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

Diagnosis: Varicose Veins.
Treatment: Sclerotherapy (36471).
The insurer denied: Sclerotherapy (36471).
The denial is overturned.

The patient is an adult female. She has been followed for right leg varicose vein disease. She underwent successful ablation of the right greater saphenous vein (GSV) 6 months ago. The treatment improved her symptoms, but on multiple postoperative visits, the patient has complained of residual painful varicosities. The provider has recommended two sessions of sclerotherapy. A postoperative duplex showed successful GSV (greater saphenous vein) closure, but it also showed a residual branch varicose vein measuring 7.2 mm (millimeters).

The requested Sclerotherapy (36471) is medically necessary.

The patient has undergone successful axial ablation. The partial improvement of her symptoms suggests that the diagnosis of symptomatic varicose vein disease is correct. She has residual symptomatic varicose veins several weeks following ablation. Duplex confirms GSV (great saphenous vein) closure but demonstrates large residual branch veins with maximal diameter 7.2 mm (millimeters). The patient meets well-accepted indications for sclerotherapy [1-3], because (1) her axial reflux disease has been successfully managed; (2) she has symptomatic residual varicose veins; (3) sufficient time has elapsed after the ablation; and (4) she has failed a trial of compression stockings.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath and Joint Pain.
Treatment: Inpatient Admission.
The insurer denied: Inpatient Admission.
The denial is upheld.

The patient is an adult male with a past medical history of heart failure, chronic kidney disease, cerebral vascular disease (CVA), gout, and sleep apnea who presented to the emergency department for evaluation of worsening left foot pain and right and pain associated with his gout flares. He also complained of worsening lower back pain. He also complained of shortness of breath and stated that he had not taken his Bumex for two days. 
On arrival to the emergency department, the patient was afebrile and hemodynamically stable. His oxygen saturation was 97% on room air. Labs were notable for a sodium of 136, potassium of 3.4, creatinine of 2.7, blood urea nitrogen (BUN) of 62, and brain natriuretic peptide (BNP) of 921. Chest x-ray showed cardiomegaly with mild pulmonary vascular congestion. The patient was admitted to the inpatient unit and was treated for heart failure exacerbation with intravenous diuretics. He was also given Percocet for pain which resulted in drowsiness, requiring administration of Narcan. He responded well to diuresis and was ultimately discharged with outpatient follow-up.

The proposed treatment was not medically necessary.

The patient was admitted to the inpatient unit and was treated for heart failure exacerbation with intravenous diuretics. The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease.
Treatment: Rinvoq 45 milligrams (mg).
The insurer denied the request for Rinvoq 45 mg.
The health plan's determination is upheld.

This patient is a male with a history of Crohn's disease. He has tried and failed numerous therapies, including Infliximab, Humira and conventional therapies.

The health plan in its determination of medical necessity acted reasonably and in the patient's best interest.

Rinvoq is not medically necessary in this case. Rinvoq is Food and Drug Administration (FDA) approved for the treatment of ulcerative colitis in adults. The safety and efficacy of Rinvoq in treating pediatric Crohn's disease are not well established.
There is some evidence supporting efficacy of Rinvoq in adults with Crohn's disease. However, more studies are needed in order to better understand the efficacy and safety profile of Rinvoq in pediatric and adult patients with Crohn's disease. There is no pediatric based literature supporting the use of Rinvoq for Crohn's disease.
There are more suitable alternatives that have not been tried in this case, such as Stelara and Entyvio. These alternatives are recommended for refractory cases by the clinical practice guidelines (Van Rheenen, P. F). Therefore, Rinvoq is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myelodysplastic syndrome. 
Treatment: Venclexta. 

The insurer denied Venclexta. The health plan's determination is overturned. 

This is a female with myelodysplastic syndrome (MDS-EB2). The patient was treated with decitabine. The patient experienced an increasing blast count in the bone marrow and thus was switched to azacxtadine. 

Venclexta 100 milligrams (mg) Tab is medically necessary for this patient. 
As overexpression of the BCL-2 (B-cell lymphoma-2) protein has been linked to disease progression in MDS. Venetoclax is a BCL-2 inhibitor. This patient has hypomethylating agent (HMA) refractory myelodysplasia and is not a candidate for alternative therapies including formal induction. Trial data on the use of venetoclax in this patient population is limited but there is significant overlap with the acute myeloid leukemia population where this is an accepted standard of care. 

