. The patient was observed via webcam struggling with activities of daily living (ADL's) with reported decline. Needs were frequent, unpredictable, and unscheduled.

The medical records show deterioration on several levels. There is documentation of worsening as per the treating physician. This patient is at great risk for complications secondary to underlying clinical problems. The patient has dementia, poor cognitive function, is not oriented and has been reported to wander. Leaving the apartment in the night is of great concern, as she does not know where she is. It would be important to maintain a safe environment. 

There is documentation of physical frailty and the increased requirements of care. There is no evidence of independence. There is a great risk for a fall. Several evaluations and Web Cam video confirm the progression. As the clinical condition has worsened, additional care would thus be 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 Personal Care Assistance (PCA) 24 hours per day 7 days per week (Monday through Sunday) is overturned. Medical Necessity is substantiated.