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

Diagnosis: Dizziness.
Treatment: Inpatient hospital admission.

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

This case involves a female who presented to the emergency department to evaluate an onset of dizziness as well as unsteady gait and vomiting. The documentation indicated upon arrival she had a temperature of 96 degrees with a heart rate of 65 beats per minute (bpm). Oxygen saturation was 99% (percent) on room air. Blood pressure was 120/85 mm/Hg (millimeters of mercury). The documentation indicated she reported feeling off balance when walking with a dizziness sensation. She vomited twice despite receiving Zofran per emergency medical services. The documentation indicated on physical examination she was alert with a clear speech. She had 5/5 strength to the bilateral arms and legs. She scored 0 on the National Institutes of Health (NIH) stroke scale. It was recommended she undergo laboratory diagnostic studies. A computed tomography (CT) scan of the head revealed no acute territorial infarct or hemorrhage identified. The electrocardiogram (EKG) revealed a normal sinus rhythm. The physician indicated upon recheck the labs and imaging were grossly unrevealing which included a normal computed tomography angiography (CTA). She indicated her symptoms were improving and was evaluated by neurology. It was recommended she be admitted. The documentation detailed she was admitted for further evaluation and management. She continued to improve and denied any further adverse events. She was discharged.
 
The submitted documentation indicated the patient presented initially with complaints of dizziness. She was initially evaluated for a stroke; however, with a normal neurological examination as well as a 0 on NIH stroke scale, a normal CT and CTA in addition to improving symptoms, the requested hospital admission was not warranted. 

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

The insurers denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Atopic Dermatitis. 
Treatment: Dupixent 300 milligrams per 2 milliliters (300 mg/2 ml) subcutaneous (SC) solution pen injector (SOPN). 

The insurer denied coverage for Dupixent 300 milligrams per 2 milliliters (300 mg/2 ml) subcutaneous (SC) solution pen injector (SOPN). 

The denial is overturned. 

The patient has a history of severe atopic dermatitis.  The patient, according to the documentation provided, has failed therapy with topical steroids and topical calcineurin inhibitors.  The requested medication is Dupixent.  

Dupixent is medically necessary for the treatment of the patient's diagnosis, atopic dermatitis.  The patient is a child with decreased systemic treatment options available which could safely be administered given her age.  The patient has failed reasonable topical therapy with steroids and requires systemic therapy for severe atopic dermatitis. Dupixent is approved for use in the treatment of the patient's atopic dermatitis under close medical supervision and at an appropriate dosing schedule at the discretion of the treating physician.  The health plan did not act reasonably with sound medical judgment in the best interest of the patient.  
	
Based on the above, the medical necessity for Dupixent 300 milligrams per 2 milliliters (300 mg/2 ml) subcutaneous (SC) solution pen injector (SOPN) is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Breztri Aerosphere, Pre-service
The insurer denied the Breztri Aerosphere, Pre-service.
The denial is upheld.

The patient is a female with asthma who is prescribed Breztri Aerosphere. The patient has tried and failed Trelegy Ellipta, Zyrtec, and albuterol inhalers. 

The Breztri Aerosphere was denied due to lack of medical necessity. This denial is being appealed.

No, the proposed treatment is not medically necessary.
The patient has asthma who is prescribed Breztri Aerosphere. The patient has tried and failed Trelegy Ellipta, Zyrtec, and albuterol inhalers. The Breztri Aerosphere is denied due to lack of medical necessity.  

Breztri Aerosphere is not Food and Drug Administration (FDA) indicated for the treatment of asthma. It is an off label use and there are formulary alternatives of different classes available for escalation especially since the discontinuation on Trelegy is self-initiated due to the way it felt in the patient's throat. The proposed treatment is not medically necessary.  The formulary alternatives (Budesonide/Formoterol [generic Symbicort], Fluticasone/Salmeterol powder for inhalation [generics of Advair Diskus and AirDuo RespiClick] or Wixela In hub in combination with Montelukast, Zafirlukast, or Spiriva Respimat 1.25 micrograms) are preferred for escalation of therapy.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Full hospital admission

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

This patient has menorrhagia and known iron deficiency anemia. She was sent by her treating provider to the emergency room for a hemoglobin (HGB) of 5.5. She was hemodynamically stable on arrival with a normal chest x-ray, and otherwise normal labs. She was given one unit of packed red blood cells (PRBC) and admitted.  Her computed tomography (CT) showed an enlarged uterus. She was given two more units of PRBC and the HGB improved to 7.8. Hematology and gynecology were consulted. She refused embolization and was discharged with outpatient follow up.

