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

Diagnosis: Cardiac/circulatory
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The denial is upheld in whole. 

The patient  had a history of hypertension, hyperlipidemia, diabetes, and vascular ring surgery, and  presented with right sided numbness and headaches concerning for acute cerebrovascular accident (CVA). Patient  stated that the symptoms resolved on their own. Patient reported that the headache was 10 out of 10 in severity. There was no photophobia and denied specific weakness or speech or visual deficits. Patient refused tissue plasminogen activator (TPA) in the emergency department. Vital signs showed temperature 36.7 Celsius heart rate 109 blood pressure 146/97 respiratory rate 16. On physical examination, heart was regular, breath sounds were normal and there was mild sensory loss and no focal motor deficits. Labs showed sodium 135 potassium 4.2 creatinine 0.89 glucose 146 calcium 9.5. Chest computed tomography (CT) angiography demonstrated a right sided aortic arch. An electrocardiogram (EKG) showed normal sinus rhythm. The patient also had a negative head CT. The patient was admitted for suspected CVA. The plan of care included aspirin, Lipitor, monitor mental status, permissive hypertension, echocardiogram, telemetry, physical therapy, and consider brain magnetic resonance imaging (MRI). The patient was seen by neurology and their impression was that aspirin and statin therapy should be continued and the brain MRI could be performed as an outpatient. The patient had no recurrent symptoms and was discharged. 

The inpatient stay was not medically necessary.

The patient presented with suspected stroke versus transient ischemic attack (TIA), and initial imaging in the emergency department showed a negative head CT and a negative head CT angiography. There was no evidence of atrial fib on the EKG and the patient's vital signs were stable. In addition, there were no new or worsening symptoms. There were also no other complications, including acute infection, sepsis, hemodynamic instability, end organ injury, or cardiac arrhythmia.

The patient was hemodynamically stable with initially mildly elevated blood pressure and heart rate, and  had no evidence of ongoing hemorrhage or ischemia on head CT. There were no acute electrolyte abnormalities or evidence of acute kidney injury, and there was no evidence of sepsis or other acute complicating disease. The patient did have risk factors for thromboembolic disease, but did not require inpatient level of care. The patient needed further care, but it could have been safely and effectively provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/circulatory.
Treatment: Inpatient hospital stay.
Issue: Medical necessity of the inpatient hospital stay.
The health plan's determination is upheld in whole.

The patient was post-partum 3 days following vaginal delivery who presented to the emergency department via Emergency Medical Services  with complaints of chest pain, shortness of breath and edema. The patient reported the chest pain was worse with deep breath. The patient noted swelling of hands, abdomen, and lower extremities. Vital signs in emergency department (ED) upon arrival with blood pressure (BP) 130/79, respiratory rate (RR) 20, heart rate (HR) 96 and oxygen saturation 98%. On examination there was 1+ pitting lower extremity edema. Laboratory data showed elevated white blood cell (WBC) of 13,000, hemoglobin 9.9, hematocrit 31 and brain (or B-type) natriuretic peptide (BNP) 371 (normal 0-100). An electrocardiogram (EKG) showed sinus bradycardia. Chest x-ray was normal. Bilateral venous ultrasound was negative for deep vein thrombosis (DVT). A computed tomography (CT) angiogram of the chest showed atelectasis but no pulmonary embolism. The patient was transferred to another hospital so that the patient could receive cardiology consultation. The patient received 20 milligrams (mg) intravenous (IV) Lasix prior to transfer. The patient was admitted to inpatient level of care. The patient was seen by cardiology noting the patient's symptoms were likely due to postpartum status and unlikely from heart failure and a repeat echocardiogram was recommended in 3 months and patient was stable to discharge to home. The patient's telemetry and vital signs were stable. The patient was discharged to home with azithromycin for possible bronchitis. 
The patient presented with complaints of pleuritic chest pain, shortness of breath and edema. The vital signs were normal. Venous doppler and CT angiogram did not show venous thromboembolism. EKG was normal. The patient had mild elevation of BNP and did have echocardiogram with minor valvular findings. The patient was seen by cardiology for consultation of symptoms and mild elevation of BNP and was felt stable to discharge with symptoms felt related to postpartum status. WBC was elevated without evidence for infection on laboratory data and imaging. The patient did not require urgent procedure. The patient did not require complex IV therapy. The patient's severity of illness and intensity of care at admission were appropriate at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth decay #19.
Treatment: Root Canal, Post, Core and Crown for Tooth #19.
The insurer denied the Root Canal, Post, Core and Crown for Tooth #19.
The denial is upheld. 

