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

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

The patient is a man who presented to the hospital for scheduled catheter ablation of atrial tachycardia and possible recurrent atrial fibrillation. His medical history was remarkable for paroxysmal atrial fibrillation that had been treated with ablation. The procedure involved ablation of a left atrial tachycardia focus within the left pulmonary veins as well as "bonus lesions" around the right and left pulmonary veins. The procedure was uncomplicated. Post-procedure, the patient was admitted to the hospital. 

The inpatient hospital admission was not medically necessary.
This patient underwent a transcatheter ablation for left atrial tachycardia as well as re-isolation of his pulmonary veins for recurrent atrial fibrillation. Given the complexity of the procedure, with transseptal puncture, catheter manipulation and ablation within the left atrium, full dose anticoagulation, and the proximity of the ablation lines to the esophagus, the complication rate is higher with pulmonary vein isolation (PVI) as compared to that of catheter ablations for other supraventricular arrhythmias. Accordingly, despite at least two reports demonstrating the safety of same day discharge after PVI, most electrophysiologists admit the patients for overnight observation post-procedure. However, this patient's procedure was uncomplicated. While, per the appeal letter, he had an episode of mild hypotension post-procedure, it apparently resolved uneventfully as it was not discussed further or mentioned in the discharge summary. Accordingly, while overnight observation was reasonable and prudent, the records provided do not indicate that an inpatient level of care was medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Rhinitis/Nasal Inflammation
Treatment: Dymista  (Pharmacy/Prescription Drugs)

The health plan denied the requested prescription drug Dymista. 

The health plan's determination is upheld.

This is a female with a history of allergic rhinitis and eustachian tube dysfunction. It is documented that her symptoms are under control on Flonase nasal steroid spray with Astelin; antihistamine spray. Her side effects included "nasal sores" with epistaxis.
Dymista (combination spray of Fluticasone with Azelastine) was recommended and is the service under review.

The health plan's determination is upheld in whole.

As the patient reportedly had symptomatic control with separate Fluticasone with separate Azelastine but experienced sores in her nose with epistaxis, the provider felt that the patient might benefit from the products combined in Dymista. The patient has failed only two formulary drugs due to inefficacy, including Mometasone and Fluticasone and is as likely as not that the combination products in Dymista may have adverse effect, as well including epistaxis. In a review of the literature by Chong, it found insufficient evidence to suggest that one type of intranasal steroid is more effective than another in patients with chronic rhinosinusitis, nor that the effectiveness of a spray differs from an aerosol. It is unclear if higher doses result in better symptom improvements (low quality evidence), but there was moderate quality evidence of an increased risk of epistaxis as an adverse effect of treatment when higher doses were used, but using Dymista has the same amount of each product as when using the products separately.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis. 
Treatment: Otezla. 

The insurer denied Otezla. 
The determination is upheld. 

The patient has moderate to severe psoriasis (over 50% body surface area involvement) that includes the face, neck, trunk, extremities, and groin, and also psoriatic arthritis. The patient also has nail pitting and the skin condition is most severe on the lower extremities. The patient had a good response at first to Humira. The patient has also tried and failed topical triamcinolone, hydrocortisone, and betamethasone, as well as prednisone, but steroids were limited to concerns of adverse effects of long-term use. Tremfya was used with significant improvement to the patient's psoriasis but not to the psoriatic arthritis. Enbrel was also tried and failed and was discontinued. Taltz and then Methotrexate (up to 15 milligrams (mg) /weekly) were used together but with limited cutaneous improvement. Taltz and Otezla are to be used concurrently. At issue is the medical necessity of the requested Otezla. 

The Otezla is not medically necessary. Otezla used concurrently with Taltz has insufficient literature support [1-4] to confirm that the long-term benefit of their combined use is of any greater efficacy, safety, or long-term outcomes compared to other alternative and standard-of-care treatments. Open-labeled studies with relatively small numbers of patients are insufficient to confirm appropriate use and clinical utility of Otezla combined with biologic agents such as Taltz. Either alternative biologic therapies, and/or light therapy, and/or higher or alternative disease modifying anti-rheumatic drug (DMARD) therapies, are most appropriately utilized for this patient based on current standards of care. Accordingly, the Otezla to be used concurrently with Taltz is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Darzalex.

The insurer denied Darzalex.  The denial is upheld in whole. 

