Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic arm weakness
Treatment: L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
The insurer denied coverage for  L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
The denial is upheld

This is an adult male with history of stroke and left upper extremity hemiparesis with spasticity. Prior treatments included occupational therapy, Botox injections and splinting. 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the requested prosthetic; L8702, is best described for this patient as investigational/experimental. The medical literature cited by the appealer (who is the Chief Medical Officer for the manufacturer of this device) was reviewed. The clinical records do not indicate that the appealer is the patient's treating physician. More specifically, the quality and quantity of data in the current peer-reviewed scientific medical literature is inadequate to conclude the clinical utility, safety and efficacy of the requested L8702 prosthetic, for the treatment of this member's clinical condition. The studies are plagued by limited sample size, lack of control group and/or funded by the manufacturer. The device is not proven likely to be more beneficial than any available standard treatment for this particular patient.  

The scientific evidence in peer-reviewed literature support is insufficient to prove a result of improvement in health outcome. The L8702 device has final approval from the appropriate regulatory bodies for this diagnosis. This patient is not a good candidate for the requested device. The L8702 device is not proven to be the best available treatment for this patient at this time .Adverse risks are not increased over standard treatment/services for the requested device.

In summary, the denial of  L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis vulgaris

Treatment: Otezla 30 milligrams (mg) or tabs

The insurer denied coverage for Otezla 30 milligrams (mg) or tabs

The denial is overturned

 
The patient has a diagnosis of psoriasis vulgaris. The patient has failed therapy with triamcinolone, tacrolimus, and oral methotrexate. The requested medication is Otezla.

The use of Otezla is medically necessary in this clinical scenario based on the standard of care and the documentation provided. The patient has a documented diagnosis of psoriasis and has failed topical therapies as well as methotrexate. The patient is noted to have a positive response to Otezla. Although, other medications may provide relief of his psoriasis symptoms, the patient has been successfully treated with Otezla and failed reasonable alternatives. The decision is overturned and the use of Otezla to treat the patient's psoriasis is approved under the medical supervision of the treating physician.

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 Otezla 30 mg or tabs services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD), diabetes, heart failure, and dementia. 
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 70 hours per week. 

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS) 70 hours per week. 

The denial is overturned. 
 
This is a geriatric patient with multiple medical problems including Chronic Obstructive Pulmonary Disease (COPD) who intermittently requires 2 liters of oxygen, diabetes, heart failure and dementia. The patient lives with spouse in a 2-bedroom apartment. The insurer approved Consumer Directed Personal Assistance Services (CDPAS) 42 hours per week, and the request is for 70 hours per week. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "moderately impaired." The patient is totally dependent to maximal assistance for Instrument Activities of Daily Living (IADL) including meal preparation, ordinary housework, and shopping. The patient requires extensive assistance for bathing, personal hygiene, dressing, locomotion, ambulation, and toilet transfer/use. The patient is frequently incontinent of bladder and continent of bowel. Limited assistance is needed for bed mobility and supervision for eating. There were no falls over the prior 90 days. The combination of the patient's cognitive deficits and functional decline support the medical necessity of increasing CDPAS to 70 hours per week. 

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 consumer directed personal assistance services (CDPAS) 70 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is an adult male with atopic dermatitis, treated with triamcinolone and dexamethasone. The patient has eczematous plaques to the extremities and trunk, with 30% (percent) BSA (body surface area) affected. The patient's provider is requesting Dupixent. The health plan denied coverage of the request, as it requires a trial and failure to a topical calcineurin inhibitor or Eucrisa. The denial is being appealed. The provider states that further topicals are not effective for the severe disease.

The requested Dupixent is medically necessary.

