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

Diagnosis: Vomiting and Constipation
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male with alcohol (ETOH) abuse, drug abuse, and asthma who presented to the hospital with flank pain and vomiting. Laboratory data was significant for acidosis and elevated renal function with a creatinine of 4.8 milligrams per deciliter (mg/dl). The patient was treated with fluid hydration and seen by Nephrology team. His creatinine improved to 1.4 milligrams per deciliter (mg/dl) and vomiting improved and the patient was subsequently discharged. Inpatient level of care was denied per the Milliman Care Guidelines (MCG) criteria that the patient could have been managed at a lower level of care such as observation. The physician is appealing the determination.

No, the proposed inpatient hospital admission was not medically necessary.
The requested inpatient admission was not medically necessary as it would be provided primarily for convenience of the patient or the practitioner nor is it the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The patient had an elevated kidney function in the setting of vomiting and suspected dehydration. The kidney function improved rapidly with fluid hydration and the patient was able to take oral intake without refractory vomiting or diarrhea. There was no documentation of hemodynamic instability, electrolyte abnormalities that were severe or altered mental status that is severe or persistent, severe hypertension, cardiac arrhythmias of immediate concern, significant respiratory findings that were severe, significant electrolyte abnormality or metabolic abnormalities, or acute treatment of renal failure (eg, dialysis) needed at an inpatient level of care. There was no documentation that the denial of inpatient level of care was reasonable and in the best interest of the patient as patient could have safely and effectively been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic inflammatory demyelinating polyneuropathy

Treatment: manual adult size wheelchair and accessories codes (E1161, K0108, E2231, E2203, E2213, K0040, E0951, E0973, E0971, E0955, E0128, E2607, E2620, E0978)

The insurer denied coverage for manual adult size wheelchair and accessories codes (E1161, K0108, E2231, E2203, E2213, K0040, E0951, E0973, E0971, E0955, E0128, E2607, E2620, E0978) 

The denial is overturned.

This is a male who is bed bound with a history of atrial fibrillation, chronic inflammatory demyelinating polyneuropathy and Lewy body dementia. The patient has a K0005 Strongback wheelchair; for which he privately paid. Under review is a request for manual adult size wheelchair and accessories. 

The insurer denied the requested wheelchair due to "The plan did not receive enough information from the provider to know the make and model of the patient's wheelchair. They need to know if the current wheelchair can be modified to fit the patient's needs."  This physician agrees with the treating physician and occupational therapist who indicated, the patients' "current StrongBack Mobility K5 manual wheelchair is completely inappropriate for his needs." In addition, his StrongBack Mobility K5 manual wheelchair cannot be sufficiently modified to meet his functional needs as compared to the requested wheelchair and would not be cost effective. The requested wheelchair is clinically appropriate and 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 E1161, manual adult size wheelchair, includes tilt in space, K0108, wheelchair component accessory, not otherwise specified, E2231, manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware, E2203, manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches, E2213, manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each, K0040, adjustable angle footplate, each, E0951, heel loop/holder, any type, with or without ankle strap, each, E0973, wheelchair accessory, adjustable height, detachable armrest, complete assembly, each, E0971, manual wheelchair accessory, antitipping device, each, E0955, wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each, E0128, wheelchair accessory manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory, E2607, skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth, E2620, positioning wheelchair back cushion, planar back with lateral supports, width less than 22 inches, any height, including any type of mounting hardware, E0978, wheelchair accessory, positioning belt/safety belt/pelvic strap, each is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain.
Treatment: Pain Management (facet joint injections).
The insurer denied the Pain Management (facet joint injections).
The denial is overturned.

The patient is a male with history of chronic low back pain localized to the left gluteal area. The pain is made worse with extension, and the pain sometimes radiates to the left leg.

He has tried and failed Physical therapy, Hydrocodone, Gabapentin, Meloxicam, Cyclobenzaprine, Ibuprofen, Tramadol, Left L4-L5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) Transforaminal Epidural Steroid injections.

The request is for diagnostic Left L4-L5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) facet injection to also rupture facet cysts at that level towards possible facet neurotomy.

MRI (magnetic resonance imaging) lumbar spine showed mild multilevel discogenic degenerative disease with small disc bulges at L3/L4 (third lumbar spine vertebra/fourth lumbar spine vertebra) and L4/L5 (fourth lumbar spine vertebra/fifth lumbar spine vertebra), and facet arthropathy at L4/L5 (fourth lumbar spine vertebra/fifth lumbar spine vertebra).

Yes, the requested fact joint injection is medically necessary.

