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

Diagnosis: Atypical Chest Pain.

Treatment: Inpatient Hospital Admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This patient presented to the hospital complaining of abdominal pain in the epigastric region radiating to the left arm and to both scapulae. Pain began three days prior to admission and was associated with nausea. Eating resulted in exacerbation of the pain.  Past medical history was significant for hypertension, diabetes mellitus, non-ischemic cardiomyopathy with a left ventricular ejection fraction (LVEF) of 20 percent (%) and intermittent left bundle branch block on electrocardiogram (ECG). Cardiac catheterization performed six months prior to presentation revealed non-obstructive coronary artery disease.  On physical examination the blood pressure (BP) was 183/78, pulse was 66 beats per minute (bpm), lungs were clear and no signs of fluid overload were noted. Pain was reproduced with palpation of the epigastric region.  ECG revealed normal sinus rhythm (NSR) with left ventricular hypertrophy (LVH) and associated T wave changes.  A prior ECG revealed sinus rhythm with left bundle branch block (LBBB).  Serum high sensitivity troponin was not elevated (<50 nanograms per liter [ng/L]).  Following treatment with zofran and famotidine, symptoms resolved.

This patient presented with atypical chest pain.  Physical examination was remarkable for reproducible pain along the epigastrium and ECG failed to reveal specific findings consistent with an acute coronary syndrome. Serum blood testing did not reveal elevated troponin levels and the patient was discharged on the day of presentation.  Risk assessment of patients presenting with chest pain and no significant ST (intervals on ECG) changes on ECG as well as negative cardiac enzymes was performed by Poldevaart et al. (1)  Using the HEART (history, ECG, Age, risk factors, and troponin) score risk stratification schema, this patient would have a low risk of future myocardial infarction or death within one year. Other investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. (2, 3)  They found no significant difference in outcome at 30 days between the two groups.  Fernando Bellolio et al. noted that patients presenting with chest pain that were managed in an observation unit had similar 30 day myocardial infarction rates as those admitted to the hospital. (3)  Admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this patient could have been managed at a lower level of care. Inpatient admission was not medically necessary.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myelodysplastic Syndrome (MDS). 
Treatment: Venetoclax SGM, Pre-service. 
The insurer denied the Venetoclax SGM. 
The denial is upheld. 

The patient in this case is a man who has been diagnosed with myelodysplastic syndrome. He had 8% blasts on bone marrow biopsy done earlier this year. He has been treated with azacitidine and after several months bone marrow biopsy was done and revealed no evidence of response, with 5-9% blasts noted.  Treatment with decitabine plus venetoclax was recommended. 

No, the proposed treatment is not medically necessary. 

At the present time there is insufficient evidence to support use of this treatment following failure of single agent azacitadine therapy.  The combination of decitabine and venetoclax has been shown to have some efficacy though has also been shown to be associated with high rates of myelosuppression. Furthermore, there is no published prospective clinical trial that has shown it to be associated with improvement in health outcomes following failure of single agent azacitidine.  NCCN (National Comprehensive Cancer Network) guidelines do not endorse this as a standard treatment option and at the present time it is felt that while there is some preliminary evidence of efficacy, it is also felt that further studies are needed to define the safety and efficacy of this treatment approach. Therefore, it is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple sclerosis, urinary and bowel
incontinence, anxiety, hyperlipidemia and
narcolepsy.
Treatment: Personal Aide (PCA) Services 70 Hours per Week, Pre-service
The insurer denied the Personal Aide (PCA) Services 70 Hours per Week, Pre-service
The denial is overturned. 

This male has conditions including multiple sclerosis, urinary and bowel incontinence, anxiety, hyperlipidemia and narcolepsy.  He is wheelchair bound due to multiple sclerosis (MS).  He is appealing denial of personal care aide (PCA) 70 hours per week. He has been approved for personal care aide (PCA) 27.5 hours per week.  

Uniform Assessment System (UAS) evaluation completed shows cognition is modified independent and functional status: total dependence with housework, stairs, walking, and locomotion; maximal assistance with meal preparation, managing medications, shopping, bathing, personal hygiene, dressing, toileting, and bed mobility; extensive assistance with managing finances;  limited assistance with eating; and supervision with phone use.  He uses a wheelchair and scooter for locomotion.  He has bowel and bladder incontinence.   Compared to Uniform Assessment System (UAS) evaluation performed a month prior, it is remarkable for decline in eating from independent to limited assistance.  The patient was hospitalized with COVID pneumonia.  

Appeal statement from New York states the patient needs assistance with activities of daily living (ADLs) as already accounted for in the Uniform Assessment System (UAS) evaluation due to advanced age and multiple medical conditions.  His primary care physician (PCP) recommends increase in care due to the patient being wheelchair bound as a result of multiple sclerosis (MS).

Yes, the proposed treatment is medically necessary.
The proposed treatment is consistent with generally accepted standards of medical practice.