The patient is a female requesting root canal treatment, post/core and crown on tooth #19.

No, the proposed treatment, Root Canal, Post, Core and Crown for Tooth #19, is not medically necessary. 

The x-rays indicate that tooth #19 is severely decayed below the level of the bone. This makes the treatment outcome very questionable as to the long term prognosis of this tooth. Based on the records submitted, the tooth is not savable.  Standard of care would be to extract and replace with a more predictable restoration.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriatic Arthritis
Treatment: Xeljanz
The insurer denied Xeljanz.
The denial was upheld.

This is a patient with a history of psoriasis, hypertension, congestive heart failure (CHF) as well as cardiomyopathy. The clinical note indicates the patient has had worsening of his psoriasis off the methotrexate-which he did not tolerate- and the plan was to add Xeljanz to his current regimen which includes Otezla.   The provider requests coverage for Xeljanz to treat psoriatic arthritis and is to continue to use Otezla.

The use of Xeljanz with other medications such as methotrexate and corticosteroids has been studied in the medical literature; however, there is insufficient evidence by way of large randomized controlled trials showing the safety and efficacy of Xeljanz when used with another medication such as Otezla.  A medical exception for the use of Xeljanz for this patient who is also on Otezla has not been established.

As reported by Nash, et al., "In the study reported here (OPAL Balance), adult patients with PsA took tofacitinib for up to 3 years.  We report a planned interim analysis, i.e., an analysis of information collected before the study finished.  This early information suggests that the safety of tofacitinib, and how well it improved symptoms and quality of life (efficacy), was similar in this long study as in shorter studies.  Information from the finished study will be reported later. OPAL Balance started on 17 February 2014.  This interim analysis includes information collected by 31 August 2017. Before joining, patients had finished a 6-month or 12-month tofacitinib study (OPAL Broaden or OPAL Beyond).  Patients in OPAL Balance took a 5 mg tofacitinib pill twice a day, but if PsA symptoms did not improve after 1 month, they could take a 10 mg pill twice a day.  They could also take other medicines (including methotrexate or corticosteroids).  Most blood test results and tofacitinib efficacy were stable over 2.5 years."      

The use of Xeljanz in combination with apremilast is not considered medically necessary for this patient. There is a lack of studies to demonstrate safety and efficacy with the combination of these medications.  There are small studies demonstrating Otezla's safety and efficacy with biologics such as Sterlara, Humira, Enbrel, Cimzia, Simponi, and Remicade. However, in the review by Metyas, et al. there is no data supporting apremilast combined with tofacitinib.  Moreover, Menter, et al. in a report from the AAD did not support combining tofacitinib with any other biologic and in their comments regarding apremilast stated "There is currently no strong evidence to support the combined use of apremilast with other systemic or phototherapy treatments for psoriasis." 
                                            
The health care plan did act reasonably, with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for Xeljanz is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive system /gastrointestinal /abdominal pain. 
Treatment:  Inpatient hospital.

The insurer denied the entire inpatient stay.  The denial is upheld in whole.

This is a patient with a history of chronic obstructive pulmonary disease (COPD) and chronic hepatitis C, who presented to hospital with abdominal pain and melena.  

No, the requested health service/treatment of inpatient stay is not medically necessary for this patient.  This patient with COPD and chronic hepatitis C presented with abdominal pain and melena.  On presentation, the patient was hemodynamically stable without fever, tachycardia or hypotension.  Bloodwork did not reveal leukocytosis, anemia or significant electrolyte derangements.  The patient's CT abdomen/pelvis revealed liver lesion and enteritis.

The patient was admitted and treated with intravenous fluid hydration and pain control.  The patient 's EGD revealed esophageal varices, portal hypertensive gastropathy and duodenal ulcer.  Colonoscopy revealed terminal ileitis and colon polyps.  He was initiated on therapy with a proton pump inhibitor.  This patient remained hemodynamically stable and did not have ongoing overt gastrointestinal bleeding or require transfusion with packed red blood cells or require endoscopic or surgical intervention to the stop the bleeding in this case.

According to the Milliman Care Guidelines (MCG) guidelines, as the patient did not have active bleeding, high risk endoscopic features, severe liver disease, significant active comorbid disease, previous aortic graft placement, coagulopathy, syncope, associated condition requiring hospitalization, hemodynamic instability, complicated anemia, severe pain requiring acute inpatient management, high risk low platelet count, requiring intravenous fluid administration, or immediate surgery, an acute inpatient level of care and inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Diabetes, below the knee amputation, gait ataxia.
Treatment:  Personal Care Assistance Services, Level II, 40 Hours/Week.