The patient is a male with multiple medical issues, with immunoglobulin G (IgG) kappa multiple myeloma. Bone marrow biopsy showed 35% bone marrow involvement by CD138 positive plasma cells. Cytogenetic showed t(11;14) translocation. Congo stain was negative for amyloidosis. He was treated with regimen of Revlimid + Velcade + Dexamethasone (RVD) for one cycle and was hospitalized with COVID-19 infection and right sided pneumothorax requiring video-assisted thoracoscopic surgery (VATS) surgery. The patient now returns to his oncologist for follow up after recovering from his recent acute medical illness. He has decreased performance status. Daratumumab (Darzalex) is recommended for treatment for multiple myeloma. The subject under review is whether this treatment will be more beneficial for this patient's disease.

The proposed treatment with Daratumumab as monotherapy is unlikely more beneficial than the standard regimen such as RVD for treatment of multiple myeloma in the current setting (first line treatment).

This patient has not progressed on RVD regimen. The recent hospitalization was due to Covid pneumonia and pneumothorax, and not due to complications of RVD treatment. Changing treatment to single agent Daratumumab (monotherapy) is not clinically indicated based on the information provided.

Daratumumab is approved by Food and Drug Administration (FDA) for both first line and second line treatment for multiple myeloma. For the first line setting, it is approved (1) in combination with bortezomib, thalidomide, and dexamethasone in adults who are eligible for autologous stem cell transplant, (2) in combination with bortezomib, melphalan, and prednisone in adults who are ineligible for autologous stem cell transplant, (3) in combination with lenalidomide and dexamethasone in adults who are ineligible for autologous stem cell transplant.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Darzalex.

The insurer denied Darzalex.  The denial is upheld in whole. 

The patient is a male with immunoglobulin G (IgG) Kappa multiple myeloma who received 1 cycle of Velcade, Revlimid, Dexamethasone (VRD) and then developed pneumothorax and then COVID 19. He was then placed on Darzalex. The subject under review is whether Darzalex is likely to be more beneficial than any standard treatment for this patient.

The proposed health service or treatment Darzalex is not likely to be more beneficial than any standard treatment or treatments for the patient's disease. The package insert for Darzalex, according to Lexicomp, provide for the following indications of Darzalex in patients with multiple myeloma. Newly diagnosed patients may receive Darzalex in combination with Velcade, melphalan and prednisone, or in combination with Revlimid and dexamethasone and, lastly, in combination with thalidomide, Velcade and dexamethasone.

In patients with relapsed/refractory myeloma, Darzalex may be used in combinations similar to previous regimens listed under newly diagnosed patients. It may also be used as monotherapy in patients, who have received at least 3 prior lines of therapy including a proteasome inhibitor and an immunomodulatory agent or who are double refractory to a proteasome inhibitor and an immunomodulatory agent.

This patient was not relapsed or refractory, as he had received only 1 cycle of VRD and developed other medical problems that were unrelated to the cancer treatments. He did not fulfill criteria for the use of single agent Darzalex according to the package insert and National Comprehensive Cancer Network (NCCN) guidelines which are in accordance with package insert of Darzalex.

Therefore, the use of Darzalex is not indicated or supported by data in this instance. It does not follow any established guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Darzalex.

The insurer denied Darzalex.  The denial is upheld in whole. 

The patient is a male with immunoglobulin G (IgG) kappa multiple myeloma. The patient received induction with Revlimid + Velcade + dexamethasone (RVd) but subsequently was diagnosed with COVID-19 and had a complicated course. His performance status is impaired, and he has developed pulmonary hypertension. Following recovery, he was started on single agent Darzalex; this is under review.

The proposed treatment with Darzalex is not likely to be more beneficial.

