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

Diagnosis: Psoriasis with psoriatic arthritis.
Treatment: 300 mg milligrams of Consentyx every 2 weeks.
The insurer denied coverage for 300 mg of Consentyx every 2 weeks.
The denial is overturned.

The patient is a female with a diagnosis of Psoriasis with psoriatic arthritis.  The patient has been successfully treated with Cosentyx 300 mg every (Q) month.  The efficacy of Cosentyx has decreased and rather than switch to a different biologic, the prescribing physician requests dosing of Cosentyx at 300mg Q 2 weeks.  The request is for increased dosing of Cosentyx, 300mg Q 2 weeks.

Based on the documentation submitted, the request to increase Cosentyx dosing to 300 mg Q 2 weeks is within the standard of care.  The patient has been successfully treated with Cosentyx for many years with good efficacy and no reported side effects.  An adjustment of the dosing schedule is within the standard of care prior to switching to an alternative treatment modality.  Reich et al found that "Significantly more patients with Q2w [week] vs. q4w dosing showed minimal disease activity (Investigator's Global Assessment score 0 or 1: 730% (percent) vs. 641%, P < 005) and improved quality of life (Dermatology Life Quality Index score 0 or 1: 589% vs. 506%, P < 005)." 

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 300 milligrams (mg) of Consentyx every 2 weeks is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypoxic brain injury.
Treatment: acute inpatient rehab.
The insurer denied acute inpatient rehab. 
The health plan's determination is upheld.

The patient is a female who has diagnosis of hypoxic ischemic brain injury, and history of drowning with cardiac arrest. The records indicate she had cardiac arrest, severe metabolic acidosis, and respiratory failure after drowning in the family tub. She underwent 25 minutes of cardiopulmonary resuscitation (CPR) before spontaneous circulation returned. She had refractory status epilepticus, underwent tracheostomy and G-tube (gastrostomy tube) placement. She currently has sialorrhea on glycopyrrolate, seizures controlled on Keppra, extensor posturing, increased muscle tone on all four extremities with left more affected than right. 

The Intensive Acute Inpatient Rehabilitation is not medically necessary for this patient.
The patient's clinical needs do not require intensive rehabilitation specifications for needs related to therapy, physician, multidisciplinary, and nursing services. The patient does not have a medical necessity for 3 hours of therapy per day. The patient is dependent in all activities of daily living and requires hands-on care for all feeding/grooming/ hygiene/skin care needs. The patient would benefit from the level of physical, occupational, and speech therapy that is available at subacute rehabilitation level. Intensive Acute Inpatient rehabilitation is not medically necessary to meet these needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease.
Treatment: Stelara.
The insurer denied Stelara.
The determination is overturned.

The has stricturing and fistulizing Crohn's disease complicated by an abscess and status post right hemicolectomy; she now has congestive heart failure. She has stopped infliximab (with secondary nonresponse) and subsequently adalimumab (due to congestive heart failure). At issue is the medical necessity of Stelara for the treatment of Crohn's disease.

The Stelara is medically necessary. Current medical literature supports the use of Stelara in this case. Stelara is Food and Drug Administration (FDA) -approved for the treatment of Crohn's disease. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohn's disease that was resistant to anti-tumor necrosis factor (TNF) therapy (Sandborn, et al). Another study showed a 73% response in patients with anti-TNF-resistant Crohn's disease, and 80% of responders maintained remission for 1 year (Kopylov, et al). A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of immunosuppressants and anti- tumor necrosis factor (TNF) medications, which the enrollee has failed (Tuskey, et al). A recent study demonstrated that a significant majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara (Wils, et al). Furthermore, the most recent guidelines for the treatment of Crohn's disease (2021 American Gastroenterological Association (AGA) guidelines) state that "In adult outpatients with moderate to severe Crohn's disease who previously responded to infliximab (secondary nonresponse), the AGA recommends the use of adalimumab or ustekinumab and suggests the use of vedolizumab over no treatment for the induction of remission" - Stelara is recommended, whereas Entyvio is suggested (Feuerstein, et al). Additionally, there is limited but prospective data which supports the greater efficacy of Stelara compared with Entyvio when used for the treatment of Crohn's disease (Biemans, et al). Another larger study concurred (Manlay, et al). In this patient with severe disease (given fistulizing phenotype and prior surgical resection), and risk for complications such as fistula, stricture, and need for further surgery, the use of Stelara is, therefore, more appropriate than Entyvio. For these reasons, the request for Stelara should be considered medically necessary for the treatment of this patient's Crohn's disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hemoptysis