The insurer denied the Personal Care Assistance Services, Level II, 40 Hours/Week.  The denial is upheld.

The proposed treatment of an increase in Personal Assistance Services from 28 to 40 hours per week is not deemed medically necessary. 

The patient is a male with a history of right below the knee amputation, chronic fatigue, insomnia, hypertension, diabetes mellitus, low back pain and gait ataxia.  Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). 

This is a male with a history of right below the knee amputation, chronic fatigue, insomnia, hypertension, diabetes mellitus, low back pain and gait ataxia.  Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs).  However, an in-home assessment of the patient's functionality and ability to perform ADLs was completed and revealed that the currently approved plan of 28 hours per week Personal Assistance Services is sufficient to meet the patient's current needs.  There is no additional medical documentation, which demonstrates that the patient has sustained objective evidence of further functional loss since the date of this last assessment.  For these reasons, the proposed treatment of an increase in Personal Assistance Services from 28 to 40 hours per week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Small Bowel Obstruction 
Treatment: Inpatient admission 	

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

This is a male patient with a medical history of bowel obstruction, abdominal adhesion surgery, appendectomy, and jejunostomy tube placement. The patient presented to the emergency department (ED) with complaints of abdominal pain, nausea, and vomiting.  The patient reported periumbilical and lower abdominal pain with non-bilious vomiting. The patient was not passing gas. The patient had recurrent episodes of small bowel obstruction with the most recent surgery being in early 2019. The patient had a recent esophagogastroduodenoscopy (EGD)/colonoscopy the week prior to presentation that revealed gastritis. The physical examination revealed tenderness in the right and left lower quadrant. The laboratory results revealed white blood cell count 13.5, lactic acid 2.5, ALT 107, and AST 56. The patient was treated with intravenous fluid bolus, Dilaudid, Zofran, and Omnipaque. Gastroenterology was consulted. Recommendations for a nasogastric tube be placed and the patient undergo bowel rest. A computed tomography (CT) of the abdomen and pelvis revealed a small bowel obstruction with a transition point suspected within the left upper pelvis and hepatic steatosis. The EKG revealed an RSR or QR pattern in V1 suggesting right ventricular conduction delay with a possible inferior infarct. The patient was admitted to the hospital with a small bowel obstruction. X-rays of the abdomen showed a resolving small bowel obstruction. On the day prior to discharge, the patient was having bowel movements and passing flatus after a Gastrografin challenge. The patient was tolerating a clear liquid diet and had been advanced to a soft diet. The patient was cleared for discharge home without patient follow up. 

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

The patient had previous episodes of small bowel obstruction which resolved without surgical intervention. An appropriate plan would have been to admit the patient under observation and if his SBO did not improve with conservative management, then change to inpatient status. The SBO resolved within 24 hours in this patient. 

Based on the above, the medical necessity for inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Plaque psoriasis.
Treatment:  Otezla 28 Day Starter Pack.

The insurer denied the Otezla 28 Day Starter Pack.  The denial is upheld. 

The patient is a female with psoriasis affecting >10 % BSA (body surface area), affecting her feet and extremities, and for whom Otezla is requested.  She has tried clobetasol, triamcinolone and Enstilar.

No, the Otezla 28 Day Starter Pack is not medically necessary.

The current treatment guidelines, which are in accordance with nationally accepted standards of medical practice for moderate to severe plaque psoriasis, recommend typical first-line treatments, such as topical corticosteroids and calcipotriene, followed by typical second-line treatments, such as ultraviolet phototherapy, oral systemic treatments (methotrexate, cyclosporine) and biologics.  After failure or contraindication to these treatments, newer agents for which less clinical experience and medical evidence exists, and that have not yet been incorporated into current treatment guidelines, such as Otezla, would be considered. 

The patient in this case has no documented FDA listed contraindications to the use of oral systemic treatments (methotrexate, cyclosporine or acitretin) and biologics.  Evidence from the peer-reviewed published scientific literature suggests that biologic and conventional systemic therapies are similarly safe and effective, and TNF- (tumor necrosis factor alpha) inhibitors have been shown safe and effective in the treatment of psoriasis. 

