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

Diagnosis: Pityriasis rubra pilaris (PRP)
Treatment: Tremfya
The insurer denied: Tremfya
The denial is: Upheld

The patient is a male with Pityriasis rubra pilaris (PRP). His palms and soles are affected. Per the clinical note, his skin is markedly improved after the first injection of Tremfya. He has failed hydrocortisone, triamcinolone, and prednisone. The subject under review is the medical necessity for Tremfya.

The health plan's determination is upheld.

The requested health treatment of Tremfya is not medically necessary for this patient. The patient has not tried and failed the standard of care treatments (1-3).
Bolognia et al. writes "Acitretin is also beneficial in the treatment of PRP" (1). Chapalain et al writes in "Treatment of pityriasis rubra pilaris: a retrospective study of 14 patients" that "Nine patients were treated with retinoids (etretinate or acitretin) for an average period of 18.8 months. This treatment achieved in seven of them a partial or complete clearing without major side-effects...Our results suggest that retinoids should be considered a first-line treatment at an initial dosage of 0.5 mg/kg per day" (2). Therefore, based on the standard of care, Trefmya is not medically necessary in this patient prior to a trial and failure with the conventional treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Prostate cancer.
Treatment:  Stereotactic body radiation therapy (SBRT) delivery (common procedural terminology [CPT] code 77373) to the 1) prostate and 2) cervical two (2) bone, lumbar 2 bone, and on 2 ribs.

The insurer denied coverage for SBRT delivery (CPT code 77373) to the 1) prostate and 2) cervical 2 bone, lumbar 2 bone, and on 2 ribs.  The denial is overturned.

The patient has a medical diagnosis of prostate cancer with biopsy-proven disease. He has been seen and treated for oligometastatic prostate cancer with 4 sites of bony metastatic disease. The patient has been treated with androgen deprivation therapy and abiraterone. He has now been recommended to proceed with a course of ablative radiotherapy to all sites of gross disease. The treating provider is requesting plan approval for treatment with SBRT.

SBRT is standard of care and widely utilized in the patient's setting, as it is proven to maximize chances for improved long-term survival. Use of SBRT is supported by prospective randomized clinical outcomes reported in the peer-reviewed medical literature [e.g., the Stereotactic Ablative Radiotherapy for the Comprehensive Treatment of Oligometastases (SABR-COMET) trial study]. The requested SBRT allows for optimal target coverage with dose escalated/ablative radiation levels, while employing narrow margins and steep dose gradients to minimize normal tissue exposure. The SBRT in the patient's situation is also supported by the American Society for Radiation Oncology (ASTRO) Model Policy and National Comprehensive Cancer Network (NCCN) guidelines. 

"Conclusion: With extended follow-up, the impact of SABR on overall survival (OS) was larger in magnitude than in the initial analysis and durable over time. There were no new safety signals, and SABR had no detrimental impact on quality of life (QOL)." (Palma, et al., 2020)  

"Conclusions: To our best knowledge this review on oligometastatic prostate cancer included the largest number of original articles. It demonstrates the therapeutic potential and challenges of metastasis-directed therapy (MDT) for oligometastatic prostate cancer. Prospective studies are under way and will provide further high-level evidence." (Rogowski, et al., 2021)

"Conclusion: SBRT appears to be effective in controlling overall disease burden in metachronous oligometastatic prostate cancer (OMPC) patients and is associated with minimal significant toxicity. The current prospective literature is scarce, and further prospective data are needed to guide treatment recommendations." (Yan, et al., 2020)

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 SBRT delivery (CPT code 77373) to the 1) prostate and 2) cervical 2 bone, lumbar 2 bone, and on 2 ribs is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara (ustekinumab)
The insurer denied Stelara (ustekinumab).
The denial is overturned

The patient is an adult female with moderate to severe fistulizing Crohn's. She has been treated with Stelara 90 milligrams (mg) every eight weeks with good results. The attending physician (AP) is requesting to continue Stelara 90 milligrams every eight weeks.

The proposed treatment is medically necessary.
The patient has fistulizing Crohn's. Both Stelara and Entyvio are effective first line agents for the treatment of moderate to severe Crohn's. However, the patient has been doing well on Stelara 90 milligrams every eight weeks, and continuation of Stelara is therefore clinically appropriate and accepted standard of medical care. Therefore, the proposed Stelara would be medically necessary. Changing Stelara to the plan preferred Entyvio, at this point in time, would not be medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral vascular accident.
Treatment: Home health care.
The insurer denied Personal Care Aide (PCA) Services, Level 2: 12 Hours per Day - 7 Days per Week + 12 Hours per Day - 7 Days per Week (Split Shift) for a Total of 168 Hours per Week.
The health plan's determination is overturned.