Treatment 71260, CT (computed tomography) scan, a special picture of the chest with contrast

The insurer denied coverage for 71260, CT scan, a special picture of the chest with contrast

The denial is overturned

The patient is an adult female with a history of dysphagia, dysphonia, reflux laryngitis, vocal cord nodules, gastroesophageal reflux disease (GERD), diabetes mellitus (DM) and obstructive sleep apnea (OSA) who was being followed by Ear Nose and Throat (ENT). The patient was seen now for symptoms of chronic cough and hemoptysis. The patient has had extensive workup including evaluation of sinuses, upper airway, and gastrointestinal (GI) tract. No cause for hemoptysis was found.

The patient has been treated adequately for GERD, asthma, allergic rhinitis, etc. She continues to complain of cough and hemoptysis. Her doctor is requesting a chest computed tomography (CT) with contrast for evaluation of hemoptysis.

A chest CT is part of a workup for hemoptysis if no other cause has been detected with other studies. The request is appropriate in this setting to rule out any pulmonary lesion that may not have been seen on chest x-ray.

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

The insurer's denial of coverage for 71260, computed tomography (CT) scan, a special picture of the chest with contrast is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Wounds
Treatment: Custodial Care (long term care)
The insurer denied the Custodial Care (long term care)
The denial is overturned

The patient is a male. He reportedly had a large wound and multiple pressure ulcers. He needed wound care. Patient had an open wound of lower back, and sacral wounds. The patient also had other comorbidities, including kidney failure and DVT (deep venous thrombosis).

The health plan denied coverage on the basis that the request was not medically necessary.

Yes, the requested health service is medically necesary.
The patient was admitted to the hospital with sepsis due to infected wounds before post-acute care. The patient has large sacral wounds, which need regular care. The patient requires assistance with ADLs (activities of daily living) and functional mobility. The patient needed close monitoring of the wounds, which could not be done at home.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis (MS).
Treatment: Immunoglobulin injections.

The insurer denied coverage for immunoglobulin injections.
The denial is overturned.

This case involves a female diagnosed with multiple sclerosis (MS). According to an evaluation, the patient was doing overall better. There was a difference with intravenous immunoglobulins (IVIG). The patient was not sleeping through most of the day and activity routine was better. There was some neurologic pain within the past weeks and psychotropic side effects were noted on the steroids. Cognition and memory were poor according to family. The patient was feeling scattered. There was chest tightness. The patient was to continue IVIG.

According to an evaluation, the patient felt that treatment was very beneficial. There were reports of a flareup the past weeks involving cognitive status. There was relapsing MS. There was significant benefit from IVIG which allowed her to reduce some of her medications.

According to an evaluation, the patient had been off Tysabri for a few months. Daptomycin was not as effective on its own. Over time, the patient had reduced tizanidine and gabapentin. The patient was now using a cane a few times a week due to the left lower extremity. There were also reports of chest spasms. There were reports that the patient believes she had COVID (coronavirus) and never had a positive polymerase chain reaction (PCR) or antibody test. The patient was recommended a trial of IVIG.