Personal assistance services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  

This patient has multiple chronic conditions including multiple sclerosis.  He is wheelchair bound.  This patient requires assistance with all activities of daily living (ADLs) and personal care needs except phone use.  Uniform Assessment System (UAS) evaluation completed compared to Uniform Assessment System evaluation completed a month prior is remarkable for decline in eating from independent to limited assistance.  He has bowel and bladder incontinence. 

 Appeal statements recommend additional hours due to the patient's weakness resulting in him being wheelchair bound and needing assistance with all activities of daily living (ADLs) except phone use.  As a result of this patient's weakness and inability to ambulate, he requires significant assistance with activities of daily living (ADLs) / instrumental activities of daily living (IADLs).  The approved personal care aide (PCA) 27.5 hours per week is inadequate to meet this patient's needs.   The proposed increase in personal care aide (PCA) 70 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, coronary heart disease and strokes

Treatment consumer directed personal assistance services (CDPAS) of 24 hours per day (split-shift)

The insurer denied coverage for consumer directed personal assistance services (CDPAS) of 24 hours per day (split-shift)

The denial is overturned

This case involves a male who has been recommended for 24-hour (split-shift) home care assistance due to diagnoses of dementia, coronary heart disease and strokes resulting in hemiplegia of the left side.  The documentation indicated the patient exhibited poor and limited awareness of safety risk as well as assistance with activities of daily living (ADLs).  The documentation indicated he also has mobility issues. According to the letter from the patient's daughter, the patient was recommended to have 24-hour split-shift care versus 24-hour live-in care.  The documentation indicated the patient required frequent assistance overnight with toileting as well as with walking at unpredictable times.  The documentation indicated he required approximately 3-4 diaper changes per night and that he will wake up in the middle of the night wanting to go outside.  He cannot walk on his own and therefore between diaper changes and redirecting him when he wakes up to go outside in the middle the night it is unusual to get more than 2 to 3 hours of sleep at a time.  According to the physician the patient has significant cognitive impairment with weakness, particularly to the lower extremities.  The documentation indicated that the patient had a stroke and that he also had aspiration pneumonia.  He received physical therapy services after his hospital stay which allowed him the ability to walk after being bedridden.  The physician indicated his improvement was minimal.  The cognitive impairments have worsened over time, and he is oriented only person. Due to his worsening condition, he needs assistance in multiple areas.

Based on the information provided this patient has advanced dementia in addition to bilateral lower extremity weakness resulting from multiple strokes. He is therefore at risk for frequent falls and potentially severe injury due to his physical limitations. He is also at risk for self-injury due to his impaired cognition and dementia. There was sufficient evidence to support that consumer directed personal assistance services (CDPAS) of 24/7 care 7 days a week (split-shift) was considered medically necessary treatment for the patient's condition.

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient.

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance Services (CDPAS) of 24 hours per day (split-shift) is reversed. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Atopic Dermatitis.

Treatment Dupixent Syn 300.

The insurer denied coverage for Dupixent Syn 300.

The denial is upheld.

The patient is a female with a diagnosis of dyshidrotic eczema of the hands who has failed therapy with topical steroids. The requested medication is Dupixent.  

According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the conventional medications such as topical steroids, protopic, elidel, and methotrexate are effective treatments for the management of atopic dermatitis. (1, 2) 

Within the peer-reviewed literature, Gerbens et al writes "Methotrexate (MTX) and azathioprine (AZA) seem to be effective and safe as maintenance treatments in moderate to severe atopic dermatitis (AD) up to 5 years." (3) Shah et al 2018 writes "Methotrexate is an effective treatment for moderate to severe atopic dermatitis with an acceptable safety profile. A low dose can be used to control the disease for prolonged periods without significant risk." (4) There are several published studies that show that methotrexate is effective and safe for moderate-severe atopic dermatitis. (5-8) 

The requested medication, Dupixent is not required for this patient's condition. There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Dupixent for this patient's condition as an accepted standard of practice in the U.S. compared to alternative therapies.  

The requested medication Dupixent is not medically necessary based on the standard of care, and there are no unique clinical circumstances to this particular individual in the documentation provided that would make it medically necessary. The patient has failed therapy with topical steroids.  However, the patient has no true contraindications to the conventional medications commonly used for atopic dermatitis.  

The conventional medications, such as methotrexate, should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not crucial for this patient according to the standard of care.

The insurer's denial of coverage for Formulary Exception for Dupixent Syn 300 for treatment of atopic dermatitis is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endometriosis.

Treatment Orilissa 200 mg (milligrams) tablets.

The insurer denied coverage for Orilissa 200 mg tablets.

The denial is upheld.

The patient is a female with surgically proven endometriosis and a prior left salpingo-oophorectomy. The patient's pain was not controlled on oral contraceptives. The provider prescribed Orilissa (elagolix) 200 milligram (mg) tablets to treat the patient's medical condition. The patient has already received 6 months of therapy with Orilissa. The provider is requesting additional treatment with Orilissa.