Overall, psoriasis is associated with a 5-year malignancy rate of 115.5 cases per 10,000 person years compared with 96/10,000 for the general population.  Stratified by type of treatment, malignancy rates were in a relatively narrow range bounded by 94.6/10,000 for patients treated with adalimumab (Humira) and 138.1/10,000 for patients treated with infliximab (Remicade).  The data shows that malignancy rates are similar for psoriatic patients treated with Humira and the general population.  In an extensive review of the safety of adalimumab in a variety of inflammatory diseases it was noted: No serious opportunistic infections have been reported with adalimumab in psoriatic arthritis or psoriasis clinical trials.  The most common adverse events associated with Otezla have been nausea, diarrhea, nasopharyngitis and upper respiratory tract infection, thus establishing that there are risks associated with its use.  Also, there is no evidence to support that Otezla is more efficacious in the treatment of psoriasis versus the listed alternatives.  Based on these reasons, Otezla is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is upheld.

This male patient had no prior medical history and presented to the emergency department (ED) with the complaint of intermittent left-sided chest pain.  The pain was worse after eating and radiated to his left arm.  He also endorsed shortness of breath and nausea with his chest pain.  Vital signs were stable.  An EKG showed normal sinus rhythm.  Physical exam was remarkable for presence of a dry cough, sinus congestion, fever and chills.  Troponin level was negative.  A chest x-ray showed no acute pulmonary pathology.  A computed tomography angiogram (CTA) scan of the chest showed no acute pathology.  The patient was admitted to the telemetry unit for further evaluation.  An echocardiogram showed normal left ventricular size and systolic function with ejection fraction between 55-60% with mild concentric left ventricular hypertrophy and mild diastolic dysfunction.  Cardiology consult noted reproducible tenderness on the left 2nd costochondral junction, consistent with atypical chest pain due to costochondritis.  There was no evidence of acute coronary syndrome, chronic heart failure or arrhythmia.  He was ambulating in the hallway with no symptoms.  The patient was medically cleared for discharge to home to continue his home medications and was instructed to follow up with his primary care doctor in 5 to 7 days. 

The patient presented with chest pain.  He was ruled out for pulmonary embolism with a negative CTA.  He was initially and remained clinically and hemodynamically stable during his evaluation in the ED.  Further evaluation in the ED was unremarkable, including a normal EKG and negative cardiac biomarkers.  Though it was appropriate and indicated for the patient's symptoms to be evaluated to rule out myocardial infarction, inpatient admission was not medically necessary in this instance.  The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing.  There were no high-risk or concerning findings on diagnostic testing to suggest acute coronary syndrome or the need to necessitate further inpatient evaluation.  During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. The observational level of care would have been appropriate. 

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial is: upheld in whole.

The patient is a female infant, who was found to have elevated direct bilirubin in the newborn nursery with concerns for biliary atresia and was scheduled for liver biopsy. She was otherwise doing well, with good appetite, no vomiting or fevers. Liver panel revealed normal albumin, elevated direct bilirubin (4.1), elevated alkaline phosphatase (679), elevated gamma GT (266), and elevated transaminases (aspartate aminotransferase [AST] 130, alanine aminotransferase [ALT] 73). Ultrasound completed prior to admission revealed diffusely mild coarsening hepatic parenchymal pattern as a non-specific finding. She underwent the biopsy with general anesthesia via laryngeal mask airway (LMA). The procedure was uncomplicated, and she was admitted to the Pediatric Intensive Care Unit (PICU) post-operatively for monitoring because of her age and potential for apnea and desaturations. Admission orders included Tylenol as needed for pain, ad lib diet, and serial labs to evaluate for post-procedure bleeding. She did well overnight, with no spells and good appetite, and was deemed stable for discharge home. Ultimately, the biopsies revealed biliary atresia.
The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

Biliary atresia is a disease that affects the extrahepatic biliary tree in infants, characterized by rapidly progressive liver fibrosis, bile duct obstruction, and cholestasis over the first months of life. Liver biopsy in conjunction with other testing is used to make the diagnosis. Management involved surgery with a Kasai hepatoportoenterostomy to relieve the obstruction, resulting in successful bile drainage in 50%. Eventually, the majority of children experience ongoing fibrosis and inflammation leading to end-stage liver disease necessitating liver transplantation.
This female infant, five weeks of age at the time of evaluation, had persistent direct hyperbilirubinemia raising concern for biliary atresia. Liver biopsy was deemed necessary, a procedure that requires general anesthesia. In such a young infant, there are risks inherent to both the anesthesia (apnea, desaturation) and liver biopsy (bleeding). Based on the risks and potential complications, overnight observation was reasonable and medically necessary. In the absence of respiratory difficulty, bleeding, or hemodynamic instability, however, she did not require acute inpatient management.
The patient could have been managed at a lower level of care status.