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

Diagnosis: Psoriasis 
Treatment: Cosentyx Sensoready (300 MG (milligrams)) 150MG/ML (milliliter) SC (subcutaneous) SOAJ (Solution Auto-injector)
The insurer denied coverage for Cosentyx Sensoready (300 MG) 150MG/ML SC SOAJ
The denial is upheld
 
The patient is an adult with psoriasis affecting 30% total body surface area (TBSA), including the scalp, trunk, and extremities.  The patient has tried and failed only topical triamcinolone.  There are "risk factors" for psoriatic arthritis; however, it is not documented that the patient has signs or symptoms of psoriatic arthritis.   

Based on the submitted documentation and the standard of care Cosentyx is not medically necessary. The patient has failed one topical therapy and has no true contraindications to numerous appropriate available treatment modalities. There are no definitive, comparative, controlled, double blinded, head-to-head studies showing that Cosentyx has a superior efficacy or safety profile for a patient of this type compared to reasonable alternatives such as Humira, Stelara, Tremfya, Taltz or other biologics.  According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient.  

The patient has failed only one topical steroid. There is no documentation to suggest that Cosentyx would be more effective than available alternatives or that the patient has a contraindication to a preferred medication which would specifically necessitate Cosentyx. The denial is upheld.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Cosentyx Sensoready (300 MG) 150MG/ML SC SOAJ is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic pain.
Treatment: Inpatient surgery request for a total hysterectomy.
The insurer denied coverage for inpatient surgery request for a total hysterectomy.
The denial is upheld.

This patient is an adult transgender (female to male) with a history of fibromyalgia, gender dysphoria, breast cancer and pelvic pain. Per the office visit note, the patient presented with pelvic pain and the desire for a hysterectomy for gender affirmation. The patient has been on testosterone therapy for 2 years. The patient has had an intrauterine device (IUD) for the past 5 years and is amenorrheic.

Regarding the pelvic pain, the note indicates symptoms for the past several months. The note concludes that the "pelvic pain is of unclear etiology" and the patient was to get an ultrasound to rule out structural causes. There are reports of an ultrasound and a Computed Tomography of Abdomen/pelvis that did not identify an etiology of the pelvic pain. A note indicates the ultrasound was negative, the exact etiology is unclear and if "the patient desires a hysterectomy for gender affirmation, it would be reasonable to proceed with surgery." 

Genital surgery is essential and medically necessary to alleviate gender dysphoria in some, affected individuals. All patients considering extirpative surgery should also meet the World Professional Association for Transgender Health (WPATH) criteria prior to surgery, which includes: 

Two referral letters from qualified mental health professionals. NOT AVAILABLE 
Persistent, well-documented gender dysphoria. CONDITION MET 
Capacity for informed decision making and consent. CONDITION MET 
Age of majority. CONDITION MET 
Well-controlled medical and mental health comorbidities. CONDITION MET 
Twelve continuous months of hormone therapy. CONDITION MET 
Twelve continuous months of living in the desired gender role congruent with the individual's gender identity. CONDITION MET 
Regular visits with a mental health or other medical professional are also recommended but not explicitly required for surgery. CONDITION MET 

This patient meets all of the above criteria except for the absence of two referral letters from qualified mental health professionals. Note that the request for those 2 letters is not to burden the patient but to make sure that this is the right decision and procedure for the patient. Also note that prior to surgery a Pap smear needs to be performed and documented to be normal, as an abnormal Pap smear may affect the surgical procedure. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient surgery request for a total hysterectomy is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory viral infection 

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld

 
This is a child with no past medical history who had been coughing for 5 days. The mother measured the pulse oximetry at home and when the result was 94%, she decided to bring the child to urgent care where he was noted to have wheezing. He was treated with oxygen, 3 back-to-back DuoNeb treatments and dexamethasone. A respiratory viral panel was positive for adenovirus and rhino/enterovirus. Following treatment, he continued to have wheezing and was transferred to the emergency room (ER) by EMS (emergency medical services).

In the ER he was noted to not be in respiratory distress with a pulse oximeter of 95% on room air. On physical exam there were no retractions noted and upon auscultation of the lung there was mild expiratory wheezing. Following treatment in the ER, the decision was made to admit the child to the hospital with a diagnosis of virus induced reactive airways for continued treatment with 4 puffs of albuterol every 2 hours.