While topical calcineurin inhibitors can be used in atopic dermatitis, they are not indicated for severe disease. This patient has 30% BSA (body surface area). Dupixent (Dupilumab) is United States Food and Drug Administration indicated for treatment of recalcitrant atopic dermatitis, approved in 2017. Two trials SOLO-1 and SOLO-2 demonstrated that patients treated with Dupilumab experienced significant, clinically meaningful improvements in their atopic dermatitis at week 16 as measured by the EASI score (Eczema Area and Severity Index). Dupilumab was well tolerated with the most commonly reported side effects including injection site reactions and conjunctivitis. Dupilumab is a novel interleukin-4 and interleukin-13 blocker, which inhibits the arm of the immune system responsible for atopic dermatitis. In clinical trials, after 12 weeks of monotherapy with dupilumab, 85% of patients had a greater than 50% reduction in eczema severity and pruritus scores decreased by 57.1%. In phase III clinical trials, dupilumab led to a 75% improvement in eczema severity, when compared to placebo, and decreased symptoms of anxiety and depression. It also led to a significantly decreased use of topical corticosteroids. The safety and efficacy were supported in a recent meta-analysis of all published dupilumab paper. (Han, et al)

Therefore, given the above, the requested Dupixent is medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Dupixent
The insurer denied Dupixent.
The determination is upheld.

This is a patient with atopic dermatitis. The body surface area affected is 11 percent (%). She has failed prednisone, clobetasol, and hydrocortisone. The medication under review for medical necessity is Dupixent.

The requested health service/treatment of Dupixent is not medically necessary for this patient. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications, such as tacrolimus ointment, are effective treatments for the management of atopic dermatitis (1, 2).
A Cochrane Database of Systematic Reviews for Topical tacrolimus (which is a preferred, formulary drug) for atopic dermatitis concluded that "In summary, tacrolimus ointment seems to be safe and effective for moderate to severe atopic dermatitis in children and adults" (3).

It is noted that the patient has tried and failed topical steroids. However, the patient has no true contraindications to the other preferred, formulary medications which have been shown to be effective for the treatment of atopic dermatitis. The evidence-based literature is consistent. The preferred agents, such as tacrolimus ointment, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma, lung fibrosis and osteoarthritis
Treatment: consumer directed personal assistance services (CDPAS) 168 hours per week
The insurer denied coverage for CDPAS 168 hours per week
The denial is overturned.

This is an elderly female with multiple medical problems including asthma, lung fibrosis and osteoarthritis. She is currently approved by the insurer for CDPAS 62 hours/week and is requesting an increase to 168 hours/week, which is currently under review.  

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as minimally impaired. She requires extensive assistance for bathing, personal hygiene, dressing, and toilet use. Limited assistance is needed for toilet transfer. She requires supervision for bed mobility and is independent with eating. She is frequently incontinent of bladder and continent of bowel. The patient requires home oxygen, becomes short of breath with minimal exertion and as a result remains in bed most of the day. Her functional ability is much the same as documented in the UAS. The associated medical records document the severity and progression of her underlying lung disease. The combination of the patient's impairments and rapidly deteriorating cardiopulmonary condition supports the requested increase CDPAS 168 hours/week. The patient's health and safety can be more appropriately provided and maintained at home with the increased CDPAS 168 hours/week.

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 consumer directed personal assistance services (CDPAS) 168 hours per week services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial Fibrillation
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

This is the case of an adult male that presented to the hospital complaining of palpitations and dyspnea on exertion. Relevant past medical history included hypertension, hepatitis C virus, heart failure with preserved ejection fraction, diabetes, paroxysmal atrial fibrillation, and active heroin abuse. On arrival to the hospital, the patient was tachycardic with a pulse of 137 beats per minute (bpm). Blood pressure was 138/96. Physical examination revealed an irregular pulse and no other abnormality. A 12-lead electrocardiogram (EKG) was significant for atrial fibrillation with a rapid ventricular rate. Serum blood testing revealed an elevated serum Brain natriuretic peptide (1100). The patient was admitted to the hospital and treated with metoprolol and diuretic therapy. The patient eloped after two days.

Patients presenting with atrial arrhythmia and rapid ventricular rates require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days (Reference 1). This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. American Heart Association/American College of Cardiology Guidelines for the management of patients with atrial fibrillation recommend telemetry monitoring for patients treated with atrial fibrillation requiring treatment with rate control and antiarrhythmic therapies. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. In conclusion, inpatient admission was medically necessary in this case. 

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

Diagnosis: Abdominal Pain. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult male with type 2 diabetes status post left foot amputation and history of decompressive craniotomy status-post traumatic brain injury and history of seizures. He presented to the emergency department with nausea/vomiting, decreased urine output and dark urine. He had run out of his medication. He was living in a homeless shelter. 