This patient has not failed RVd in the first line; rather, treatment was curtailed after one cycle due to complications related to his COVID-19 infection. For this reason, the patient has not achieved a remission and is essentially receiving first-line induction therapy. There are multiple alternatives known to be safe and effective in the front line treatment of multiple myeloma; and data demonstrating that daratumumab (Darzalex) is more beneficial is lacking in the peer-reviewed literature. For this reason, this approach is not recommended by the National Comprehensive Cancer Network (NCCN), by the authors of UpToDate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders-Dermatitis.
Treatment: Pharmacy/Prescription Drugs-Dupixent Injector pen.
The plan denied Dupixent 300 milligrams (mg) /2 milliliters(ml) injector pen as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has atopic dermatitis (AD), for which the patient has had more than 10% body surface area coverage at several times. The patient has tried and failed topical Triamcinolone. A letter from the treating provider reports treatment failure of topical triamcinolone, Kenalog injection, oral methotrexate, and oral hydroxyzine. A clinic note notes that the patient took methotrexate about 3-4 years ago for 6 months, but it did nothing for him.
There is insufficient documentation of recent combined use of more potent topical steroids and a topical immunomodulator (tacrolimus or pimecrolimus, or Eucrisa (crisaborole))The use of methotrexate is both too far in the past and poorly-documented to conclude any confirmed trial and failure of this systemic therapy. 
"Atopic dermatitis (AD) is a common chronic inflammatory skin disease that predominantly affects children. However, it can persist in adulthood and/or start at older ages. Due to its chronic nature and frequently occurring relapses, AD has a substantial effect on patients' quality of life, often requiring long-term systemic treatment, especially in adult patients, who are more frequently refractory to adequate topical treatment with mid- to high-potent corticosteroids and/or calcineurin inhibitors. Therefore, treatment with systemic therapies is often needed to take control of the disease, prevent exacerbations and improve quality of life. However, data regarding systemic treatment effectiveness and long-term safety in adult patients with AD are insufficient. Indeed, standardized international guidelines are lacking, and the treatment approach widely differs among diverse countries. "[2]
The patient has insufficient documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors(CNI), and/or standard, first-line oral medications such as Methotrexate, Azathioprine, or Mycophenolate Mofetil that would obviate the need for further topical treatment. Dupixent is not proven to be superior to all other alternatives as per comparative, controlled studies. Therefore, consistent with current medical literature reviews, the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: leg pain.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a male with history of diabetes, hypertension, right total hip replacement and heroin abuse who presented to the hospital with bilateral leg pain for the past two weeks. He was concerned about infection and reported redness, discharge, and swelling. He denied fevers, chills, nausea, vomiting and diarrhea. He described the pain as an aching sensation. Vital signs showed blood pressure 135/78, heart rate 96, and temperature 98.4 Fahrenheit. On physical exam, heart was regular, breath sounds were normal and there was erythema to the calves with honey crusted vesicles bilaterally in the lower extremities. An electrocardiogram (EKG) showed normal sinus rhythm with a right bundle branch block. Labs showed erythrocyte sedimentation rate (ESR) 57, C-reactive protein (CRP) 6.5, white blood cell (WBC) 11, creatinine 1.35, sodium 134, and potassium 4.6. Lower extremity ultrasound showed greater than 50% stenosis in the left femoral artery and occlusion of the right femoral artery. The patient was admitted with cellulitis and acute peripheral vascular disease. The plan of care included intravenous (IV) antibiotics, IV fluids, infectious disease consult, vascular surgery consult, blood cultures, wound care, Statin therapy, consider starting aspirin therapy, lisinopril for hypertension, monitor glucose, initiate methadone, and check thyroid function. 

The inpatient hospital admission was medically necessary. The patient had a complex presentation of cellulitis/impetigo and needed prompt consultation with specialty services, with the infectious disease service and vascular surgery team seeing the patient. He was at an increased risk of developing sepsis, septic shock and bacteremia. Ultimately, the decision was made to not perform inpatient revascularization but this was a consideration that directed the decision to admit him. Although he left against medical advice, it was appropriate to treat him at the inpatient level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Behcet's Disease, Acantholytic dermatosis.
Treatment: Otezla.
The insurer denied the Otezla.
The determination is overturned.

The patient had Behcet's Disease. The patient reportedly failed use of colchicine (which caused diarrhea and upset stomach), but only one paid claim is noted. The patient is currently only on prednisone. The health plan formulary alternatives include colchicine, azathioprine, or cyclosporine. Cyclosporine and azathioprine have been avoided because they are not good for long-term use in this patient. A clinic visit on  noted a skin biopsy as being reported as "acantholytic dermatosis". Tender erythematous nodules and aphthae were noted on examination. Paid claims for mycophenolate mofetil, methotrexate, prednisone, and dapsone are noted in this patient's pharmacy claims. At issue is the medical necessity of Otezla.
The requested Otezla is medically necessary. An exhaustive literature review [1-10] that addresses treatment of Behcet's Disease supports use of Otezla (apremilast) as the only Food and Drug Administration (FDA)-approved and literature-supported treatment for Behcet's Disease among all specialties. A noted dearth of literature supporting azathioprine or cyclosporine was observed, and the other treatment (Colchicine) was not tolerated by this patient. Ideally, a three-month trial of Colchicine would therefore be utilized but has proven not possible.
There are very few confirmed and reliable treatments for this patient's condition (Behcet's Disease), and Otezla (apremilast) is the only reliable treatment with respect to literature support [1-10], consensus, and standard of care. Colchicine was not tolerated by the patient, and both azathioprine and cyclosporine have little to no mention in literature reviews over the past five years. Accordingly, at this time, Otezla is medically necessary to best treat this patient's disease with respect to safety and efficacy, and over the formulary alternatives that appear to have very little reliability and safety in treating Behcet's Disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uncontrolled Hypertension