The patient's clinical presentation correlated with the MRI (magnetic resonance imaging) lumbar spine finding of Left L4-L5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) facet arthropathy.

In the systemic review by Manchikanti et al, the conclusion was "Based on the present assessment for the management of spinal facet joint pain, the evidence for long-term improvement is Level II for lumbar and cervical radiofrequency neurotomy, and therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine; Level III for lumbar intra-articular injections; and Level IV for cervical intra-articular injections and thoracic radiofrequency neurotomy."

The treating physician requested Left L4-L5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) facet injections for diagnostic purpose towards possible neurotomy.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient's clinical presentation, along with imaging correlation, pointed to pain due to possible facet pain. The patient has failed Physical therapy, Hydrocodone, Gabapentin, Meloxicam, Cyclobenzaprine, Ibuprofen, Tramadol, Left L4-L5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) Transforaminal Epidural Steroid injections.

The treating physician requested Left L4-L5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) facet injections for diagnostic purpose towards possible neurotomy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis (AD).
Treatment: Dupixent 300 milligrams per 2 milliliters (300 mg/2 ml).
The insurer denied coverage for Dupixent 300 milligrams per 2 milliliters (300 mg/2 ml).
The denial is overturned.

The patient is a female with a history of atopic dermatitis who has reportedly failed topical therapies and prednisone. She has tried and failed multiple topicals and prednisone. 

Based on the provided documentation, the requested medication, Dupixent, is medically necessary for this patient's condition. 

As noted in Lexicomp, both methotrexate and Imuran are associated with adverse events during a pregnancy. In contrast, Dupixent appears to be safe during pregnancy. Furthermore, as per Up to Date in choosing a systemic therapy, "The choice of a systemic treatment depends upon consideration of AD severity, impact on the patient's quality of life, the patient's age and sex, family planning issues, presence of comorbidities, the patient's preferences, and costs." In addition, they note that cyclosporine is time limited and as already noted other agents commonly used are associated with adverse effects. Furthermore, "Dupilumab is an interleukin (IL) 4 receptor alpha antagonist approved by the US Food and Drug Administration and by the European Medicine Agency for the treatment of adults and children older than six years with moderate to severe AD not adequately controlled with topical prescription therapies. In adults, dupilumab is initially administered as a loading dose of 600 mg (milligrams) given by subcutaneous injection, followed by a maintenance dose of 300 mg every two weeks. Laboratory monitoring is not required." (2)

In a separate discussion in Up to Date "A network meta-analysis of 74 randomized trials with over 8000 participants indicated, with a high degree of certainty, dupilumab as the most effective treatment in achieving a 75 percent reduction in the Eczema Area and Severity Index (EASI-75) score and improving the Patient-Oriented Eczema Measure (POEM) score during short-term follow-up when compared with placebo (risk ratio [RR] 3.04, 95% [percent] and mean difference 7.3, 95%) [120]. Dupilumab was also ranked first among other investigational and non-investigational biologics in terms of achieving EASI-75 and improving POEM scores during short-term follow-up. However, due to the lack of comparative data, the ranking of conventional immunosuppressive treatments for efficacy, compared with dupilumab and other biologic agents, remained uncertain."(3)

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 Dupixent 300 milligrams per 2 milliliters (300 mg/2 ml) to treat atopic dermatitis is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

According to the medical records, the patient is a female with a history of hypothyroidism. The coverage request is for coverage of an inpatient stay under the diagnosis of hypothyroidism. The coverage was previously denied by the insurance carrier, this is an appeal initiated by the hospital. The coverage for an inpatient admission was previously denied because it was deemed not medically necessary. The patient presented to the emergency department (ED) with worsening facial edema, left sided numbness, and increased fatigue. She had not been on thyroid medication for a year due to lapse in care. A stroke code was called. A computed tomography (CT) and magnetic resonance imaging (MRI) did not show that it was a stroke. Blood pressure was 80/42 and a fingerstick was 73.  She had unsteady gait, mild dysmetria, and decreased left facial sensation. TSH (thyroid stimulating hormone) was >100 and free T4 (thyroxine) was <0.4. She was given 60mcg (micrograms) IV (intravenous) Synthroid and 50mg (milligrams) IV hydrocortisone. Neurology felt symptoms were likely due to hypothyroidism. The patient was discharged home with follow up.

The inpatient admission is considered medically necessary for this patient. This patient presented in severe hypothyroidism - although mentation was not altered.  She had hypotension, unsteady gait, and neurologic symptoms that were significant for a possible stroke. An inpatient admission for treatment with IV levothyroxine and close neurologic/vital monitoring was medically necessary.