The patient's temperature was 98.4, heart rate 69, BP (blood pressure) 102/61, respiratory rate 19, and SpO2 (pulse oximetry) 100%. On exam, the patient was noted to be in no acute distress. He was noted to have likely gastroenteritis on admission history and physical and patient requesting food at time of admission. CT (computed tomography) scan showed several tree-in-bud nodules in bilateral lower lung lobes, most likely infectious and several prominent loops of jejunum in left upper quadrant, may be related to enteritis. 

The patient was treated with Flagyl, ceftriaxone, and doxycycline. He had a history of tuberculosis, which was treated for in the past. He was seen by pulmonologist. CT (computed tomography) lung findings were thought to be consistent with micro aspirations and not typical for post-primary tuberculosis. A1C (glycated hemoglobin) was 9.2%. WBC (white blood count) was 10.6. He left against medical advice with a diagnosis of viral gastroenteritis. 

The Inpatient Hospital Admission was not medically necessary. 

This patient presented with nausea and vomiting. The CT (computed tomography) scan of his abdomen showed several prominent loops of jejunum in left upper quadrant. The patient was diagnosed with viral gastroenteritis. By the time of admission, the patient's symptoms were significantly improved, and he was noted to be in no acute distress and requesting food. He was hemodynamically stable. He had leukocytosis and a finding of tree-in-bud nodules in bilateral lower lung lobes on CT (computed tomography) scan with a history of treated tuberculosis. He was seen by Infectious Disease, and these were determined to not be tuberculosis but instead micro aspirations. Therefore, the patient did not have an acute medical condition that required an inpatient stay. The documentation does not indicate that the patient failed a lower level of stay. Therefore, no, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder/Anemia
Treatment: Inpatient Admission
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a medical history of hemiparesis secondary to a gunshot wound, seizure disorder, asthma, and a Caesarean section. She presented to the emergency department with acute bilateral lower abdominal pain. Vital signs were notable for fever of 101.2 F (Fahrenheit), and a rapid pulse rate of 106/minute. Physical examination was notable for left lower quadrant and right lower quadrant abdominal tenderness, guarding, and decreased bowel sounds. Labs showed an elevated white blood cell count of 14.5, a normal hemoglobin but low hematocrit of 36.9, and an unremarkable comprehensive metabolic panel. Urinalysis was notable for 3+ blood and large leukocytes. A computed tomography scan of the abdomen and pelvis showed no definite evidence for acute appendicitis, probable involuting follicle of the left ovary, intrauterine device, and probable mild central intrahepatic biliary dilation. The patient was treated with intravenous fluids, Ceftriaxone, Metronidazole, and Famotidine. She reportedly had improvement in symptoms. Labs showed normalized white blood cell count, low hemoglobin of 10.5 and a hematocrit of 32.4, and an unremarkable comprehensive metabolic panel. A general surgery consultation concluded that she had a possible urinary tract infection versus surgical process, and recommended serial abdominal examination, intravenous antibiotics, regular diet, Lovenox, and Famotidine. She was discharged on Famotidine and Bactrim DS, with a plan for urine culture follow-up.
At issue is the medical necessity for the inpatient level of care.

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

The inpatient level of care is not supported as medically necessary, and the care provided could have been provided at an alternate level of care for the duration of the stay. 
In this case, the patient presented with lower abdominal pain and fever; a urinalysis was consistent with a urinary tract infection, and imaging did not show any other cause for abdominal pain. She was appropriately treated with antibiotic therapy for diagnosis of urinary tract infection, which was not complicated by pyelonephritis, sepsis, or other complications. [1-5] She had improvement in symptoms with treatment. All of the measures that were undertaken, including monitoring, labs, antibiotic therapy, and general surgery consultation, could have been performed in sequence after presentation, without the inpatient level of care, at an alternate level of care. [1-5]
Appeal type: Medical necessity
Decision: Overturned

