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

Diagnosis: JAK2- mutated polycythemia vera
Treatment: Pegasys
The insurer denied the Pegasys. 
The denial is upheld. 

No, the treatment with Pegasys is not medically necessary.

The patient is a male. The patient was diagnosed with JAK2 mutation positive polycythemia vera. Hemoglobin at that time was 18.9g/dl. He had symptoms of pruritus, fatigue and non-exertional chest pain.  He was treated with phlebotomy every other week plus low-dose aspirin.  Bone marrow biopsy was done in and revealed hyper cellular marrow without fibrosis.  Findings were consistent with P. Vera and cytogenetics were normal.  

The patient was on treatment with as-needed phlebotomy and low-dose aspirin.  This was done based on target hematocrit of under 45% and target RBC (red blood cell) count under 5 million.  He required eight phlebotomy treatments. The progress note noted that he had low-risk polycythemia vera.  Pegasys was recommended with a goal of achieving complete hematologic response and phlebotomy free state.  CBC (complete blood count) was notable for WBC (white blood count) 10.7, hematocrit 44.4 and platelet count was not reported.  Symptoms at this visit included headache and mild nausea, beginning the night before the visit.

This patient has low risk polycythemia vera based on NCCN classification.  He is being managed with periodic phlebotomy and he had no documentation indicating worsening elevations in blood counts or worsening constitutional symptoms despite phlebotomy treatments.  He is also not noted to poorly tolerate phlebotomy.  

Pegylated interferon has been shown to have a beneficial effect on polycythemia vera but has not been shown to be associated with improved overall health outcomes in comparison to phlebotomy.  No prospective clinical trial has shown this to be true. Pegylated interferon is associated with multiple possible side effects and complications that would not be a risk for this patient if he were continued on phlebotomy alone.  

NCCN only recommends consideration of pegylated interferon in younger patients or those in need of cytoreductive therapy who do not tolerate or defer hydroxyurea.  There is no documentation to indicate that this patient has failed phlebotomy or that he requires cytoreductive therapy.  Use of pegylated interferon is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia.
Treatment: Inpatient admission.

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

This is a female patient with history of diabetes mellitus, hyperlipidemia and hypothyroidism. The patient presented to the Emergency Department (ED) with a history of malaise, myalgias, headache, chills and upper respiratory infection (URI) symptoms. The patient had recently received Repatha injection. The patient's presenting vital signs were: temperature 100.4, blood pressure 142/79 mm Hg, heart rate 96, respiratory rate was 18, and oxygen saturation was 99%. The patient was alert and oriented and was in no acute distress. The patient's lung exam revealed some rales. The patient's bloodwork showed: white blood cell count 10.1K, hemoglobin 15.7, BUN/Creatinine 13/0.8, and her electrolytes were within normal limits. A chest x-ray and computed tomography (CT) scan were done that both revealed right upper lobe consolidation. The patient was admitted for treatment of community acquired pneumonia (CAP). The patient was given intravenous (IV) fluids and IV antibiotics; Rocephin and doxycycline. Pulmonary was consulted. The patient was discharged home in stable condition. 

Based on the review of the medical record and literature, this patient did not need acute inpatient hospitalization for her community acquired pneumonia (CAP). The patient's CAP was mild with a CURB 65 score of zero. The patient was hemodynamically stable. The patient's oxygen saturations were acceptable, and did not required supplemental oxygenation. The patient was ambulatory and was not in acute distress. The patient was tolerating oral intake, and her labs were within normal limits. The patient's chest x-ray did not reveal any pleural effusion, empyema or pneumothorax. There was no history of failed treatment as an outpatient. This patient could have been placed in observation status for up to 48 hours if needed while diagnostic testing and treatment were initiated. This patient remained stable during his inpatient stay. The patient's blood and sputum culture/ sensitivity were also negative. The patient could have been discharged home on oral medications after a period of observation with close follow-up in an outpatient setting. Thus, inpatient admission was not medically necessary. 

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

The carrier's denial of coverage for the full hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Musculoskeletal/orthopedic.
Treatment: Home health care.
The insurer denied the increased home health care hours.
The health plan's determination is upheld in whole. 