"Generally, a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association).

This individual could have been managed in an alternative level of care. On arrival, she did have anemia, but was hemodynamically stable. She had a known explanation for her anemia. Simple blood transfusions can be administered in alternative care settings and are even given on an outpatient basis. Two units of PRBCs and consults with gynecology and hematology could have all occurred in observational status. As this patient was hemodynamically stable and could have been managed in a lower level of care, acute hospitalization was not medically necessary for the dates of service in question. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.                                                  
 
The insurer's denial of coverage for a full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypotension. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This patient with end stage renal disease (ESRD) on hemodialysis was admitted to the hospital for hypotension. Cardiac markers were negative, electrocardiogram (EKG) showed normal sinus rhythm, COVID-19 (2019 Novel Coronavirus) was negative, but her chest X-ray did show interstitial lung infiltrates. She was started on Midodrine and discharged the following day. 

This patient had normal oxygenation and negative blood cultures. She did not have a significant electrolyte disturbance or change in kidney function. There were no cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration. There was no documentation of refractory pain. She was able to tolerate an oral diet and her condition responded to intravenous fluid and midodrine in 24 hours. 

There is no evidence-based literature supporting inpatient level of care was medically necessary and her condition could be treated safely under a lower level of care. 

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 inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine
Treatment: Ajovy 225 milligrams auto-injector (pre-service)

The insurer denied coverage for Ajovy 225 milligrams auto-injector (pre-service).
The denial is overturned.

The patient is diagnosed with migraine without aura and without status migrainous not intractable.  The office visit noted the patient had subjective complaints of headaches.  The prior treatments included Advil, rizatriptan, and Zofran, Migrelief, cyproheptadine, nortriptyline, and Ajovy.  The patient had started Ajovy.  The headache frequency improved drastically.  The patient only had one migraine during the month and then stopped having headaches altogether.  Oral contraceptive pills were ineffective for her headaches.

The Letter of Medical Necessity noted the patient had severe headaches that did not respond to multiple treatment options while Ajovy cured her headaches without side effects.  The request was made for Ajovy and it was noted this would be for off label use and there was nothing that was on label for pediatric migraines.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

Szperka, C. L., & Gelfand, A. A. note "Anti-CGRP[calcitonin gene-related peptide] mAbs [monoclonal antibodies] have been shown to be effective for migraine prevention in adults and have not raised major safety issues, though long-term safety data are not yet available. Pediatric and adolescent trials of anti-CGRP mAbs should be designed to maximize the chances of determining efficacy in these age groups, and should focus on those who have not been successful with current multidisciplinary care. In the interim, the use of anti-CGRP mAbs for the treatment of headache disorders in children and adolescents may be considered in appropriate cases, but should be done with close follow-up and attention to patient characteristics such as age, pubertal state, and medical comorbidities."

The patient diagnosed with migraine without aura and without status migrainous not intractable had previously trialed Advil, rizatriptan, and Zofran, Migrelief, cyproheptadine, nortriptyline, and Ajovy.  The Ajovy cured the patient's headaches without side effects.  The literature supports that this type of medication appears to benefit a proportion of adolescents with chronic refractory headache disorders.  The patient had a chronic refractory headache disorder.  The medication was efficacious for this patient.  It would not be in the patient's best interest to deny this medication.  Ajovy 225 milligrams auto-injector (pre-service) is considered medically necessary for this patient.

Based on the above, the medical necessity for the medication Ajovy 225 milligrams auto-injector (pre-service) is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity
Treatment: Routine liver biopsy at the time of bariatric surgery.
The insurer denied routine liver biopsy at the time of bariatric surgery.
The determination is upheld.