The patient has a clinical history of medically refractory MS. The patient has been treated in the past with IVIG and consistently noted clinical benefit. IVIG has been used in treatment for the last few decades in cases where the patient does not respond to frontline and second line immune modulating treatments. Therefore, given the specifics of this case, the use of IVIG is warranted as treating physician documents that the patient has failed multiple frontline, second line as well as third line therapies and that the patient has been stable while taking IVIG. Therefore, the use of IVIG is medically necessary and the decision is overturned.    

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 immunoglobulin injections is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dizziness.
Treatment:  Inpatient admission.

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

The patient is a female with astrocytoma treated with prior surgery presented to the emergency room (ER) with nausea and vomiting and dizziness for 1 week following a prior fall. The computed tomography (CT) was stable in the ER. Vital signs were stable. She was given intravenous fluids (IVF) and admitted. A magnetic resonance imaging (MRI) on the day of admission was unchanged. She was given Zofran and reported improvement. Her dizziness persisted, and she worked with physical therapy (PT), who recommended PT three times weekly. She was discharged.

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

This patient on presentation to the ER had concerns for tumor progression or intracranial hemorrhage, which were immediately excluded by CT and MRI scans. Her vital signs were stable, and electrolytes were within normal limits for patient. The following day she had noted improvement with Zofran in her symptoms and was able to eat with the use of Zofran. She was stable for discharge within 2 days of presenting to the ER and could have been managed in observational status as opposed to acute level care with discharge. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.

"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).

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine).

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease
Treatment; Stelara
The insurer denied Stelara (90 mg every 6 weeks). The health plan's determination is overturned. 

The patient is a male with fistulizing Crohn's disease complicated by an abscess and status post small bowel resection. He failed high-dose Humira (due to anti-Humira antibodies). He started Stelara. The Stelara level was low at 4.0. A Colonoscopy showed anastomotic ulceration and small ulcers in the neo-terminal ileum consistent with active disease. He has had disease symptoms including diarrhea and bowel urgency.

Stelara to 90 milligrams (mg) every 6 weeks is likely to be more beneficial than any standard treatment or treatments for this patient's Crohn's disease. In this case, the patient had initial improvement, followed by symptoms and objective evidence of active disease (on colonoscopy) on Stelara every 8 weeks. Additionally, the Stelara level was low. Continuation of dosing every 8 weeks, or discontinuation of Stelara (even if an alternative therapy is attempted immediately), may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this patient with moderate to severe disease and history of fistula, abscess, and surgery. For all of these reasons, the use of Stelara 90 mg every 6 weeks is likely to be more beneficial than any standard treatment or treatments for the treatment of the patient's Crohn's disease.
Appeal type: Experimental/Investigational
Decision: Overturned


Diagnosis: Crohn's disease
Treatment; Stelara
The insurer denied Stelara (90 mg every 6 weeks). The health plan's determination is overturned. 

This is a male patient who has severe fistulizing Crohn's disease with extra intestinal manifestations and has had prior bowel resection. He has previously tried and failed steroids and an anti-tumor necrosis factor (TNF) agent (adalimumab). He was started on Stelara. He was initially doing well on Stelara at standard dosing every 8 weeks but lost response as manifested with a flare of his Crohn's disease. Therapeutic drug monitoring revealed low ustekinumab levels. Therefore, the attending provider escalated the dose of Stelara to 90 milligrams (mg) every 6 weeks to treat his severe Crohn's disease. His Crohn's disease is in remission on the escalated dose of Stelara. 

Stelara (90 mg every 6 weeks) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Since this patient was not responding to standard dosing of Stelara, it is reasonable to increase the dose of Stelara to 90 mg every 6 weeks. Dose escalation in biologic therapy used in inflammatory bowel disease can be done either based on clinical symptoms or laboratory markers or endoscopic or radiological features with or without therapeutic drug monitoring. Dose escalation is done either by increasing the dose of the medication or shortening the interval between doses or sometimes a combination of both. There are only a finite number of biological agents used to treat inflammatory bowel disease and the standard of care is to optimize dose of the biological agent before switching to another agent. Therefore, Stelara 90mg subcutaneous (SC) every 6 weeks to treat this patient's severe Crohn's disease is indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Memory Loss.
Treatment: PET scan.
The insurer denied a PET scan.
The determination is upheld.