The child was treated appropriately at the urgent care center for an acute episode of wheezing, related to a respiratory viral infection. There was no previous history of asthma. When he arrived in the ER he was not in acute distress and had no retractions and mild expiratory wheezing. He was not having a low oxygen level and did not require additional back-to-back albuterol treatments in the ER. Since there was no evidence of increased work of breathing, it was not consistent with the standard of care to admit the child to the hospital. Based on the physical examination the child was not in status asthmaticus and he could have safely been discharged with oral prednisone and an albuterol metered dose inhaler and an aero chamber for treatment at home every 4 hours with a follow up visit with his pediatrician in 24 - 48 hours. The child was not in respiratory distress, and he was stable enough to be safely discharged.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease.
Treatment: Humira 40 mg (milligrams) weekly.
The insurer denied Humira 40 mg Weekly. 
The health plan's determination is overturned. 

The patient is a male with fistulizing Crohn's disease and psoriasis. He presented with intermittent nausea and abdominal pain while on Humira 40 milligrams (mg) weekly. Humira 40 mg weekly for the treatment of Crohn's disease is under review.

Humira 40 mg weekly is medically necessary. Anti-tumor necrosis factor (TNF) medications such as Humira are recommended by current guidelines for Crohn's disease in patients with moderate to severe disease. The use of Humira 40 mg more frequently than every 14 days is supported to prevent disease complications. This patient has moderate to severe Crohn's disease, based on fistulizing disease phenotype, and has been stabilized on Humira 40 mg weekly (with ongoing symptoms including nausea and abdominal pain). In this case, decrease to dosing every other week, or discontinuation of Humira (even if an alternative is attempted immediately), could result in complications of disease activity, such as disease flare, fistula, need for surgery, hospitalization, or colonic dysplasia leading to colorectal cancer. For these reasons, Humira 40 mg weekly is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's dementia.
Treatment: Personal Care Aide Level 2 Services: 168 Hours per Week, 12 Hours x 2 x 7 Days (Split Shift). 
The insurer denied Personal Care Aide Level 2 Services: 168 Hours per Week, 12 Hours x 2 x 7 Days (Split Shift). 
The health plan's determination is upheld.

The patient is a female with past medical history of osteoarthritis, diabetes mellitus type 2, Alzheimer's dementia, diabetic retinopathy, lumbar disc disease with radiculopathy, history of pressure ulcer right buttock, breast cancer, depression, anxiety, osteoporosis, coronary artery disease, hypertension, hyperlipidemia, urinary incontinence, and bowel incontinence.

Personal Care Aide Level 2 Services: 168 Hours per Week, 12 Hours x 2 x 7 Days (Split Shift) are not medically necessary for this patient. 
Although the patient has 24-hour care needs, there is no documentation of specific care needs in the overnight hours that would not allow a PCA (personal care aide) to obtain at least 5 hours of uninterrupted sleep. There are no documented overnight care logs specifically outlining assistance needs. The patient's medical provider did not document the need for turning and repositioning every 2 hours overnight or other assistance needs that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. Because the patient has a mutual case with her husband, there would also need to be documentation of the care needs that the PCA is unable to perform given the spouse's care needs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 168 Hours per Week, 12 Hours x 2 x 7 Days (Split Shift) are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Duchenne Muscular Dystrophy (DMD).
Treatment:  Occupational Therapy (39 home health visits).

The insurer denied Occupational Therapy (39 home health visits).  The determination is overturned.

The patient has a history of Duchenne Muscular Dystrophy status post cardiac transplant, immunosuppression and osteoporosis. The patient is wheelchair bound, due to weakness and contractures in the extremities. The patient's treating providers recommended continued occupational therapy.

The patient's health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.  The requested occupational therapy 39 home health visits is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: tachycardia.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This woman was referred to the emergency department (ED) after having had an episode of wide complex tachycardia (WCT) during an outpatient cardiac stress test that was performed for atypical chest pain. She remained hemodynamically stable. It was unclear whether the WCT represented ventricular tachycardia (VT) or sinus tachycardia with left bundle branch block. 