The patient is a female with past medical history of cerebrovascular accident (CVA) with hemiparesis, atrial fibrillation on chronic anticoagulation, congestive heart failure, bowel incontinence, bladder incontinence, hypertension, anxiety, depression, and osteoarthritis who had been assigned PCA (Personal Care Aide) services. 

Personal Care Aide (PCA) Services, Level 2: 12 Hours per Day - 7 Days per Week + 12 Hours per Day - 7 Days per Week (Split Shift) for a Total of 168 Hours per Week are medically necessary for this patient. 

There is documentation from the patient's PCP (Primary Care Provider) and neurologist of worsening cognitive and physical functioning following cerebrovascular accident (CVA) and COVID infection. There is documentation that the patient is bedbound and requires assistance with all Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). The patient has 24-hour care needs and therefore a task based tool should not have been utilized to calculate PCA services. There is documentation from the patient's PCP of the need for turning and repositioning every 2 hours, including the overnight hours. Overnight care logs provided show that the patient required assistance with care needs at least every 2-1/2 hours which would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The patient had previously completed physical therapy prior to the recent assessment. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and 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 12 hours/day, 7 days/week + 12 hours/day, 7 days/week to total 168 hours/week are medically necessary for this patient. Personal care services 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: Migraines and blepharospasm
Treatment: Botox
The insurer denied the Botox.
The determination is overturned.

The patient is prescribed Botox for prevention of migraines and blepharospasms. The drug was denied by the plan because recent clinical documentation was not supplied by the provider to show that the patient continues to derive benefit from the treatment. The provider appealed the determination. At issue is the medical necessity of the Botox.

The requested Botox is medically necessary. The patient has diagnoses of chronic migraine and blepharospasms. Prevention of chronic migraine is a Food and Drug Administration (FDA) approved indication for treatment with Botox. Blepharospasms, while not an FDA approved indication, are a literature supported indication for treatment with Botox and diagnoses of hemifacial spasm and blepharospasms are recognized indications for treatment with Botox per the plan.

The plan originally denied Botox because there were no recent chart notes submitted showing benefit from the drug. The provider issued a letter of medical necessity indicating that the patient has continued benefit and notes that show that the member has benefit from the drug. As such, there is no reason to not continue Botox for these approved indication as the patient has benefit and is stable on the requested medication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine. 
Treatment: Emgality. 
The insurer denied Emgality. The health plan's determination is upheld. 

The patient is a male with relapsing remitting multiple sclerosis. The patient also suffers from chronic migraines. Treatment with Emgality is the subject of this review. The drug was denied because the patient has not tried and failed Depakote ER (extended release), topiramate, venlafaxine, or amitriptyline. 

Emgality is not medically necessary. 

The patient has chronic migraine. Emgality is prescribed for prevention of chronic migraine. The drug was denied as the patient had not tried and failed other formulary alternatives such as Depakote ER, Topamax, venlafaxine, or topiramate. All of these drugs are considered to be safe and effective for prevention of migraine. These drugs are considered standards of care for prevention of migraine. While there may be some particular treatment considerations in a patient with multiple sclerosis, it is not uncommon for a patient with multiple sclerosis to be treated with anticonvulsants or anti-depressants for a variety of indications. There are no contraindications to the use of the plan's preferred drugs in this case. In this instance, there are no head to head comparisons between the requested therapy and the available formulary alternative as all are recognized treatments for migraines. Therefore, the use of Emgality is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Venous malformation of the posterior right thigh
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a several year history of a venous malformation of the posterior right thigh. He had a sclerosing direct stick embolization procedure performed using sodium tetradecyl sulfate (STS) foam.
His past medical history showed a history of leg pain. Magnetic resonance imaging (MRI) confirmed vascular malformation. Pertinent past medical records note findings of Klippel-Trenaunay syndrome. Past surgery history was reviewed, medications and lab work noted. He was discharged with appropriate medications.

