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

Diagnosis: Pancreatitis

Treatment is an inpatient admission 	

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

This patient presented to the hospital complaining of abdominal and back pain. Past medical history was significant for diabetes mellitus and hyperlipidemia.  One day prior to presentation, the patient was in another hospital where a CT (computed tomography) scan of the abdomen revealed pancreatitis. The patient signed out against medical advice. Upon arrival to Maimonides hospital, vital signs were stable, the pulse was 109bpm (beats per minute) and BP (blood pressure) was 116/76 mmHg (millimeters of mercury). The abdominal exam was significant for epigastric pain with palpation without guarding or rebound. A 12-lead electrocardiogram revealed normal sinus rhythm without ischemic ST (interval on a ecg) or T wave (interval on a ecg) changes. Serum blood testing revealed an elevated serum troponin of 0.06ng (nanogams) /ml (milliliter) and a mildly elevated lipase of 83 U (units) /L (liter). The patient was admitted to telemetry for further monitoring and treatment but signed out against medical advice.

This patient presented with atypical chest pain and a past medical history of diabetes. His pretest probability of coronary artery disease was low. (Reference 1) Utilizing the HEART score he was considered low risk. (Reference 2) Utilizing the TIMI risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days . (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART (history, ecg, age, risk factors, and troponin) score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. Despite this, the patient was suffering from abdominal pain and pancreatitis and had a positive serum troponin. The studies did not include patients with concomitant pancreatitis. In a large study designed to identify readmission rates in more than 400,000 patients presenting with pancreatitis, the average length of stay was 4-6 days. (Reference 4)   In conclusion, the inpatient hospital admission was medically necessary.

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 the inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right below knee amputation

Treatment:  continued alternate level of care at a SNF (skilled nursing facility) 

The insurer denied coverage for continued alternate level of care at a SNF
 
The denial is upheld.

This is a patient with chronic medical problems including diabetes mellitus, hypertension and history of a right below knee amputation. He was admitted to a skilled nursing facility (SNF) for treatment of right residual limb cellulitis with an abscess. Under review is the medical necessity for continued alternate level of care.

The patient was initially appropriate for the SNF subacute rehabilitation level of care (1, 2, 3).  His clinical condition and functional deficits were amenable to medical intervention and comprehensive rehabilitation. He participated in physical and occupational therapy with demonstrated gradual improvement.  According to the physical therapy notes, the patient was at the modified independent level for bed mobility and transfer tasks. He was able to ambulate with only stand by assistance, which improved to supervision. A similar high functional level was documented by the occupational therapist. The patient required only set-up assistance for activity of daily living (ADL) tasks such as bathing, dressing and toileting and dressing. He was modified independent for wheelchair mobility. In addition, there were no acute medical or complicated nursing issues that required a continued stay at the SNF for the time period under review.  

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued alternate level of care was not medically necessary.

The insurer's denial of coverage for a continued alternate level of care is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
treatment: skilled Nursing Facility Stay
The insurer denied the Skilled Nursing Facility Stay. The health plan's determination is overturned. 

The patient is a female with a medical history of obesity, obstructive sleep apnea & obesity hypoventilation syndrome on bi-level positive airway pressure (BiPAP), type 2 diabetes mellitus, hypertension, and agoraphobia with anxiety. She was initially admitted to the hospital for acute on chronic hypoxic and hypercarbic respiratory failure, acute kidney injury and hyperglycemia. She was evaluated by both physical and occupational therapy. She was determined to have deconditioning and a functional decline. As per the physical/occupational therapy notes, the patient would benefit from continued therapy to improve functional strength to improve transfer ability, mobility, balance and endurance.