The patient underwent bariatric surgery (laparoscopic sleeve gastrectomy and concomitant liver biopsy). The records support that she had a body mass index (BMI) of 40 kilograms per square meter (kg/m2) with the listed comorbid illnesses of hypertension and back pain. The operative dictation states that a wedge liver biopsy was obtained from the left lobe of the liver. A subsequent appeal letter from the provider states that he obtained a 1-centimeter (cm) wedge of liver tissue. There is no description of suspected liver pathology other that 'some blunting' of the liver. The submitted records do not include any pre-surgical lab, imaging or clinical data to indicate liver pathology. The pathology report provides the diagnosis of mild steatosis. The provider submitted current procedural terminology (CPT) code 47100 (liver biopsy, wedge).
At issue is the medical necessity of routine liver biopsy at the time of bariatric surgery.

The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of gastric sleeve surgery. There is no documentation of liver pathology as might be obtained by preoperative imaging or lab data to warrant liver biopsy.
Accepted indications for liver biopsy include: Documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology). In this case there is no such documentation to warrant wedge liver biopsy.
According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery. Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre operative imaging or lab data that requires biopsy.
In this case, the patient had morbidly obesity and had hepatic steatosis and mild steatohepatitis on biopsy. Lab data and pre-operative imaging are not included with the review material and there is no description of clinical symptomatology to indicate liver pathology. The operative dictation also does not describe specific liver pathology to warrant liver biopsy. The steatohepatitis identified on the biopsy is an anticipated pathologic condition in the setting of morbid obesity and does not mandate biopsy.[1,2].
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep apnea
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has trisomy 21, sleep apnea, and complex congenital heart disease who underwent multiple surgical procedures to include laryngeal cleft repair. She had an apnea hypopnea index (AHI) of 2.
She underwent adenoidectomy and laryngeal cleft repair along with other ear, nose, and throat (ENT) procedures. The surgery was uncomplicated. She was admitted to the hospital overnight and had no complications. The medical necessity of an inpatient stay is under review.

Yes, the inpatient admission was medically necessary.
The patient has Down's syndrome and aspiration due to a laryngeal cleft. She has a complicated cardiac history. Based on the standard of care, the inpatient admission was medically necessary. She has multiple co-morbidities to include Down's syndrome and cardiac abnormalities which would place her at risk of post-operative complications. She had airway surgery (laryngeal cleft repair) which placed her at increased risk of post-operative complications. It is considered standard of care to admit children who undergo laryngeal cleft repair and therefore, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Fentanyl patches 100 micrograms, 20 per month. 
The denial is upheld.

The patient is a female with chronic pain syndrome. The patient is being treated for chronic pain related to fibromyalgia, and chronic pelvic pain following cervical procedures. The patient is being maintained on extremely high dose opioids, including Duragesic 200 micrograms per hour (mcg/hr.) every (Q) 48 hours along with oxycodone 30 milligrams (mg) 3 times per day. The subject under review is the medical necessity for Fentanyl patches 100 micrograms (MCG) 20 per month.

No, the requested health service/treatment of Fentanyl patches 100 micrograms (MCG) 20 per month is not medically necessary for this patient.

Several published guidelines and consensus statements recommend judicious use of opioids in appropriately selected patients with chronic non cancer pain who have not responded to other treatments and analgesic medications. There are concerns about dependency, and evidence is controversial for the benefit of chronic opiate therapy for nonmalignant pain. Although there is no ceiling dose for opiates, evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose-dependent risk for serious harms. The requested dose puts the patient at a high risk of overdose and death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign prostatic hyperplasia (BPH) status/post (s/p) TURP (transurethral resection of the prostate). 
Treatment: Permanent Placement (Long-Term Care). 
The insurer denied Permanent Placement (Long-Term Care). 
The health plan's determination is upheld. 

The patient is a male with multiple medical problems including diabetes, hypertension, hyperlipidemia, chronic kidney disease, depression, benign prostatic hyperplasia (BPH) status/post (s/p) TURP (transurethral resection of the prostate) with need for chronic indwelling foley and right below knee amputation (BKA). 