Ball, et al, noted that treatment-naive and relapsed/refractory MDS patients receiving venetoclax and HMAs have an ORR (overall response rate) of 59%. This data, in combination with that of Azizi, et al and Dinardo, et al, lend support to the use of venetoclax in this clinical scenario. For these reasons, the National Comprehensive Cancer Network (NCCN) Guidelines do recommend the use of this agent for treatment of patients with high grade myleodysplasia. The authors of Up-To-Date also lend support to this approach. For these reasons, medical necessity criteria have been satisfied.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent
The insurer denied: Dupixent
The denial is overturned

The patient is an adult male with severe atopic dermatitis that has flared over the past six months, resulting in an IGA (Investigator's Global Assessment) score of 4, and affecting most of his body surface area. He has tried and failed oral prednisone, topical, steroids, and oral antihistamines. He has also been on multiple oral antibiotics because of multiple skin infections. Dupixent was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The requested Dupixent is medically necessary.

The patient has severe atopic dermatitis affecting multiple areas of the body. He is a candidate for systemic therapy, as the BSA (body surface area) is too large for reasonable control with topical medications. Topical therapies are not appropriate therapy for severe, widespread atopic dermatitis, 
affecting sensitive areas, which should be treated with systemic therapy. Dupixent (dupilumab) is a monoclonal antibody that inhibits IL (interleukin)-4 and IL (interleukin)-13 signaling by blocking the shared IL (interleukin)-4Ra (receptor) and originally demonstrated efficacy in phase 2 clinical trials. In March 2017, it was approved by the US Food and Drug Administration (FDA) for adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. It 
is a subcutaneous injection administered initially at a dose of 600 mg and then every 2 weeks thereafter.
Approval of dupilumab was based on clinical trials investigating dupilumab as monotherapy (SOLO 1 and SOLO 2) and in concomitant administration with topical corticosteroids (CHRONOS). Results from the SOLO 1 (n=671) and SOLO 2 (n=708) trials showed 36-38% of patients who received 
dupilumab had scores of 0 or 1 (clear or almost clear) on the Investigator's Global Assessment scale compared with placebo (8-10%) (P< .001). Additionally, improvement from baseline to week 16 of at least 75% on the Eczema Area and Severity Index (EASI) was reported in significantly more patients who received each regimen of dupilumab than in patients who received placebo (P < .001). Given its unprecedented efficacy, dupilumab is now a first-line therapeutic for moderate-to-severe AD (atopic dermatitis). The patient has failed topical steroids and calcineurin inhibitors. Cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil are not FDA (United States 
Food and Drug Administration) approved for use in atopic dermatitis (Insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulating medication. Strength of Recommendation: B Level of Evidence: I or II, depending on agent), while Dupixent is. Systemic steroids and cyclosporine are not a reasonable long-term treatment for moderate to severe atopic dermatitis due to their severe side effect profile.
Therefore, for the reasons above, Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Services (PCS), 24 hours/day, 7 days/week (live in)
The insurer denied the PCS, 24 hours/day, 7 days/week (live in).
The health plan's determination is overturned.

The patient is a female with past medical history of depression, anxiety, dementia, urinary incontinence, bowel incontinence, osteoarthritis, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), congestive heart failure, and chronic anticoagulation who had been assigned PCA (personal care assistant) services.

Personal Care Services (PCS), 24 hours/day, 7 days/week (live in) are medically necessary for this patient.

There is documentation from the patient's PCP (primary care provider) of need for increased PCA services due to the patient's worsening physical and cognitive functioning. The plan incorrectly assumed the patient had informal care outside of the currently assigned PCA services but her granddaughter was moving and would no longer be able to provide informal support. The patient requires maximum assistance with walking, locomotion, transfer toilet, and toilet use and therefore the patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient had continuous care needs and therefore a tasking tool should not have been utilized to calculate PCA hours/week. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 24 hours/day, 7 days/week, live-in are medically necessary for this patient. PCS are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is overturned.