The Skilled Nursing Facility Stay is medically necessary for this patient.
This patient was initially admitted to the hospital for acute on chronic hypoxic and hypercarbic respiratory failure, acute kidney injury and hyperglycemia. She was evaluated by both physical and occupational therapy. She was determined to have deconditioning and a functional decline. As per the physical/occupational therapy notes, the patient would benefit from continued therapy to improve functional strength to improve transfer ability, mobility, balance and endurance. Based on the patient's condition, the need for continued physical/occupational therapy, the inability to care for herself and lack of support system at home with the ability to help her would make a discharge home unsafe. Per the most recent notes, she was working with physical/occupational therapy and was making consistent gains towards returning to her previous level of functional ability. In addition, per the physical/occupational therapy notes, the patient exhibits good rehabilitation potential with training for activities of daily living and therapeutic functional activities. Therefore, with the ongoing benefit from skilled rehabilitation services (physical/occupational) up to five days per week, the requested Skilled Nursing Facility Stay is medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Ankylosing spondylitis

Treatment:  Cimzia

The insurer denied coverage for Cimzia
 
The denial is upheld.

The patient has a history of ankylosing spondylitis. The treating provider is requesting approval for Cimzia, which is under review.

The formulary drugs are not likely to cause the patient an adverse reaction. Though, there is not enough information in the records to prove that the patient is at risk for side effects.      

The formulary drugs have not been ineffective based on the patient clinical history. The patient has not tried and failed all of the preferred formulary alternatives for his diagnosis.     

The requested drug would not be more effective than the formulary drugs. The patient has a history of ankylosing spondylitis. There are no studies showing the superiority of Cimzia over the formulary alternatives.

As such, Cimzia is not medically necessary, and the request is denied.

"Secukinumab is a novel biologic agent that specifically targets interleukin-17 (IL-17) involved in a pathological process. It is a fully human monoclonal antibody. Many clinical trials have demonstrated its efficacy for the management of plaque psoriasis in 2015, psoriatic arthritis, and ankylosing spondylitis in 2016. Additionally, the drug has a commendable safety profile. FDA (food and drug administration) approved indications include moderate to severe psoriasis, hypertrophic palmoplantar psoriasis, generalized pustular psoriasis, psoriatic arthritis, and ankylosing spondylitis. It can be used off label for rheumatoid arthritis, SLE (Systemic lupus erythematosus), familial Mediterranean fever, and tumor necrosis factor receptor-associated periodic syndrome (TRAPS)" (Aboobacker, S., et al. 2022).

"Etanercept is a medication used to manage and treat autoimmune conditions such as plaque psoriasis, rheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis, and ankylosing spondylitis. It is a biologic fusion protein in the TNF blocker class of medications." (Pan, et al., 2022).

"Adalimumab is a fully human, high-affinity, recombinant anti-tumor necrosis factor (TNF) alpha monoclonal antibody used to treat rheumatoid arthritis, ankylosing spondylitis, psoriasis, psoriatic arthritis, Crohn disease, ulcerative colitis, etc." (Ellis, C. R., & Azmat, C. E., 2022).                                                       

The insurer's denial of coverage for Formulary Exception for Cimzia starter kit is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COPD (chronic obstructive pulmonary disease), hypertension and dementia

Treatment:  24 hours per day - split shift personal care aide (PCA) services

The insurer denied coverage for 24 hours per day - split shift personal care aide (PCA) services
 
The denial is overturned.

This is a patient who is legally blind with chronic medical problems including COPD, hypertension and dementia. She lives alone on the 5th floor of an apartment building.  She is currently approved for PCA 84 hours/week. Her daughter reportedly lives in the same building and periodically checks on her mother. The daughter is requesting 24 hours per day - split shift personal care aide (PCA) services, which is currently under review. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as "severely impaired" and has declined over the past 90 days. She is totally dependent for activities of daily living including bathing, personal hygiene, and dressing. Toilet transfer/use is also totally dependent. The patient is frequently incontinent of bladder and occasionally incontinent of bowel.  She requires extensive assistance for eating. She was noted to be wandering outside of her apartment on 1-2 days of the last 3 days. She reportedly fell.  

The patient has severe cognitive deficits and significant functional impairments that support the medical necessity of PCA services 7 days x 24 hours split shift.  In a clinical note her doctor indicated that she frequently wanders and along with being legally blind, this has led to repeated falls. Based on these findings, her condition and functional needs are at a level or are unpredictable as to require the requested continuous care split shift; 24 hours, 7 days/week. A live-in, 24-hour PCA could not provide the needed services and would likely not obtain, on a regular basis, 5 hours daily of uninterrupted sleep during the aide's 8-hour period of sleep. The patient's health and safety cannot be appropriately provided and maintained by live-in 24-hour PCA services. 