The patient has a listed diagnosis of dementia. The patient is reported to have depression and bipolar disorder, and to be currently on both diazepam and olanzapine, known to cause cognitive deficits. His examination reports perseveration, reduced awareness, hearing loss and impulsivity. Neuropsychological testing reported executive dysfunction.
A positron emission tomography (PET) is reported to show "not definitive" findings, but "raise the possibility" of Alzheimer's Disease.
At issue is whether the radiology services- brain imaging, positron emission tomography services (PET scan) are likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No. The radiology services- brain imaging, positron emission tomography services (PET scan) are not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
There is insufficient evidence in the quality, peer reviewed medical literature, that routine PET scanning in patients with dementia improves patient's health care outcomes.
There are not any large, well designed, randomized trial showing any sustained benefits from such imaging as compared to standard clinical evaluation and imaging with brain magnetic resonance imaging (MRI). Albeit such test may help in the differentiation between Alzheimer's Disease and frontotemporal dementias, it has not been shown to significantly alter treatment or the patient's outcomes. The submitted medical records do not discuss how such additional imaging would alter the patient's treatment or outcome.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Memory Loss.
Treatment: PET scan.
The insurer denied a PET scan.
The determination is overturned.

The patient has memory loss. He underwent neuropsychological testing that was unable to distinguish between Alzheimer's disease and frontotemporal dementia. A fluorodeoxyglucose-positron emission tomography (FDG-PET) scan was ordered. The FDG-PET showed hypometabolism in the frontal lobes and cingulate gyrus that was more consistent with a diagnosis of Alzheimer's disease. The FDG-PET scan of the brain was denied by the insurer. At issue is whether the radiology services- brain imaging, positron emission tomography services (PET scan) are likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes. The proposed health service or treatment radiology services-brain imaging, positron emission tomography services (PET scan) were likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
An FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months. The patient has experienced cognitive decline for at least 6 months. Additionally, FDG-PET is only reasonable when the patient meets diagnostic criteria for both Alzheimer's disease and frontotemporal dementia. Neuropsychological testing was unable to determine if the patient had Alzheimer's disease or frontotemporal dementia. The patient has features of both. Additionally, it is important that such patients have been evaluated for specific alternate neurodegenerative diseases or other causative factors. The documentation indicates that other causes of dementia, such as metabolic abnormalities or other structural brain disease, were ruled out.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ureteral stone
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of obesity and presented to the emergency room (ER) with abdominal pain and associated diarrhea. The patient was afebrile and hemodynamically stable on presentation. The review of systems was normal and the physical examination showed right abdominal tenderness. Lab results were grossly normal other than a creatinine of 1.67. A computed tomography (CT) showed an obstructing proximal ureteral stone. The patient was admitted. A urology consult recommended medical expulsive therapy. The patient had an uneventful hospital course and was discharged.
At issue is the medical necessity of an inpatient stay.

No. The inpatient stay was not medically necessary. The majority of patients who present with renal colic can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. There was no procedure performed. The information provided and the patient's clinical status does not suggest the need for acute inpatient care. A lower level of care for this patient's clinical presentation and hospital course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I Occlusion.
Treatment: C8080 Braces and D8670 Monthly Visits (x12), Pre-service.
The insurer denied the C8080 Braces and D8670 Monthly Visits (x12), Pre-service.
The denial is upheld.

This patient, a female, has an unknown dental history or diagnosis. The reason for denial was a handicapping score of 21, which is less than the 25 threshold score.

The proposed treatment is not medically necessary.
The patient has a Class I occlusion. The handicapping index score is 21, which is below the threshold of 26 for benefits. The patient does not have any speaking or chewing difficulties. The patient also does not have any severely handicapping malocclusion.

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