The full hospital admission was not medically necessary.
This patient was sent to the hospital for cardiac catheterization after she had a wide complex tachycardia during an outpatient stress test and there was concern that the tachycardia was ventricular in origin. She was hemodynamically stable and stress echocardiography showed no evidence of ischemia. Coronary angiography showed single vessel disease with a 60-70% right coronary artery lesion. No intervention was deemed necessary. The procedure was uncomplicated. The patient was seen by an electrophysiologist who opined that the tachycardia was sinus tachycardia with left bundle branch block (LBBB) aberrancy.
Ventricular tachycardia is a potentially lethal arrhythmia, usually associated with structural heart disease or myocardial ischemia. Given that there was concern that this patient had ventricular tachycardia, cardiac monitoring pending cardiac catheterization and cardiac electrophysiology consultation was reasonable and prudent. However, this patient was hemodynamically stable, no treatment for the tachycardia was required and echocardiography did not show evidence of ischemia or significant structural heart disease. Coronary angiography showed no evidence of an acute coronary lesion. The tachycardia was ultimately judged to be sinus tachycardia with LBBB. While exercise-induced LBBB has been associated with coronary artery disease, it does not require any treatment, and has also been shown to occur in normal hearts. Based on the documentation provided, this patient's care could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

This case involves a child who presented to the emergency room after a witnessed seizure. Records indicated the patient had a history of seizures and was given rectal diazepam prior to arrival. When seen in the emergency room, there was postictal drowsiness. Comorbidities included mild persistent asthma with acute exacerbation and a breakthrough seizure. The patient's mother described the initial symptoms as lip-smacking with the uprolling of the eyes, drooling, nonresponsive, and then having a tonic seizure on the right side of the body which progressed to a generalized seizure. Following administration of Diastat, the seizure was aborted. Records indicated the last reported seizure was several months earlier. Vital signs while in triage included blood pressure 102/59. The patient was sleepy/drowsy with no other abnormalities documented. The patient was reassessed less than an hour later, and vital signs had stabilized. Records indicated the patient was admitted for further work-up with concerns for breakthrough seizures. The admission was denied coverage with claims that the patient could have been placed in observation under monitoring with no indication of hemodynamic, pulmonary, metabolic, or neurological reason to treat at an acute level of care.  

According to the Milliman Care Guidelines (MCG), the patient was not a candidate for inpatient admission. While there was a history of seizures, the patient was not found to have suffered a febrile seizure, was not status epilepticus, did not have a brain disorder, nor was there etiology that required monitoring or intervention available only at inpatient level of care. There was no severe or persistent altered mental status, new focal neurologic deficit and there was not a history of a metabolic disorder. The patient was not having recurrent seizures, nor was there an indication that outpatient antiepileptic regimen could not have been established. There was no cerebral bleeding, hydrocephalus, or vasospasm monitoring required and no increased intracranial pressure or cerebral edema monitoring required. The patient had a history of seizures, and while there was a witnessed seizure on the morning of presentation, the child's condition stabilized shortly after arrival to the emergency department. There was no recurrent seizure activity documented and the patient was hemodynamically stable. Based upon the provided information, the patient could have had care rendered on an outpatient basis or observational basis with appropriate treatment rendered without the need for acute level care.  

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

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

Diagnosis: Dizziness. 
Treatment: Inpatient Admission. 

The insurer denied: Inpatient Admission. 
The denial is upheld. 

The patient is a female with a past medical history significant for breast cancer who presented to the hospital with complaints of dizziness, nausea, and vomiting for one day. The patient was in her usual state of health. She drank homemade beet juice and afterward became very dizzy and described the sensation that the room was spinning around. The patient became very nauseous and vomited. The patient described her dizziness as being aggravated by the movements of her head. The patient denied ringing in her ears. She denied headaches. Nausea improved after the administration of Zofran. 

Computed tomography (CT) scan of the head showed no acute intro-axial or extra-axial hemorrhage. There was no mass effect or midline shift. There was no CT evidence of an acute vascular territorial infarct. 
CT angiogram of the neck showed no significant stenosis in the cervical carotid arteries. CT angiogram of the head was also unremarkable. 
The patient was admitted to the hospital with vertigo, hypokalemia, and anxiety.
In the hospital, the patient was seen by a neurologist who suspected that the patient had peripheral vertigo most likely due to benign paroxysmal postural vertigo (BPPV) versus viral infection. 
It was mentioned that the patient had no magnetic resonance imaging (MRI) findings to suggest central vertigo. 
During the hospital stay, the patient was also seen by an ear, nose, and throat (ENT) specialist who recommended conducting special maneuvers to help with that vertigo.
The patient received treatment with antiemetics and Meclizine. 
The patient's clinical condition gradually improved, and she was discharged from the hospital. 

The health plan's determination is upheld. 