The insurer's denial of coverage for 24 hours per day - split shift personal care aide (PCA) services is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gardner syndrome, rectal adenocarcinoma
Treatment: Long-Term Custodial Care 
The insurer denied Long-Term Custodial Care.
The health plan's determination is upheld. 

This is a case review for a male with Gardner syndrome, history of stage IIIB rectal adenocarcinoma status post chemotherapy and radiotherapy, status post proctocolectomy with ostomy, and metastatic disease.

The requested Long Term Custodial Care is not medically necessary for this patient. The patient is stable and appears to function independently. There is no functional assessment provided, but per review of the notes, he is able to ambulate and direct his own ostomy care without difficulty. He does have an ongoing chronic back wound that will need continued management; however, this is not sufficient to meet the criteria for Long Term Custodial Care. This can be effectively managed in the outpatient setting with suitable services, such as home nursing care for dressing changes.

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

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

Diagnosis: Keratoconus. 
Treatment: Corneal Collagen Cross-Linking (CXL), procedure code 0402T-2 units/visit. 

The insurer denied coverage for Corneal Collagen Cross-Linking (CXL), procedure code 0402T-2 units/visit. 
The denial is upheld. 

The patient is with bilateral keratoconus. 

The patient has a diagnosis of progressive keratoconus, but there is insufficient clinical information provided to support this. For instance, progressive keratoconus is typically defined by one of the following criteria: 
A) An increase of 1 diopter (D) in the steepest keratometry value (Not met) 
B) An increase of 1 diopter (D) in regular astigmatism evaluated by subjective manifest refraction (Not met) 
C) A myopic shift (decrease in the spherical equivalent) of 0.50 D on subjective manifest refraction (Not met) 
D) A decrease >= 0.1 mm (millimeters) in the back optical zone radius in rigid contact lens wearers where other (Not met). 

The patient does not meet any of these criteria based on the information provided. Further information is needed to support the diagnosis of progressive keratoconus. 

Based on the medical records and provided clinical rationale, the corneal cross-linking procedure is not medically necessary. The patient has a diagnosis of keraotoconus, but the records provided for review does not demonstrate progressive keratoconus. Corneal cross-liking has been shown to stabilize the progression of keratoconus and provide significant improvement in visual acuity and keratometric values. However, there is insufficient information in the medical records to support progressive keratoconus. 

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

The insurer's denial of coverage for Corneal Collagen Cross-Linking (CXL); procedure code 0402T-2 units/visit is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis
Treatment: Rinvoq 15 milligrams (mg) OR TB24
The insurer denied coverage for Rinvoq 15 mg OR TB24
The denial is upheld

The patient is a male with a history of atopic dermatitis for unknown duration apparently affecting the arms and legs. The patient has failed topical therapy with unspecified creams with clotrimazole (an antifungal) mentioned in the notes. The patient is not currently using any medications to treat his condition based on the provided progress note, other than "Mr Cream" which does not appear to be a prescription medication.  The requested medication is Rinvoq 15 mg.

Based on the submitted documentation Rinvoq is not considered medically necessary.  The documentation fails to identify the surface area of involvement to better assess for severity. Furthermore, there is no documentation provided that the patient has failed topical steroids, or non-steroidal options (Protopic, Elidel, or Eucrisa). There is no documentation provided which would indicate an absolute contraindication to light therapy, methotrexate, or Dupixent.  

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

The insurer's denial of coverage for Rinvoq 15 milligrams (mg) OR TB24 is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional - Hyperlipidemia.
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Vascepa.
The denial is overturned in whole. 