"Recommendation 21 of the ATA (American Thyroid Association) Guidelines for the treatment of hypothyroidism (Jonklaas et al. 2014) deals with the management of myxedema coma. It favors an initial loading dose of levothyroxine (200-400 g (grams) intravenously) and intravenous glucocorticoid administration (strong recommendation, low-quality evidence). Additional administration of intravenous liothyronine in a loading dose of 5-20 g can be considered (weak recommendation, low-quality of evidence)." (Wiersinga, WM. et al. 2018).

"Levothyroxine has long been the main tool for treating hypothyroidism and is one of the world's most widely prescribed medicines. In adults with overt hypothyroidism, levothyroxine is usually prescribed at a starting dose of 1.6 g(microgram)/ kg (kilograms) /day, which is then titrated to achieve optimal TSH levels (0.44.0 mIU (milli-international unit)/L (liter)), according to the therapeutic target. We summarize the history of levothyroxine and discuss future issues regarding the optimal treatment of hypothyroidism." (Chiovato, L. et al. 2019).                                                         

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

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

Diagnosis: Epigastric Pain.
Treatment: EGD (esophagogastroduodenoscopy).
The insurer denied the EGD (esophagogastroduodenoscopy).
The denial is overturned.

The patient is a female. Per the initial evaluation note, the patient had abdominal pain that resolved with PPI (proton pump inhibitors).

An appeal letter indicates denial reason due to the presence of response to PPI (proton pump inhibitor) for the abdominal pain.

Endoscopy report indicates the diagnosis is epigastric pain. Esophagus was normal; stomach showed gastritis status post biopsy.

The appeal letter indicates that the reason for the endoscopy was Barrett esophagus history and chronic reflux.

Per clinic visit the patient had history of chronic GERD (gastroesophageal reflux disease) and Barrett's esophagus based on a prior endoscopy. In addition, the patient developed chronic diarrhea and epigastric pain symptoms over the last 10 months prior to the visits.

Yes, the EGD (esophagogastroduodenoscopy) procedure was medically necessary.
Although the coding for the endoscopy was for abdominal pain for which the endoscopy was not indicated, the appeal letter indicated the presence of Barrett's esophagus history. Per the documentation from the clinic note the patient had history of Barrett's esophagus previously diagnosed. 

Per the American College of Gastroenterology (ACG) guidelines about the Diagnosis and Management of Barrett's Esophagus, it is recommended that surveillance for history of Barrett's esophagus with endoscopy with intervals in accordance of the degree of dysplasia and the length of the Barrett esophagus segment.

For non-dysplastic short segment (< [less than] 3 centimeters) Barrett's esophagus it is recommended to repeat the endoscopy for surveillance every five years.

Therefore, given the above, the EGD (esophagogastroduodenoscopy) procedure was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
While the initial documentation did not support medical necessity, the subsequent appeal letter and the clinic note indicated a reasonable indication for the repeat endoscopy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower back pain
Treatment: Surgery to join bones in the low back and placement of a spacer device (Minuteman Interspinous Spacer)

The insurer denied coverage for surgery to join bones in the low back and placement of a spacer device (Minuteman Interspinous Spacer)
The denial is upheld.

This woman has a history of lower back pain, pre-diabetes mellitus, asthma, anxiety, gastroesophageal reflux disease (GERD), hyperlipidemia, and hypothyroidism. The patient initially presented during an office visit complaining of long-term pain in the bilateral legs with the left being worse than the right. A magnetic resonance imaging (MRI) of the lumbar spine showed moderate central canal stenosis, bilateral foraminal stenosis, and degenerative changes. Per the office visit note with a pain management specialist, the patient was noted to have tried and failed conservative treatment. The plan was for a Minuteman interspinous spacer and fusion device at L (lumbar) 3-4 for lumbar degenerative disc disease at L3-4. 
 
Gala et al. (1) reviewed the role of InterSpinous Spacers (ISS) in the treatment of Lumbar spinal Stenosis (LSS): 
 
ISS may play a role in the treatment of LSS. While ongoing research is still needed to clarify the safety and adverse event profiles of these devices, ISS have been shown to provide at least comparable results to decompression surgery while mitigating the risks associated with open laminectomy. Nevertheless, additional studies need to be performed in order to assess the long-term results for these implants and to document their durability over time. Kaye et al. (2) have commented on the Minuteman system: "Currently, there are no published clinical studies on the Minuteman G3 procedure. However, there is an ongoing multicenter randomized controlled trial in the UK. The study is designed to compare the Minuteman spinal fusion implant versus surgical decompression for lumbar spinal stenosis in addition to monitoring the patients for up to 5 years post-treatment. The initial unpublished results have demonstrated equal effectiveness between Minuteman and open direct decompression in improving overall lumbar spine stenosis symptoms with superiority of the Minuteman G3 procedure in reducing leg pain."
 
