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

Digestive system
Pharmacy/prescription drugs

Diagnosis: ulcerative colitis
Treatment: Stelara at 90 mg (milligrams) every 4 weeks
The insurer denied Stelara at 90 mg every 4 weeks
The health plan's determination is overturned.

The patient is a young female with a history of ulcerative colitis. She has tried and failed many treatments. She was started on Stelara at the standard dose, 90 milligrams (mg) every 8 weeks. However, she continued to have active disease and her Stelara drug level was low.

Stelara 90 mg every 4 weeks is medically necessary for this patient.
Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease and ulcerative colitis (UC) in adults. Despite the lack of FDA approval for pediatric patients, there are many peer reviewed publications supporting the efficacy and safety of Stelara in children with inflammatory bowel disease.
A report by Dayan JR et al, showed that ustekinumab (Stelara) is efficacious and safe in pediatric patients with inflammatory bowel disease.
According to Koudsi, Mounzer, et al: "In this retrospective, multicentral study, ustekinumab proved to be efficient in paediatric patients resistant to anti-TNF (tumor necrosis factor). PCDAI (Pediatric Crohn Disease Activity Index) has been significantly improved in patients with severe disease, treated with Ustekinumab."
Finally, per Dhaliwal, Jasbir, et al: " Ustekinumab demonstrated efficacy in this paediatric cohort with otherwise treatment-refractory UC".
Therefore, the off-label use of Stelara in refractory cases of pediatric ulcerative colitis is appropriate. However, some patients do not respond adequately to the standard dose. Dose escalation is often required in biologics in order to achieve therapeutic levels and clinical remission. There are many peer reviewed literature reports showing that low Stelara levels were associated with poor clinical response.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperhidrosis; alopecia
Treatment: Onabotulinum Toxin A Injection 1 Unit J0585
The insurer denied Onabotulinum Toxin A Injection 1 Unit J0585.
The denial is upheld.

The patient is an adult female with hyperhidrosis on the medial frontal scalp, left superior upper back, right superior upper back, superior thoracic spine, and inferior thoracic spine. Two months ago, the patient presented for a follow-up for alopecia and hyperhidrosis. The patient has alopecia on the central frontal scalp, right medial frontal scalp, left anterior occipital scalp, right occipital scalp, mid-occipital scalp, right inferior occipital scalp, and left occipital scalp. She was seen 4 months ago, and at that time, eight lesions were injected with Kenalog. She also presented for a follow-up of hyperhidrosis. She was prescribed Drysol and Qbrexza, and she was advised to discontinue glycopyrrolate. Since then, her hyperhidrosis is stable. The hyperhidrosis has been interfering with her personal relationships. The patient's physical examination revealed hyperhidrosis on the medial frontal scalp, left superior upper back, right superior upper back, superior thoracic spine, and inferior thoracic spine. There is alopecia on the right central frontal scalp, left central frontal scalp, and left side. There is forced articulation skin on the left inferior occipital scalp, mid-occipital scalp, and right occipital scalp. There is diffuse nonscarring hair loss distributed on the left central frontal scalp, right medial frontal scalp, left inferior occipital scalp, right occipital scalp, mid-occipital scalp, right inferior occipital scalp, and left occipital scalp. An appeal was made for Botox for hyperhidrosis. This was previously denied because "clinical criteria" were not met. Botox injections were only recommended for hyperhidrosis for axillary sweating. An appeal was made. It is noted that Botox 100 units were effective a few years ago. 
Drysol 20% (percent) solution and Qbrexza towel were denied due to the location of the condition.

The requested Onabotulinum Toxin A Injection is not medically necessary.

This is an adult female presenting with hyperhidrosis situated on the medial frontal scalp, left superior upper back, and right superior upper back, as well as the superior and inferior thoracic spine. The patient has previously undergone Botox treatment involving 100 units, which proved effective a few years ago. However, the precise duration and percentage of relief achieved were not specified. Additionally, there is a lack of high-quality studies evaluating the efficacy of Botox injections in the back and frontal scalp areas. As a result, the requested health service is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disease

Treatment: Coverage for D2740 all white glass crown for teeth 23, 24, 25, and 26

The insurer denied coverage for coverage for D2740 all white glass crown for teeth 23, 24, 25, and 26

The denial is upheld

 
Upon review of the documentation provided which includes copies of radiographs and insurer correspondence, it appears that this patient presented to the dentist for care involving the anterior mandibular incisor teeth. The treating dentist recommended full coverage crowns for teeth #23-26. The insurer has denied these services stating the there is no clinical/ radiographic evidence, such as traumatic injury or decay, provided to support the necessity of this service, the documentation is Insufficient to approve treatment, and therefore the service does not meet medical necessity criteria. The patient is appealing.