This patient is a male diagnosed with hyperlipidemia. He was recommended for Vascepa. As reported, he has type 2 diabetes mellitus (T2DM) and hypertension. He is currently treated with a maximally tolerated statin, Lipitor 80 milligrams (mg) daily. Prior to initiating Vascepa; his triglyceride (TG) was 302. His TG was 211, cholesterol was 139, low density lipoprotein (LDL) was 65 and high-density lipoprotein (HDL) was 32.
At issue is whether the formulary drug, will be or has been ineffective, would not be as effective as the non-formulary drug (Vascepa), or would have adverse effects.

The health plan's determination of medical necessity is overturned in whole.

The formulary drugs will not be as effective as the non-formulary drug (Vascepa).
Vascepa is United States Food and Drug Administration (FDA) approved for hypertriglyceridemia in adults. Fish oil supplements at doses greater than or equal to (>=) 3 grams/day eicosatetraenoic acid/docosahexaenoic acid (EPA/DHA) concentrate reduce very-low-density lipoprotein (VLDL) production [1-3] and can lower the serum triglyceride concentration by as much as 50 percent or more. [3]
Vascepa is an ethyl ester of eicosatetraenoic acid (EPA) indicated as an adjunct to maximally tolerated statin therapy to reduce the risk of myocardial infarction, stroke, coronary revascularization, and unstable angina requiring hospitalization in adult patients with elevated triglyceride (TG) levels (>= 150 milligrams (mg)/deciliter (dL)) and established cardiovascular disease or diabetes mellitus and 2 or more additional risk factors for cardiovascular disease. (1) There are studies showing the safety and efficacy of the requested medication in patients with hypertriglyceridemia in diabetes such as the Reduce-it trial which showed reduction in cardiovascular death. [4, 5]
This patient has an elevated triglyceride level and has type 2 diabetes. The requested medication has been shown to improve outcomes including reduction in cardiovascular death in patients such as this one. No other formulary alternatives have been shown to have this effect. The request is therefore superior to the formulary alternatives.
Therefore, the formulary drugs will not be as effective as the non-formulary drug (Vascepa).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis
Treatment: Dupixent
The insurer denied Dupixent.
The health plan's determination is upheld.

The patient is a male with moderate to severe atopic dermatitis (approximately 20% [percent] body surface area involvement) of the hands, face, legs, and chest. The patient has tried and failed systemic and topical steroids (such as mometasone, 2.5% hydrocortisone, triamcinolone, and Clobetasol). The patient has responded to, and has been successfully maintained, with Dupixent samples.

Dupixent is not medically necessary.

The patient has no documented treatment failure with, or true medical contraindication to, either the topical calcineurin inhibitor tacrolimus or standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil). Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with current medical literature, the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal.
Treatment: Inpatient admission. 
The insurer denied coverage for an inpatient admission .
The denial is overturned.

This male reportedly was admitted to an inpatient medical hospital due to alcohol withdrawal symptoms, dizziness, weakness, and dehydration. He reportedly had alcohol withdrawal symptoms including an elevated heart rate of 143 and tremors and he had a past reported alcohol withdrawal seizure. He reportedly had low potassium of 3.3, low magnesium and low platelets of 45. He reportedly had hypertension and diabetes. He reportedly was treated with 2 detoxification medications including Librium and Ativan and also treated with IV (intravenous) fluids. He reportedly was given Gabapentin. His Naltrexone was discontinued due to transaminitis.
  
The medical records provided enough specific evidence to support that he required this level of care then. The APA (American Psychiatric Association) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. He reportedly had a past withdrawal seizure and hospital treatment for detoxification is required for patients with current or past alcohol withdrawal seizures. He also reportedly had active alcohol withdrawal symptoms including tremors and a very high heart rate of 143 while drinking a large amount of alcohol as it was reported that he was drinking 1 pint of vodka 2-3 times per week. He also was considered at risk for more complicated and life-threatening withdrawal as the risk of delirium tremens can occur 3-4 days after alcohol use and he last used alcohol 2 days prior to admission. He also had comorbid medical conditions including having low potassium of 3.3, low magnesium and low platelets of 45 and had hypertension and diabetes. He did require 24-hour medical hospital treatment for alcohol detoxification, and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care then. 

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 the inpatient is overturned. Medical Necessity is substantiated.