This is an experimental/ investigational procedure and outside of clinical trial, it is considered not medically reasonable and necessary. 
 
The health plan acted reasonably with sound medical judgment in the best interest of the patient. 
 
The insurer's denial of coverage for surgery to join bones in the low back and placement of a spacer device (Minuteman Interspinous Spacer) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal - emesis and decreased oral intake
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital services. 
The denial is overturned. 

The Inpatient Hospital Services was medically necessary for this patient.
This is a patient who presented with fever, vomiting, and decreased oral intake. At the time of presentation, he was refusing any oral intake. In the emergency department he appropriately received Zofran as well as 2 boluses of normal saline. However, he continued to vomit after those treatments. He required hospital admission for continued treatment with intravenous fluids, antiemetics, and monitoring with additional treatments as needed.
Children with vomiting and decreased oral intake require hospital admission for intravenous rehydration therapy when they are unable to take oral rehydration therapy (ORT) or when ORT would not provide adequate rehydration due to persistent vomiting. This child had persistent vomiting and was refusing to take oral fluids even after appropriate treatment in the emergency department, and therefore required hospital admission for further intravenous treatments and monitoring.
The decision-making at the time of admission for this patient was consistent with his young age, the presence of poor oral intake in the setting of fever and vomiting, and the need for prompting initiation of intravenous fluids to maintain adequate hydration as well as antiemetics and close monitoring for deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent SC (subcutaneous) Pen-Injector
The insurer denied the Dupixent SC (subcutaneous) Pen-Injector.
The denial is overturned.

The patient is a female with atopic dermatitis, allergies and asthma, treated with topical steroids, tacrolimus, Eucrisa and anti-histamines.  The provider is requesting Dupixent.  The health plan requires a trial of systemic immunosuppressants and phototherapy.

Yes, the proposed treatment with Dupixent (dupilumab) is medically necessary.

The health plan requires a trial of systemic immunosuppressants and phototherapy.  Phototherapy would not be the most appropriate therapy for this patient with 85% (percent) body surface area (BSA).  Systemic immunosuppressants are not the most appropriate in this patient with asthma within the current COVID (Coronavirus) pandemic.  

The Food and Drug Administration (FDA) also approved dupilumab (Dupixent) for the treatment of patients aged six years and older with moderate to severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable.  This approval followed a phase III, randomized, double blinded placebo controlled trial that enrolled 367 patients to evaluate the safety and efficacy of dupilumab (Dupixent) in children (ages six to 11 years) for treatment of atopic dermatitis (Paller, et al).  Significantly and clinically meaningful improvements in patients signs and symptoms of atopic dermatitis as well as quality of life were reported.  As seen in adults, treatment in pediatric population was reportedly well tolerated with the most commonly reported side effects including injection site reactions and conjunctivitis.

Therefore, Dupixent is medically necessary.

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

Diagnosis: Dementia
Treatment: Increase in Personal Care Assistance (PCA) Services, From 8 Hours 6 Days (48 hours per Week) To Continuous Care (split shift) Service
The insurer denied the increase in PCA services, from 8 hours 6 days (48 hours per week) to continuous care (split shift) service.
The denial is overturned.

The patient is a female. The request is for an increase in Personal Care Assistance (PCA) services, from 8 hours 6 days (48 hours per week) to continuous care (split shift) service. The health plan approved an increase to 24 hours/day, live-in. This is being appealed.

Yes, the requested increase in PCA to 24 hours/day split shift is medically necessary.

The patient has underlying dementia with significant weakness and progressive functional decline. She lives with her spouse. She also has cognitive decline. She has limited ROM (range of motion). The patient has ataxia with frequent falls. She is dependent on others for ADLs (activities of daily living), including bathing, toileting and dressing. She needs frequent reminders for medications.

The increase in PCA services, from 8 hours 6 days (48 hours per week) to continuous care (split shift) service is medically necessary. Split shift is medically necessary over live-in, as the patient needs help both during the day and night time to help with ADLs, medications, and to prevent falls.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The patient has progressive functional and cognitive decline with Alzheimer's dementia. More hours are needed to ensure safety and prevent falls.