The requested health service/treatment with Inpatient Hospital Admission was medically necessary for this patient.
Klippel-Trenaunay Syndrome (KTS) or Klippel-Trenaunay-Weber Syndrome refers to bony and/or soft tissue overgrowth, and slow-flow venous/lymphatic malformations. The cause is unknown. The venous malformations in KTS can be quite extensive and involve bones, joints, muscles, as well as the skin and fat. The major veins of the limb themselves can also have issues with venous reflux and this can cause pooling of blood. This leads to high pressures within the compartments of the limb and increases the likelihood of debilitating pain particularly with walking, exercise or prolonged standing. When symptoms worsen, direct stick embolization of the underlying venous malformation can be performed in multiple sessions. This can help reduce symptoms significantly. Treatment of the more superficial components of the venous system in patients with KTS can be safely performed with significant improvement in symptoms. The patient's treatment was standard of care. The diagnosis of KTS is unusual and the planned treatment is necessary under general anesthesia where it is impossible to know if symptomatic complications have arisen, with the potential for post-procedure issues being significant. Patient care included continuous monitoring and access site management of the right leg. Furthermore, there is an increased risk of infections as well as clotting of the veins after the procedure along with the potential for muscle or nerve damage. Therefore, this required admission for evaluation and ongoing treatment. This would be appropriate at the inpatient level of care.
If the patient needed further therapy prior to discharge, it could easily be arranged.
Appeal type: Medical necessity
Decision: Overturned

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

The patient presented with abdominal pain. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The white blood cell count (WBC) count was 12.44. A computerized axial tomography (CAT) scan showed fat stranding and phlegmonous changes adjacent to the sigmoid colon. This was felt to be consistent with either a perforated diverticulitis or short segment colitis. While in the hospital he developed a low-grade fever. He was kept nothing by mouth (NPO). Intravenous (IV) antibiotics were given, and an outpatient colonoscopy was advised. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG (Milliman Care Guidelines) M-05) include having hemodynamic instability, severe pain, peritoneal sign identification of etiology or finding that requires inpatient care such as bowel perforation, and the need for IV (intravenous) fluid support for a period of more than 24 hours. In this case, the radiologist read the CAT (computed tomography) scan as possibly having a perforated diverticulitis and he did require being maintained NPO (nothing by mouth) with IV antibiotics.

This patient had a fluid collection adjacent to bowel inflammation. There was a concern about bowel perforation. It was appropriate to keep the patient NPO and give IV antibiotics. 

In view of the inflamed colon, with possible perforation and fluid collection, and the need to keep the patient NPO, he met MCG criteria for admission for Undiagnosed Abdominal Pain. 

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 an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: peptic ulcer disease

Treatment: procedure code 43239, esophagogastroduodenoscopy (EGD)

The insurer denied coverage for procedure code 43239, esophagogastroduodenoscopy (EGD)
 
The denial is upheld.

The patient was diagnosed with peptic ulcer disease. She was afebrile and the vital signs were stable. There was no abdominal tenderness. An endoscopy revealed a small hiatus hernia and mild gastritis. Endoscopic biopsies were negative. No complications were reported. 

MCG (Milliman Care Guidelines) ACG: A-0203 lists indications for Upper Gastrointestinal Endoscopy. Peptic ulcer disease is an indication if certain requirements are met. These include having blood in the stool, having a history of UGI (upper gastrointestinal) surgery, iron deficient anemia, having a documented gastric ulcer that requires follow up, or having an ulcer that fails to respond to treatment or has been complicated by bleeding or obstruction. The patient did not have these conditions. Dyspepsia is also an indication, if it is complicated by being age 60 or older, having dysphagia, if there is failure of medical therapy, anemia, or weight loss. The patient did not have documentation of these conditions.

This patient was being evaluated for peptic ulcer disease. However, here is no documentation that she had tried and failed ulcer therapy such as with a proton pump inhibitor (PPI). She did not meet MCG criteria for having an endoscopy for either peptic ulcer disease or dyspepsia. 

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

The insurer's denial of coverage for the procedure code 43239, esophagogastroduodenoscopy (EGD), is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Short Stature.
Treatment: Norditropin.
The insurer denied Norditropin. 
The denial is overturned.

The patient is an adolescent female with VSD (ventricular septal defect), celiac disease, and Crohn's disease. She is followed by her pediatric endocrinologist for short stature.