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

The patient had a recent diagnosis and treatment of syphilis. He presented to the emergency room (ER) with a bilateral frontal headache. He also had associated nausea, vomiting, low grade fever and chills. In the emergency room (ER), he had a temperature of 101.8 degrees Fahrenheit (F). A computed tomography (CT) scan of the head was unremarkable, however, lumbar puncture (LP) showed 288 white blood cell count (WBC) in cerebrospinal fluid (CSF) and total proteins were elevated at 83. He also had mild hypokalemia. He was started on intravenous (IV) Toradol and IV anti-emetics. He was started on IV acyclovir, IV ceftriaxone, IV doxycycline and IV vancomycin for potential viral versus bacterial meningitis. Infectious disease was consulted. The CSF cultures remained negative and herpes simplex virus (HSV) came back negative as well. His IV antibiotics and acyclovir were discontinued. He was a switched to oral doxycycline to complete a total of 10 days of antibiotics. He was subsequently discharged home once his symptoms improved and all infectious work up came back negative.
The medical necessity of an inpatient admission is under review.
The inpatient stay was medically necessary for this patient. This patient had a high risk or meningitis and clinically his presentation fit the picture. He had an elevated WBC and protein in the CSF was further confirming the suspicion of meningitis and therefore the patient needed a higher level of care and inpatient admission.
This is a patient with a recent diagnosis and treatment of syphilis who presented to the emergency room (ER) with a bilateral frontal headache. He also had associated nausea, vomiting, a low-grade fever and chills. He was started on IV ceftriaxone, IV vancomycin, IV Toradol, anti-emetics. Elevated proteins and elevated/detectable WBC in CSF are never normal. This points towards an etiology such as an infection (bacterial or virus). Typically, bacterial meningitis has greater than (>) 1000 WBC in the CSF and viral meningitis has less than (<) 100 WBC in the CSF. Fungal and treponema infections can cause variable WBC in CSF [1]. Based on the clinical findings, fever, detectable WBC in CSF, he needed treatment with IV antibiotics and anti-viral therapy as the prospect of missing the bacterial meningitis and its complication can be devastating for the patient [2,3]. Meningitis is a clinical diagnosis that is confirmed further with CSF evaluation and in patients with high suspicion, empiric antibiotic therapy is recommended. Although the patient was hemodynamically stable, meningitis patients can get sick very quickly especially in setting of meningococcemia infection [3]. Therefore, prompt recognition and empiric treatment are indicated. Although the patient improved quickly and all of the work up remained negative until his discharge, the overall the gravity of the situation and a risk of morbidity and mortality made this patient a candidate for inpatient admission and further management.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urosepsis
Treatment: Inpatient stay
The insurer denied: Inpatient stay
The denial is: Overturned

The patient is a female who presented to the hospital with lower abdominal pain radiating to the bilateral flanks. The patient experienced dysuria frequency and urgency. She also reported some nausea and vomiting episodes. The temperature was 38.1 Celsius (C) on arrival, heart rate of 121, and blood pressure 128/81. Laboratory studies in the emergency department (ED) showed a fairly normal chemistry panel with preserved renal function. White blood cell count was elevated at 19.9, with the rest of the complete blood count (CBC) fairly normal. Hepatic function tests were fairly unremarkable; lipase was 21. A venous blood gas was obtained, showing a normal potential hydrogen (pH). Cardiac troponin was negative. The urinalysis showed 3+ blood in the urine, with trace leukocyte esterase, 72 red blood cells, and nine white blood cells. There were white blood cell clumps and many squamous epithelial cells. Chest x-ray was unremarkable. Venous lactate was 2.4. The patient was started on intravenous (IV) Rocephin in the ED and admitted to the hospital due to concern for urosepsis and pyelonephritis. A renal ultrasound was obtained in the ED, which showed no hydronephrosis or obstruction.

The health plan's determination is overturned.

The inpatient stay is medically necessary for this patient. The patient has severe sepsis on admission, with lactic acidosis, fever, tachycardia, and a source of infection. Severe sepsis requires the significant deployment of resources accomplished in an inpatient setting. There is a significant risk of progression to septic shock requiring higher level care and vasopressors.
The severity of the illness exceeds the type of care that could be provided at a lower level status. Per standard of care, these patients require aggressive intravenous (IV) fluid resuscitation, monitoring of frequent labs, adjustment of antibiotics, and monitoring for decompensation. Frequently, these patients progress to septic shock and require a higher level of care. The determination on admission was appropriate.