The patient is a female who presented to the emergency department (ED) with syncope. Additional symptoms included 4 days of fever, cough, sore throat, and congestion. There was travel to Africa noted in the 2 months prior to presentation.
In the emergency department (ED) her vital signs were temperature 101.7 degrees Fahrenheit, heart rate (HR) 129, respiratory rate (RR) 18, blood pressure (BP) 85/49 and her peripheral capillary oxygen saturation (SpO2) was 98 percent (%) room air. The patient's weight was 86 pounds (lbs.). Her examination was notable for rhonchi in the lungs. Her laboratory studies showed a white blood cell count (WBC) of 12.3 with 85% segmented neutrophils (segs) and 14% band neutrophils (bands), a hematocrit (Hct) of 31.7 and her platelets (Plt) were 186. Her electrolytes, liver function tests (LFT's), troponin, and lactate were normal. The tests for influenza and respiratory syncytial virus (RSV) were negative. The patient's chest x-ray was normal. The patient was given an intravenous fluid (IVF) bolus times 2 and intravenous (IV) Ceftriaxone. She was admitted to the hospital in improved condition with concern for sepsis and the need for further management.

The health plan, in its determination of medical necessity, did not act reasonably or with sound medical judgment and in the best interest of the patient.

The requested inpatient admission is considered medically necessary for this patient. Although this patient showed a positive response to IVF boluses and antibiotics given in the ED, the concern for sepsis and additional treatment with close monitoring necessitated an inpatient level of care.
The patient presented to the ED with fever, tachycardia, hypotension, and bandemia. She had 4 days of symptoms and an acute episode of syncope on the day of admission. According to the current guidelines, this patient was at significant risk for systemic inflammatory response syndrome (SIRS) or sepsis illness and required additional monitoring and treatment at the inpatient level of care.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative colitis
Treatment: Stelara 90 mg every 4 weeks
The insurer denied Stelara 90 mg every 4 weeks.
The determination is overturned.


This is a patient with ulcerative colitis (rectosigmoiditis). She has failed oral and rectal corticosteroids, oral and rectal 5-aminosalicylates, and high-dose Entyvio. She started Stelara and has been using tacrolimus suppositories. A flexible sigmoidoscopy showed mild-moderate proctitis. Stelara was increased to 90 milligrams (mg) every 4 weeks. She had intermittent hematochezia and dyschezia while on Stelara 90 mg every 4 weeks. At issue is the medical necessity of Stelara 90 mg every 4 weeks.

The request for Stelara 90 mg every 4 weeks is medically necessary.
The patient has failed multiple therapies, both conventional and biologic; she then had improvement on Stelara [1-3]. Stelara has shown efficacy for the treatment of Ulcerative Colitis in a Phase III trial, UNIFI [1,4]. This trial demonstrated that a single intravenous dose of Stelara induced clinical remission in a significantly greater proportion of patients than placebo did, as measured by both clinical response and endoscopic response; this result was attained in a patient population which was 50 percent (%) biologic-refractory. Recent studies have demonstrated that Stelara 90 milligrams (mg) every 4 weeks is safe and well-tolerated for the treatment of inflammatory bowel disease, with recovery of effectiveness in patients with active disease [5-7]. A recent study showed that 43% of ulcerative colitis patients on Stelara required dose escalation, and over 50% of those with dose escalation achieved corticosteroid-free remission, and long-term improvement in endoscopic inflammation [8].
In this case, the patient has ulcerative colitis, and has failed alternatives, with active disease symptoms after initial response to Stelara. As the patient had initial improvement on Stelara with subsequent loss of response and then improvement on Stelara every 4 weeks, continuation of Stelara 90 mg every 4 weeks is supported. Decrease of the dose to 90 mg every 8 weeks, or a discontinuation of Stelara (even if an alternative is immediately attempted), may result in disease flare and complications such as toxic megacolon, dysplasia leading to colorectal cancer, hospitalization, or need for surgery. For all of these reasons, the request to continue Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of this patient's ulcerative colitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.