The patient was noted to have some growth deceleration after turning seven years of age. Her height used to track close to the seventh - fourteenth percentile. However after seven years old, she had poor growth velocity, and her height trended down to less than the first percentile (z= -2.237). Her mid-parental height is 62.5 inches. Earlier this year, her height was 126.5 centimeters (Z= -2.27).

The patients bone age was read as delayed by more than one year. Her screening laboratory testing came back normal by report, including normal IGF-1 (insulin-like growth hormone 1) of 137, and therefore growth hormone (GH) stimulation testing was not performed.

The patient's endocrinologist would like to initiate GH (growth hormone) treatment. Coverage was denied by the health plan for not meeting criteria. Based on her Plan's coverage guidelines for GH (growth hormone) treatment, the patient must have one of the following conditions to qualify:  1) GH (growth hormone) deficiency, 2) Prader-Willi syndrome, 3) Growth failure in children small for gestational age, 4) Turner syndrome,  5)  Noonan syndrome, 6) SHOX (short stature homeobox-containing gene) gene deficiency, or 7) Growth failure associated with chronic renal insufficiency.

An appeal letter was received, pointing out that patient meets Food and Drug Administration (FDA)'s guidelines for GH (growth hormone) therapy.

The requested Norditropin is medically necessary.

The use of growth hormone therapy is considered medically necessary if the criteria for growth hormone therapy in idiopathic short stature is met. The FDA (United States Food and Drug Administration) approved the use of growth hormone for the treatment of idiopathic short stature in 2003 as defined by height standard deviation score (SDS) less than or equal to -2.25 and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and diagnostic evaluation have excluded other causes associated with short stature that should be observed or treated by other means (1). Based on the clinical information provided, the patient's clinical characteristics did meet the criteria for treatment under the FDA (United States Food and Drug Administration)-approved indication of idiopathic short stature, as the patient's pre-treatment height is more than 2.25 SD (standard deviations) below the mean for age/sex. While this was denied coverage by the health plan because the patient's diagnosis is not considered by the plan as medically necessary and because growth hormone deficiency was not demonstrated, this patient does meet criteria for growth hormone therapy, based on current medical literature and guidelines.

Therefore, given the above, the requested Norditropin is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gallstones; choledocholithiasis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is an adult female with choledocholithiasis status post endoscopic retrograde cholangiopancreatography (ERCP). 
The appeal was denied by the health plan stating that there was no need for inpatient admission.

The proposed inpatient hospital admission was medically necessary.
This hospital admission was medically necessary based on the fact that the patient had choledocholithiasis that was appropriately worked up and underwent endoscopic retrograde cholangiopancreatography (ERCP) for her stones in her common bile duct (CBD). Post-procedure, the patient tolerated her diet and was discharged home. 

The patient met medical necessity for this admission based on the fact that the patient had a high suspicion for choledocholithiasis on physical exam and laboratory values. The patient did not get a final diagnosis until the endoscopic retrograde cholangiopancreatography and this was medically appropriate to rule out other pathologies.  Endoscopic retrograde cholangiopancreatography therapy is usually performed as an inpatient as there is a risk of pancreatitis after the procedure which needs to be monitored clinically to ensure that there are no complications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cerebrovascular accident (CVA)
treatment:  Personal Care Assistance: 12 Hours per Day, 7 Days per Week (Monday-Sunday), Total of 84 Hours per Week.

The insurer denied Personal Care Assistance: 12 Hours per Day, 7 Days per Week (Monday-Sunday), Total of 84 Hours per Week. The health plan's determination is overturned.

The patient is a female with history of cerebrovascular accident (CVA) with left hemiparesis, dementia, arthritis, coronary artery disease, hyperlipidemia, hypertension, osteoporosis, depression, and urinary incontinence who had been assigned PCA (personal care assistance) services.

Personal Care Assistance: 12 Hours per Day, 7 Days per Week (Monday-Sunday), Total of 84 Hours per Week are medically necessary for this patient.

There is documentation from the patient's medical provider of the need for the requested PCA services. In addition, occupational therapy (OT) and physical therapy (PT) notes from the rehab facility documented total assistance needs with activities of daily living (ADL). The plan's appeal decision notice stated the patient needed another assessment to make a determination of assistance needs with ADLs/ Instrumental activities of daily living (IADL); however, notes from OT and PT at the time of the appeal decision notice showed the patient required total assistance with ADLs. The patient has care needs and therefore a time-based assessment tool should not be utilized in determining the patient's hours. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and 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 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient. Personal care services 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.