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This is a male patient with a past medical history of hypertension, dyslipidemia, status post (s/p) neck surgery for gunshot injury, Cerebrovascular accident (CVA) with focal neurological deficits (left leg weakness) who presented to the Emergency Department (ED) on with a chief complaint of headache. He reported that he felt the same headache in the past and at this time his blood pressure (BP) was high and he had a stroke so he came to the ED seeking medical attention. In the ED, his BP was 159/100. He was admitted as an inpatient for uncontrolled hypertension secondary to medication non-adherence. Lab results revealed acute kidney injury (AKI) and transaminitis.  Electrocardiogram revealed normal sinus rhythm with T wave abnormality. Chest X-ray revealed no evidence of acute cardiopulmonary disease.  Computed Tomography of the head was significant for: no acute intracranial abnormality; no hemorrhage; extensive chronic microvascular ischemic changes in the periventricular and subcortical white matter; mild intracranial vascular calcifications; no midline shift; age appropriate cortical sulci; and focal encephalomalacia along the right frontal lobe.  Physiatry was consulted for progressive decline in functional status and unsteady gait and weakness, resulting in impaired physical mobility and activities of daily living (ADLs).  The patient's AKI was treated with hydration.  The patient's transaminitis improved. His antihypertensive medications were adjusted.  The patient was deemed clinically and hemodynamically stable and was discharged to sub-acute rehabilitation.

This patient presented to the ED because his blood pressure was found to be elevated during an outpatient evaluation. He had a history of hypertension but had not been complaint with taking his medications. His evaluation quickly showed that he had no evidence of end organ damage. CT scan of the head showed no abnormality and troponin and EKGs showed no evidence of myocardial damage. His renal function was within normal limits. The literature cited indicates that blood pressure in patients with hypertensive urgency can effectively be treated by rest and may not require intensive blood pressure treatment.  In fact, intensive blood pressure treatment may be harmful. The clinical history that reviewed does not provide evidence that acute inpatient admission was medically necessary.  Therefore, the denial of coverage for monitored (telemetry) level of care for should be upheld.
The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

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

Diagnosis: Left anterior cruciate ligament (ACL) reconstruction

Treatment: CPT 97530 Continued Therapeutic Activities, Direct Patient Contact (Use of Dynamic Activities to Improve Functional Performance (Physical Therapy)

The insurer is denied coverage for CPT 97530 Continued Therapeutic Activities, Direct Patient Contact (Use of Dynamic Activities to Improve Functional Performance (Physical Therapy)

The denial is upheld. 

This female patient has a history of left anterior cruciate ligament (ACL) reconstruction surgery. She presented to the physical therapist's office with complaints of pain, decreased strength, decreased balance, decreased endurance, and difficulty with daily activities. She also had a physical therapy (PT) visit. Numerical Rating Scale score at the time of the visit was 0. Functional limitations included squatting, stair negotiation, and recreational activities. The physical therapist noted that the patient continued to make good progress in PT. Her strength gradually improved. She has an increased ability to squat. She continues to have impairments in eccentric quadriceps strength and ankle range of motion (ROM) that are inhibiting her ability to negotiate stairs and return to recreational activities. She would benefit from further skilled PT.

After review of the submitted medical records, the continued therapeutic activities are not considered medically necessary. Orthopedic progress note states the patient has no effusion in either knee, gait is normal, ROM 0-140 bilaterally, hip motion pain free bilaterally, and no weakness documented. There is a vague statement of "the patient has not yet reached maximal benefit of physical therapy and has on-going weakness and mild discomfort". However, PT progress note  with no pain on encounter and minimal documentation. PT progress note from denotes the patient has completed 36 post-op visits in total. Has made significant objective progress, but 0/10 pain, good ROM, but demonstrates some impairment in eccentric quadriceps strength and ankle ROM. The progress notes or appeal letter do not demonstrate contraindication to complete home exercise program. Due to insufficient records cannot approve continued services as medically necessary.

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

The carrier's denial of coverage for the CPT code 97530 Continued Therapeutic Activities, Direct Patient Contact (Use of Dynamic Activities to Improve Functional Performance (Physical Therapy)  is upheld.  The medical necessity is not substantiated.