The increase in CDPAS hours is not medically necessary for this patient. The patient has a past medical history of osteoarthritis, anxiety, depression, vitamin B12 deficiency, chronic neck and back pain and incontinence who had been assigned Consumer Directed Personal Assistance Services (CDPAS) services of 25 hours per week. The patient had been attending social day care four days per week, but this was closed due to the COVID pandemic. There was a request for an increase in CDPAS services to 41 hours per week. The request was partially denied for the increase in CDPAS services, allowing for an increase to 34 hours per week with a reassessment of this increase in 30 days. An undated letter from the patient's psychiatrist indicated the patient has major depressive disorder and severe anxiety disorder and is undergoing medication management and psychotherapy. Included for review is the CDPAS application from the patient's provider indicating the patient cannot ambulate and has decreased physical ability due to limited range of motion with pain, lumbar disc degeneration and neuropathy. The patient had an assessment tool performed  noting the patient used a cane to ambulate and had unsteady gait. The patient was assessed at maximal assistance for tasks of meal preparation, ordinary housework, and shopping. With the tasks of phone use, stairs, transportation, dressing upper/lower extremities and bathing the patient was assessed at extensive level of assistance while limited assistance with tasks of managing finances, managing medication, personal hygiene, walking, locomotion, transfer toilet and toilet use. The patient was assessed as independent with tasks of bed mobility and eating. It is noted  that the patient had no change in function from the included assessment tool.
The patient had been attending social daycare because of psychiatric history of depression and anxiety. The patient required maximal assistance with activities of ordinary housework and shopping which would not be occurring on a daily basis. The patient did not have a change in other assistance needs from her previous assessment. The increase in hours to 34 hours per week is appropriate, given the circumstance of social daycare being closed during the COVID 19 pandemic. Her medical providers have not provided other medical reasoning to justify the need for the increase in CDPAS hours. Therefore, medical necessity is not established for an increase of an additional 16 hours of CDPAS.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headache
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was upheld.   

This is a female patient who presented to the Emergency Department with complaining of a migraine-like headache.  The patient indicated 1 day prior to admission she developed a severe headache that was associated with 2 brief episodes of blacking out and 3 episodes of vomiting with associated bilateral numbness and tingling.  The patient attempted treatment with Tylenol migraine with minimal relief.  The medical documentation was not submitted for review.  However, case notes indicate upon arrival to the emergency department she had an episode of vomiting.  She received multiple medications.  She, according to case notes, had an elevated white blood cell count.  The patient was recommended to be admitted for monitoring.  An electrocardiogram was performed that revealed a QTC interval of 697.  She received Tylenol, magnesium, intravenous (IV) Reglan and IV fluids.  Her symptoms improved and she was discharged.  The minimal submitted documentation indicated the patient was discharged the following day.

In this reviewer's professional opinion and from a neurological standpoint, there is no evidence supporting the medical necessity for inpatient care.  The patient was reported to have headache without report for abnormal neurological examination.  There was no indication this patient was neurologically or hemodynamically unstable warranting an inpatient admission in this case. 

Regarding the prolonged QTC, there are no primary data supporting this finding.  Moreover, it is unclear what was the timing of the second ECG.  It is also well known that measuring the QTC is often in error (Viskin, et al).  Therefore, based on the clinical data as reported and the lack of supporting primary data ie, ECGs, medical necessity for inpatient admission is not substantiated.

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

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain 
Treatment: Inpatient admission
The insurer has denied coverage for inpatient admission.
The denial is upheld.
 
This is a male patient with a past medical history of hypertension, hyperlipidemia, coronary artery disease status post 2 stents gastroesophageal reflux disease and gout. He presented to the emergency department with complaints of chest pain, which improved with sublingual nitroglycerin. The patient reported intermittent chest pain for the prior month and was seeing a cardiologist. Transthoracic echocardiogram (TTE) and stress test done 2-3 weeks prior were unremarkable. Cardiology consulted on the patient, and it was felt that angina was likely secondary to gastritis/GERD. Due to renal dysfunction, the recommended coronary angiography was deferred. Creatinine was 1.63 with recent baseline unknown. Urinalysis was negative for proteinuria. Nephrology consulted and recommended intravenous fluids. The patient had mild improvement to 1.4 and by discharge it was 1.48. The patient was discharged.

The patient presented with chest pain which was relieved by nitroglycerin. His initial evaluation in the ER was unremarkable, including a non-diagnostic EKG and negative cardiac biomarkers. There were no high-risk symptoms suggestive of acute coronary syndrome, rather that of stable angina pectoris. There were no high-risk or concerning findings necessitating further inpatient evaluation or testing. His recommended cardiac catheterization could be performed on an outpatient basis. During the patient's initial evaluation and subsequent hospitalization, he exhibited no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. He had chronic renal insufficiency, which itself is insufficient to substantiate medical necessity for inpatient hospital status. For all of these reasons, the observational level of care would have been appropriate.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Home health care 
The insurer denied  increase in personal care aide services - live in per diem to 24 hours per day (split shift).
The denial is overturned in whole. 

The patient is a female with past medical history of chronic obstructive pulmonary disease (COPD) with oxygen as needed, dementia, right hip fracture with bed bound status, diabetes mellitus (DM) type 2 on insulin, recurrent urinary tract infection (UTI), urinary incontinence, obesity, hypertension, and hypothyroidism.
Yes, the requested increase in personal care aide services per diem to 24 hours per day live in split shift is medically necessary.
The patient had a change in social situation since the assessment tool and no longer had informal help due to the death of a spouse and medical issues of the children, necessitating an increase in PCA hours. In addition, there is documentation from the patient's PCP on multiple occasions that the patient required turning and positioning every 2 hours, and the member is bed bound and requires assistance with toileting/incontinence care, which was further supported by PCA activity logs.
The patient did not have an improvement in her medical conditions and is prone to worsening of assistance needs given the diagnosis of dementia. The patient's overnight needs would not allow a live-in PCA to sleep for 5 uninterrupted hours and therefore split-shift care would be medically necessary. The patient's overnight needs are not solely for safety and supervision but for assistance with Activities of daily Living (ADL's).
Therefore, the requested service is medically necessary in this particular case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque psoriasis
Treatment: Tremfya 
The insurer denied the Tremfya.
The denial is upheld. 