This is a patient who underwent a laparoscopic hysterectomy and bilateral salpingoophorectomy. The patient had uterine fibroids. She was admitted as an inpatient after surgery for monitoring. There were no postoperative complications and she was discharged home. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay medically is not necessary for this patient.
There were no complications from the surgery. The patient had no hemorrhage nor anesthesia complications. She had no pulmonary, renal nor hepatic concerns. She had no cardiovascular concerns nor cardiovascular collapse. Her vital signs were normal and she progressed normally after surgery. There were no severely abnormal labs to support the need for extensive monitoring. She could have been observed at a lower level of care and then discharged to home. There was no documentation that would support the need for acute, inpatient monitoring.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: abdominal pain
Treatment; inpatient stay
The insurer denied the inpatient stay. 

The health plan's determination is overturned. 

The patient is a female who presented with right upper quadrant pain and vomiting. She was well until 4 days prior to presentation when she developed abdominal pain. She took antacids but then awoke with severe right upper quadrant pain and vomiting. Her pain continued and she continued to have nausea and vomiting and was unable to keep anything down. She also developed a fever to 101 F (Fahrenheit). She was seen by her primary doctor and due to the persistence of her symptoms, she was referred to the emergency department for further care.

Inpatient Hospital Admission was medically necessary for this patient.
This is a teenage girl who presented with abdominal pain and vomiting. She was unable to keep any fluids down and continued to have pain in the emergency department despite appropriate treatment with pain medication and intravenous fluids. She therefore required inpatient admission for ongoing treatment with intravenous fluids, pain management, and further evaluation with specialist consultation. She was subsequently found to have biliary dyskinesia and she required surgery to remove her gallbladder.
The decision making at the time of admission was consistent with her young age, the presence of persistent abdominal pain and vomiting and an inability to keep fluids down, and the need for ongoing intravenous fluids, pain control, and surgical intervention.
According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 25th Edition, hospitalization is indicated for patients with gallbladder disease who have persistent vomiting, dehydration, or severe pain. This patient had persistent vomiting and was unable to keep fluids down, and required hospital admission for intravenous fluids, pain control, and subsequent surgical intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intestinal obstruction
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission
The denial is overturned

This case is an adult patient who presented to the ED (emergency department) with complaints of abdominal pain with associated nausea and vomiting. Physical examination noted abdominal tenderness. A Computed Tomography (CT) scan of the abdomen and pelvis revealed partial distal small bowel obstruction within the distal ileum. The treatment plan included surgical evaluation. A Naso-gastric (NG) tube was placed, and the patient was admitted. The patient reportedly had a bowel movement the night prior but was not passing flatus. The treatment plan was for an NG tube for decompression and inpatient admission.  

Milliman Care Guidelines (MCG) recommend an inpatient admission when there are signs and symptoms of bowel obstruction (such as vomiting, inability to tolerate oral intake, pain, distention) that are severe (feculent vomiting, Hypotension, electrolyte abnormality, evidence of bowel ischemia or suspected perforation), or persistent (NG tube placed and will need to be continued, intravenous (IV) hydration support required) and/or imaging study consistent with bowel obstruction (such as alternative diagnosis not more likely). 

In this case, the patient presented to the emergency department with signs and symptoms of bowel obstruction that included vomiting and not passing flatus. Initial work-up did reveal a partial bowel obstruction. Treatment included NG tube placement, IV hydration, and medication management. Inpatient admission was appropriate given signs and symptoms of bowel obstruction, to allow for continued work-up and treatment.  

As such, hospital admission was considered medically necessary for this patient.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Irritable Bowel Syndrome.
Treatment: Linzess.

The insurer denied: Linzess.
The denial is: Upheld.

This patient is a female with a history of irritable bowel syndrome with constipation. She has tried and failed numerous therapies. The subject under review is the medical necessity for Linzess.

Linzess is not medically necessary. Linzess is Food and Drug Administration (FDA) approved for the treatment of irritable bowel syndrome with constipation and for chronic constipation in adults. The safety and efficacy of Linzess in pediatric patients have not been established.

Per Di Lorenzo, Carlo, et. al.: in children with constipation, no clear improvement over placebo was observed for Linzess.

Linzess is currently undergoing a clinical trial to assess its safety and efficacy in pediatric patients and to identify the proper dosing (3). No conclusion can be made from this study as the results are not published yet. There are no other supportive studies for using Linzess in children.

Given the lack of adequate scientific support for using this medicine in children, it cannot be considered medically necessary. Other medications have been better evaluated for treating children, such as Metamucil.

Therefore, the requested service is not medically necessary.