In the United States, elagolix is an oral tablet approved for treatment of moderate-to-severe endometriosis-related pain. Similar to gonadotropin releasing hormone (GnRH) analogues, it can cause hot flashes or night sweats. More importantly it can cause significant bone loss. It is available in doses of 150 mg (taken once daily for up to 24 months) or 200 mg (taken twice daily for up to 6 months). 

This patient has already taken 6 months of Orilissa 200 mg and Orilissa is not approved or indicated due to serious concern about bone loss. (5)

Based on the above, Orilissa 200 mg is not medically indicated or necessary for this patient.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.
 
The insurer's denial of coverage for Orilissa 200 milligram (mg) tablets is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class I, and deep impinging overbite.

Treatment: D8080 (comprehensive orthodontic treatment of adolescent dentition).

The insurer denied coverage for D8080 comprehensive orthodontic treatment of adolescent dentition.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The Orthodontist recommended comprehensive orthodontics due to skeletal Class I, and deep impinging overbite. The Orthodontist has completed the Handicapping labio-lingual deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating Orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 18 points (5 points overjet, 5 points overbite, 5 points anterior crowding and 3 points labiolingual spread).

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies.

Each of the peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

D8080 comprehensive orthodontic treatment of the adolescent dentition is not considered medically necessary for this patient as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

The insurer's denial of coverage for D8080 comprehensive orthodontic treatment of adolescent dentition is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Community-Acquired Pneumonia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is the case of a female patient who presented to the Emergency Department (ED) late in the evening with complaints of low back pain, fevers and headache. Vital signs (V/S) at presentation to ED included temperature (T) 102.1 Fahrenheit, heart rate (HR) 121, blood pressure (BP) 116/83 millimeters of mercury (mm Hg), respiratory rate (RR) 23, oxygen (O2) saturations 100% (percent). The patient was in no apparent distress (NAD). Lungs were clear to exam. Abdominal exam revealed some tenderness to palpation. Bowel sounds (BS) were positive. There was no guarding. The patient was alert and oriented to person, place and time. White blood cell (WBC) count was 5.7 thousand (K) and hemoglobin (Hgb) was 14.8. Electrocardiogram (EKG) revealed normal sinus rhythm (NSR) > no acute changes. Chest x-ray (CXR) showed no acute infiltrate. The patient was admitted for sepsis. She was treated with intravenous (IV) Cefepime and Vancomycin. A computed tomography (CT) scan of the abdomen and pelvis was unremarkable. It revealed an ovoid density in left lower lobe (LLL). Pneumonia (PNA) verses rounded atelectasis was suspected. The urinalysis (UA) was negative. A dedicated CT chest revealed a 3.4 X 2.5 centimeter (cm) ovoid airspace opacity in the superior segment of LLL. Some air bronchograms were noted. Differential diagnosis (DDX) included infectious process versus lipoid PNA. The patient was seen by Infectious Disease (ID) and Pulmonary consults. They recommended to treat as community-acquired pneumonia (CAP). Antibiotics were switched to IV Ceftriaxone and oral (PO) Azithromycin.
As per the History & Physical (H&P), the patient was afebrile and hemodynamically stable. O2 saturations were 98 % on room air (RA). The patient was in NAD and lungs were clear. WBC was 4K and Hgb was 13.4. Electrolytes, blood urea nitrogen (BUN)/ creatinine (Cr) were essentially normal. She was cleared by ID and Pulmonary to be switched to PO Levaquin and discharged home with outpatient follow up.

The patient was diagnosed to have a CAP. Her pneumonia severity index (PSI) score was low and CURB 65 (confusion, uremia, respiratory rate, BP, age >= 65 years) score was zero. The patient became afebrile shortly after presentation. She was hemodynamically stable and tolerating PO. CXR was unremarkable. She was not hypoxic - O2 saturations were between 98 -100%. The patient was stable for discharge on PO antibiotics after a period in observation with close follow up in outpatient setting.

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated.

The healthcare plan did act reasonably and with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fatigue, Weakness, Headache.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a history of adrenal insufficiency, stroke, residual weakness from stroke, and hypothyroidism.  She presented to the hospital with confusion, weakness and headache noted with hyponatremia. The patient's sodium was noted to be 124; desmopressin dose was unknown at home. Desmopressin was held, intravenous saline was administered as well as steroids. The patient's serum sodium stabilized and the patient clinically improved to near baseline neurologically and was subsequently discharged.

No, the proposed inpatient admission was not medically necessary.
No, the requested inpatient level of care was not medically necessary as the patient could have safely and effectively been managed at a lower level of care. 

Based on available data, there is no documentation regarding hemodynamic instability, systemic or infectious condition, no high fevers, severe adverse or toxins reaction nor allergic reaction.  Based on available data, there was no hypertension requiring inpatient treatment, cardiac arrhythmias or findings of immediate concern, sever respiratory abnormalities, severe neurologic abnormalities or new-onset severe neurologic findings requiring inpatient care, significant uremic complications nor severe electrolyte abnormalities that required inpatient level of care.