The patient is a female with psoriasis affecting 24% body surface area (BSA) for whom Tremfya is requested. She has tried and failed topical clobetasol and calcipotriene.

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

Per the enclosed policy, there must be documentation of drug failure or serious side effects with at least three months of a first-line oral medicine (such as: acitretin, methotrexate, or cyclosporine). If there is a medical reason why the first-line treatments should not be used, then a three month trial of ONE of the following is required: (1) ultraviolet B light treatment in combination with coal tar, topical steroids, or tazarotene (2) psoralen therapy used with ultraviolet A light in combination with coal tar, topical steroids, or tazarotene OR (3) topical steroids in combination with anthralin, calcipotriene, or tazarotene. 

Though the prescribing physician lists COVID-19 as the reason methotrexate and cyclosporine are not good options, the recommendations of the American academy of Dermatology (AAD) are to not start biologics unless absolutely necessary: 

Patients being considered for systemic immunosuppressive agents: We recommend physicians assess the risk versus benefits in lower-risk patients before initiating immunosuppressive agents on a case-by-case basis, recognizing that anyone may develop serious complications from COVID-19 infection. For patients in a high-risk population (e.g. individuals 60 years and older, or patients with recognized comorbidities such as cardiovascular disease, diabetes, severe hypertension, liver disease, kidney disease, respiratory system compromise, internal malignancies or tobacco use, among others), we recommend that physicians consider deferring initiation of immunosuppressive agents. Alternative therapeutic approaches can be considered to treat high-risk patients.

It is difficult to assess the risk in current circumstances, COVID-19, that conventional systemic therapies carry compared to biologics, especially one that is so recent, such as Tremfya, and long-term safety has not been established.

The health plan's requirement and denial rationale are reasonably and in line with generally accepted practice and guidelines in the dermatology community.  Therefore, it is not medically necessary over the plan's policy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is a female patient with a medical history of hypertension and diabetes mellitus. The patient presented to the Emergency Department (ED) with complaints of intermittent left-sided chest pain for several days. The patient's chest pain was associated with shortness of breath, palpitations and dizziness. The patient's electrocardiogram (EKG) showed no acute ischemic changes. The patient's troponin was negative. The patient was admitted to the hospital. The diagnosis of myocardial infarction (MI) was ruled out with negative cardiac biomarkers. A nuclear stress test and transthoracic echocardiogram were ordered however the patient wanted all tests to be performed by the afternoon of the following day. The patient signed out against medical advice (AMA).

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient presented with chest pain. The patient's initial evaluation in the Emergency Department (ED) was unremarkable, including non-diagnostic electrocardiogram (EKG) and negative cardiac biomarkers. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met. There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. The health plan allows for initial evaluation and subsequent monitoring in the hospital under both inpatient and observational levels of care. In this case, observational level of care would have been appropriate.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class I, Class II canines, maxillary and mandibular crowding, excessive overjet and anterior crossbite with gingival attachment loss (mandibular left canine)
Treatment: Braces
The insurer denied braces.
The denial was overturned.    

This is a patient who consulted an orthodontist for orthodontic care. A diagnostic work up was performed that included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images.  The orthodontist recommended comprehensive orthodontics due to skeletal Class I, Class II canines, maxillary and mandibular crowding, excessive overjet and anterior crossbite with gingival attachment loss (mandibular left canine).  The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  

It is evident that the patient exhibited a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  There are additional criteria utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. Based on the review of the medical record and literature, this automatically qualifying condition criterion is met for this patient, and does support for the request of comprehensive orthodontic care. Braces are considered medically necessary for this patient.

The healthcare plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for braces should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Anemia 
Treatment: Inpatient admission 
The insurer denied the inpatient admission. 
The denial was upheld. 

This is a young male patient with a history of sickle cell anemia and asthma. He presented to the hospital with complaints of pain in his right upper and left lower extremities; he rated it 10/10 in severity. The patient's oxygen saturation was 98% on room air. There was no evidence of other complications of sickle cell anemia. The patient's hemoglobin was at his baseline. The patient was admitted to the hospital for further medical management. The patient's medical treatment included intravenous (IV) hydration, IV morphine and IV ketorolac. The patient was medically stable and discharged home. 

According to Yawn & John-Sowah (2015), "Vasoocclusive crises require immediate and adequate analgesia appropriate to the level of patient-reported pain. Antibiotics, hospitalization, and incentive spirometry are indicated for those with acute chest syndrome." However, in this case, this patient did not have acute chest syndrome.
Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient did not require patient-controlled analgesia (PCA) for pain control, and the patient did not present with clinical evidence of stroke, acute chest syndrome, priapism, splenic sequestration or infection. The patient's care could have been safely provided and managed at a lower level of care. 

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

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.