The requested permanent long term care placement is not appropriate or medically necessary for this patient. The patient is a male with multiple medical problems. The documentation does not support long term care. For example, the provider noted 5/5 strength of proximal muscle groups with CN (cranial nerve) 2-12 normal, alert and oriented x3, with normal mood and affect. Medication management was stable with continuation of suprapubic catheter and diabetic, depression and hypertension medication regimen unchanged. Additionally, while it is noted that the patient does require wound care - such as left lateral scrotum - this can be provided as outpatient or with home health visits. Additionally, social worker scored BIMS (brief interview for mental status) as 15 - cognitively intact. From a therapy standpoint, he required MINA (minimal assist) for bed mobility and transfers. He was also walking 150' with a WW (wheeled walker) SBA (stand-by assist). None of this documentation supports need for long-term care placement.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plaque Psoriasis.
Treatment Cosentyx.
The insurer denied coverage for Cosentyx.
The denial is overturned.

The patient has a history of psoriasis, PsA (psoriatic arthritis), kidney stones and diabetes mellitus. The office visit notes from Rheumatology specialist the patient was doing well on a regimen of Cosentyx 300 milligrams (mg) every 14 days, Xeljanz currently 5 mg daily [half the usual dose], prednisone 5 mg daily and cyclosporine 100 mg twice daily. The patient's plaque psoriasis was dramatically improved on this combination. He was on a similar regimen.

According to the submitted documentation the patient has been on Cosentyx every two weeks, Xeljanz 5 mg QD [per day], cyclosporipn and prednisone with good control of skin and PsA. The insurer is denying Cosentyx because it should not be used with Xeljanz. The doctor argued that if Cosentyx is given 300 mg.  every 2 weeks (presumably) instead of every 4, Xeljanz would not be needed. 

The FDA [Food and Drug Administration] approved use of Xeljanz for psoriasis and PsA states that using it with biologics or cyclosporin is not recommended. The dose of Cosentyx 300 mg every two weeks is off-label and not addressed in the www.uptoidate.com chapter "Treatment of Psoriatic Arthritis"). A recent study by Reich et al compared 300mg q2w[every two week] to q4w [every four week] dosing. They found that in patients with a partial response switching to q2w dosing "Significantly more patients with q2w vs. q4w dosing showed minimal disease activity ...nd improved quality of life (Dermatology Life Quality Index score 0 or 1: 589% vs. 506%, P < 005) at week 32. No new or unexpected safety signals arose."

There is support for the insurer's refusal to cover Cosentyx when used concomitantly with Xeljanz. He has been on Cosentyx twice a week without apparent toxicity and with good benefit. Using more Xeljanz would have to consider unknown interactions with biologics and cyclosporin. In addition, there is published support for using Cosentyx 300 mg SC [subcutaneous] every two weeks as requested by the physician. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Cosentyx is overturned. Medical is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrent pleomorphic adenoma of the left parotid gland.
Treatment: Proton beam radiation therapy

The insurer denied the Proton beam radiation therapy.
The denial is upheld.

The patient is a female with a history of left parotid pleomorphic adenoma status post left superficial parotidectomy. She subsequently presented with a recurrence status post left revision parotidectomy. Adjuvant radiation therapy to 60 Gy (Gray) in 30 fractions was recommended and proton therapy was requested.

The initial request for proton therapy was denied because it was deemed not medically necessary per health plan guideline.

No, the requested proton beam radiation therapy is not medically necessary.
Although there are single institutional trials and case series showing that proton therapy for head and neck cancer is safe and effective, there is insufficient clinical data in the medical literature showing that it is equivalent or superior to photon IMRT (intensity-modulated radiation therapy) for the treatment of head and neck cancer. There are ongoing clinical trials (including a phase III trial) still evaluating the role of proton therapy for head and neck cancer. IMRT (intensity-modulated radiation therapy) photon radiation therapy has been shown to be safe and effective for the treatment of head and neck cancer, and is currently the standard of care. Proton beam therapy is, therefore, not considered medically necessary because it has not been shown in well-conducted randomized trials to be clinically superior to photon IMRT (intensity-modulated radiation therapy).

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

There is insufficient clinical evidence in well conducted randomized trials showing that proton therapy for parotid adenoma is clinically superior compared to photon IMRT (intensity-modulated radiation therapy). A proton/photon comparison plan was done, and the proton plan was able to reduce dose to the surrounding critical structures. However, there was no documentation provided showing that the doses to those structures exceeded tolerance per Quantec limits for either the photon or IMRT (intensity-modulated radiation therapy) plan.