The inpatient admission was not medically necessary for this patient. 
Based on the clinical evaluation, the patient had benign paroxysmal positional vertigo. There was no evidence that the patient had an acute stroke or any other significant medical condition. The imaging studies and laboratory tests were unremarkable.
Even though the patient continued to have some symptoms in the first 48 hours of the hospitalization, these symptoms were improving and there was no evidence that the patient had a severe functional disability. Furthermore, the nausea was controlled with medications and the patient was able to tolerate her meals. Nausea and vomiting, which were reported at the beginning of the hospitalization, did not lead to significant dehydration or electrolyte abnormalities. 
There was no evidence that the patient had bacterial labyrinthitis as a cause of vertigo, a condition that would definitely justify admission at the acute inpatient level of care.
Taking into consideration all these facts, admission at a lower level of care status would have been the most appropriate, to ensure improvement in the patient's condition and rule out serious reasons for her symptoms.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Pain Management (epidural injection)
The insurer denied: Pain Management (epidural injection)
The denial is upheld.

The patient is an adult female. She presented with a history of cervical, thoracic and lumbar pain. Exam of the patient's cervical spine revealed limited range of motion secondary to pain. Exam of the thoracic spine revealed mildly limited range of motion and severe TTP (tender to palpitation) midline T6-T9, TTP (tender to palpitation) bilateral thoracic facet joints. Exam of the patient's 
lumbar spine revealed right paraspinal musculature tenderness. FABER (Flexion, Abduction and External Rotation) test was positive bilateral. Facet loading was negative on the right and positive on the left. Lumbar spine range of motion was diminished. Exam of the patient's left hip revealed positive FABER (Flexion, Abduction and External Rotation), FADDIR (Flexion, Adduction, Internal Rotation) test and GTB (greater trochanteric bursitis) tenderness. Diagnosis includes cervical spondylosis, myalgia, thoracic spine pain, lumbosacral spondylosis, and lumbar radiculitis. 
The plan is for a left L4-5 and L5-S1 transforaminal epidural steroid injection.

The requested epidural injection is not medically necessary.

Based on the documentation provided, the requested transforaminal epidural steroid injection on the left is not considered medically necessary in this case. Although the patient has a history of low back pain, there was no documentation of any reproducible symptoms on exam. Additionally, imaging did not support the requested procedure. As such, the request is not considered medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Flat foot deformity.

Treatment: Foot Inserts.

The insurer denied coverage for Foot Inserts.

The denial is upheld.

 
The patient is a child who was prescribed custom orthotics for flat foot deformity. The patient was given a course of non-steroidal anti-inflammatories (NSAIDs) and also told to use over the counter (OTC) orthotics. The medical notes state that she continued to complain of pain. However, given the age of the patient it is very difficult to say with clarity that the patient can verbalize her pain as well as it has been outlined in the records.  Given the age of the patient there are also very few articles that address the use of orthotics in this age group.  One article that addressed metatarsus adductus in this age group addressed the fact that as a general rule there is a lot of debate as to "which patient warrants treatment since spontaneous improvement is the rule." 1 Furthermore, flatfoot deformity is very common in children at this age and the literature shows that "pediatric flat foot is often unnecessarily treated, being ill-defined and of uncertain prognosis." 2 

In the case of this patient, it is best to observe and obtain further imaging to see why she may be having pain if this is the concern of her parents. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for the durable medical equipment (DME) - Foot Inserts is upheld. Medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied: Intracept Procedure
The denial is: Upheld

The patient is a female with chronic axial low back pain for 2-3 years. She also has pain that radiates into her right hip. Past surgical history (PSH) significant for prior lumbar (L) 4/5 endoscopic decompression. Physical exam is unremarkable. Lumbar magnetic resonance imaging (MRI) demonstrated L4/5 peridural fibrosis status/post (s/p) prior decompression, moderate left (L) neuroforaminal stenosis and right (R) L4 nerve hyperintensity and swelling. Endplate degeneration and bone marrow edema was also present. Prior treatments include L4/5 decompression, epidural steroid injections (ESIs) (with benefit), acupuncture, physical therapy (PT), oral steroids, gabapentin, muscle relaxers. The patient was recommended an L4/5 fusion but is not interested in fusion surgery at this time. She subsequently was seen by radiology and was recommended L4/5 Intracept procedure. This was denied by her health plan as not the standard of care.

The patient has chronic low back pain. As per the above history, there is no clear etiology for her pain at this time. MRI showed L4/5 Modic changes but otherwise there is no indication that her pain is vertebrogenic. In fact, she previously received ESIs that were beneficial which would support her pain not being vertebrogenic in nature. Furthermore, she was also recommended a fusion which would not support a diagnosis of vertebrogenic pain. For these reasons, the proposed treatment is not likely to be more beneficial than other standard treatments.