The only objective documentation provided for review is copies of periapical radiographs. There are no other dental treatment records provided for review. It appears that there is no evidence of fracture or other pathology specifically affecting these teeth aside from occlusal attrition. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested dental services as enumerated above and therefore the crowns are deemed not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for D2740 all white glass crown for teeth 23, 24, 25, and 26 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Allergic reaction (anaphylaxis/angioedema).
Treatment: Inpatient Hospital Admission.

The insurer denied Inpatient Hospital Admission.  The denial is overturned.

The patient is a teenage male with a history of an allergic reaction. Inpatient hospital admission is under review. The prior denial reasons were: "We have no notes showing that your child had an abnormal blood pressure, heart rate, or breathing rate after treatment. We have no notes your child did not get better after observation care. We have no notes your child had breathing problems after treatment. We have no notes that your child's throat was still swollen after treatment. We have no notes your child has noisy breathing (stridor or wheezing) after treatment. Your child's doctors thought your child was safe to go home."

The requested health service was medically necessary.

The patient presented to the emergency department. He developed symptoms of dizziness, nausea, itching, and difficulty breathing after eating at a deli. Emergency medical services (EMS) was called, and the patient was found to have wheezing and stridor. He was given Duoneb, dexamethasone, and epinephrine and was taken to the emergency department. He had a history of anaphylaxis nine months prior. At initial presentation, the patient had tachycardia with a high rate of 123 and hypotension with a diastolic blood pressure of 57. Tachycardia, wheezing, and respiratory distress were noted. In the emergency department, the patient was given an intravenous saline bolus, supplemental, famotidine, Duoneb, albuterol, and magnesium. Upon serial monitoring, the patient had ongoing tachycardia, shortness of breath, and diastolic hypotension. The patient was then admitted for inpatient hospital care. The patient meets criteria given a partial pressure of carbon dioxide (pCO2) greater than 42 and potential of hydrogen (pH) less than 7.35, and required respiratory treatments (nasal cannula, face mask) only performable in the inpatient setting and patient with dyspnea, tachypnea, and abnormal breathing pattern, and hypoxemia requiring face mask.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of gout and osteoarthritis who initially presented to the emergency department with concerns about bilateral knee pain. The initial examination documented erythema, swelling, and tenderness of the right knee. An x-ray (XR) of the knee revealed a moderate knee joint effusion and severe osteoarthritis. The emergency department physician had an impression of gout in the setting of running out of gout medication. The patient was admitted to the hospital with an impression of left knee pain secondary to gout. The treatment plan included oral colchicine, oral prednisone, and oral allopurinol. Clinical improvement was noted, and therapy services recommended a discharge disposition of the home. The patient was discharged on oral medications. At issue is the medical necessity of an inpatient stay.
Based on the clinical documentation provided, evidence-based literature, and standards of care, the acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
Clebak et al. note gout is caused by monosodium urate crystal deposition in joints and tissues. Risk factors include male sex; obesity; hypertension; alcohol intake; diuretic use; a diet rich in meat and seafood; chronic kidney disease; and a diet heavy in fructose-rich food and beverages. 
The patient had a history of gout and osteoarthritis and presented with bilateral knee pain in the setting of running out of gout medication. Initial evaluation documented the patient as afebrile, hemodynamically stable, and with an elevated uric acid level. Radiographs revealed a joint effusion. Treatment included colchicine, prednisone, allopurinol, and oral analgesia. Following observation care, clinical improvement was achieved and the patient was discharged. No other issues or complications were documented.
The clinical indications for admission to inpatient care were not met. The patient did not have a severe crystal arthropathy with exacerbation that requires inpatient treatment (e.g., intravenous treatment) or severe pain requiring acute inpatient management. The patient also did not have severe rheumatologic disease (e.g., systemic lupus erythematosus, rheumatoid arthritis) with complications such as severe infection, pleural effusion, pulmonary hypertension with congestive heart failure, respiratory distress, coagulopathy with bleeding, thrombotic thrombocytopenic purpura, or thrombosis with hypercoagulable state.[2]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Renal calculi

Treatment Inpatient admission

The insurer denied coverage for Inpatient admission

The denial is Upheld

This adult male presented to Emergency Department (ED) with 3-day history of left flank pain - a 3-millimeter (mm) stone was diagnosed 3 days prior. Patient was given intravenous (IV) fluids, various intravenous medications in ED. He was admitted, taken to operating room by urology for left retrograde, left ureteroscopy (URS), left stent placement. Patient tolerated procedure well with no complications and was discharged home later that day. The insurer has denied coverage for the full hospital admission as not medically necessary. The appeal on behalf of the hospital is noted and read in detail. Per MCG Health (26th):

Renal colic and Kidney stones - patient fails to meet guidelines for acute inpatient care.
Urologic surgery or procedure GRG  (Gastroenterology Research Group) patient meets the GRG discharge parameter within 24 hours post procedure.

The full hospital admission was not considered medically necessary for this patient. This procedure is considered ambulatory per Milliman Care Guidelines (MCG).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Full thickness burn

Treatment: fractional ablative laser fenestration of burn and traumatic scars for functional improvement

The insurer denied coverage for fractional ablative laser fenestration of burn and traumatic scars for functional improvement

The denial is overturned
 

The patient is a teenager with a flame full thickness burn to the bilateral posterior lower extremities.  The resulting burn was treated with full thickness grafting and required an in-patient hospitalization for over 2 months.  The burn scar resulted in scar hypertrophy which has diminished his lower extremity range of motion.  The request is for carbon dioxide (CO2) laser ablation and procedure code 0479T.

Based on the submitted documentation, the use of CO2 laser ablation is medically necessary for the treatment of the patient's extensive scars.  The Patient has significant and symptomatic hypertrophic scar formation of the bilateral lower extremities subsequent to the burn and skin grafting.  The patient is documented to have itching and diminished range of motion in the affected scars which is demonstrating functional impairment.  Common Procedural Terminology (CPT) code 0479T is used when the provider creates openings or windows (fenestrations) in burns and traumatic scars using a fractional ablative laser technique. Report this code for the first 100 centimeters squared (cm2) in adults or 1 percent of body surface area (BSA) in infants and children.

The use of CO2 ablation has been documented in the literature as an effective treatment option for these difficult clinical scenarios.  This is a viable treatment option and within the standard of care and as such is considered medically necessary.  

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 code 0479T, fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1% of body surface area of infants and children and code 0480Tx4 -Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Proctalgia, rectal bleeding. 
Treatment: Inpatient emergency admission. 
The insurer denied the inpatient emergency admission. 
The determination is upheld. 

This is a female patient with a past medical history of mixed connective tissue disorder, rheumatoid arthritis (RA) and genital herpes who presented to the emergency room (ER) with proctalgia, rectal bleeding and perianal pruritic and a rash. She also had chronic constipation. She was hemodynamically stable and afebrile. She had a mild suprapubic tenderness and rash on her abdomen trunk and perineal areas, but the rest of her physical exam was normal.  A colonoscopy did not reveal active bleeding sources in her lower gastrointestinal (GI) tract but did show anal fissures. She was started on a bowel regimen and received topical therapy for her anal fissures. During her hospitalization, she did not have evidence of hemodynamic instability or evidence of ongoing GI blood loss. She was discharged to home with outpatient follow up. At issue is the medical necessity of an inpatient stay. 
The requested health service/treatment of inpatient admission was not medically necessary for this patient. 
This patient did not have evidence of acute massive gastrointestinal blood loss. She did not have severe hypotension or tachycardia that can indicate a loss of a large amount of blood. Therefore, she could have been managed at a lower level of care. 
Lower GI bleeding (LGIB) is diagnosed in 20 percent (%) to 30% of all patients presenting with major GI bleeding. The annual incidence of LGIB is 0.03%, and is predominantly seen in patients between the second to eighth decades of life. Approximately 35.7 per 100,000 adults in the United States are hospitalized for LGIB annually. Although blood loss from LGIB can range from trivial to massive and life-threatening, the majority of patients have self-limited bleeding and an uncomplicated hospitalization. In contrast to patients with acute upper GI bleeding (UGIB), patients with LGIB tend to present with a higher hemoglobin level and are less likely to develop hypotensive shock or require blood transfusions. The mortality rate ranges from 2% to 4% and usually results from comorbidities and nosocomial infections.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypercholesterolemia

Treatment: Injection, Inclisiran, 1 mg (milligram)

The insurer denied coverage for injection, Inclisiran, 1 mg (milligram).

The denial is overturned.

This is the case of a patient with a history of hypercholesterolemia, refractory to high intensity statin therapy (rosuvastatin 10 milligram (mg)). Past medical history is relevant for atherosclerotic cardiovascular disease with a stent placed in the mid left anterior descending artery, and hypertension. Family history was significant for familial hypercholesterolemia. The patient was treated with rosuvastatin 10 mg daily and ezetimibe 10 mg daily.  Serum blood testing revealed a total cholesterol of 190, low-density lipoprotein (LDL) of 120 mg/dl (deciliter) and high-density lipoprotein (HDL) of 49mg/dl. The patient physician submitted a prescription for Inclisiran therapy along with a letter stating that LDL cholesterol has been elevated despite more than 8 weeks of maximal statin and ezetimibe therapy.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This patient has atherosclerotic coronary artery disease and persistent elevation of LDL cholesterol despite treatment with maximally tolerated statins.  Addition of a non-statin agent such Inclisiran in this setting has been associated with significant event rate reduction regardless of serum LDL level (Reference 1, 2). Current American Heart Association and American College of Cardiology guidelines recommend addition of proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitor therapy to maximally tolerated statin therapy in patients at high risk for future atherosclerotic cardiovascular disease (ASCVD) events including those with multivessel disease and diabetes (Reference 1,2).  Such patients benefit from treatment with non-statin therapy such as Inclisiran when LDL cholesterol levels are not at goal (Reference 3). In conclusion, the proposed treatment is medically necessary and is more effective than the formulary medication as the patient has a contraindication to ezetimibe.

Based on the above, the insurer's denial must be reversed. 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 injection, Inclisiran, 1 mg is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, cardiac disease and peripheral vascular disease
Treatment: Personal care assistant (PCA) services, Live-in, 24 hours per day, 7 days per week
The insurer denied coverage for Personal care assistant (PCA) services, Live-in, 24 hours per day, 7 days per week.
The denial is upheld.
 
This is an elderly male with multiple medical problems including dementia, cardiac disease and peripheral vascular disease.  He lives alone in a private residence.  The insurer approved Personal Care Assistant (PCA) services 12 hours/day, 7 days/week.  The request is for PCA services, Live-in, 24 hours per day, 7 days per week.

The Uniform Assessment System (UAS) finalized report was reviewed.  The patient's cognitive skills are described as "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times."  He is reportedly totally dependent for much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  He also reportedly requires maximal assistance for bathing, lower body dressing and toilet use.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing, and toilet transfer.  Limited assistance is reportedly needed for locomotion and ambulation. He is otherwise at the supervision level or independent for bed mobility and eating.  

The patient is reportedly frequently incontinent of bladder and infrequently incontinent of bowel.  The patient's ADL (Activities of Daily Living) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. There have been no reported falls over the prior 90 days.  The patient's cognitive and functional ability are much the same when compared to the prior UAS (Uniform Assessment System).  The letter from the patient's treating physician describing his clinical condition and reported need for continuous human supervision, daily reminders and assistance in performing ADL was reviewed.  The associated treatment notes were not included for review.  

The patient may benefit from additional monitoring; particularly due to his reported declining cognitive status and wandering risk.  However, safety monitoring under PCA (Personal Care Assistant) does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided.  Based on the records reviewed as discussed above, attention to the patient's health, safety and physical impairments can be appropriately provided and maintained by the currently approved PCA services 12 hours/day, 7 days/week.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Assistant (PCA) services, Live-in, 24 hours per day, 7 days per week is not substantiated.