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

Orthopedic/Musculoskeletal
Pharmacy/Prescription Drugs

Diagnosis: Osteoporosis
Treatment: Prolia
The insurer denied Prolia. The health plan's determination is upheld. 

The patient is a female with Crohn's, gastroesophageal reflux disease (GERD), left wrist fragility fracture and osteoporosis. The issue in this case is that Prolia is being denied by the health plan for the treatment of osteoporosis as there is no trial of an injectable bisphosphonate on record. Lumbar T-score is -3.3 on DEXA (dual energy X-ray absorptiometry) scan.

Prolia is not medically necessary for this patient. There is no medical reason the patient cannot try an injectable bisphosphonate. Per the records provided, the patient was offered both intravenous (IV) Reclast and Prolia but she 'is more interested in Prolia', which is not a contraindication/intolerance to an injectable bisphosphonate.

When it comes to treating osteoporosis, an oral bisphosphonate is usually first line followed by either Prolia or an injectable bisphosphonate. An oral bisphosphonate is contraindicated due to the patient's history of GERD. Either Prolia or an injectable bisphosphonate (e.g. IV Reclast), would be medically appropriate in this case. There is no medical reason or contraindication why the patient cannot try IV Reclast, which would be equally medically appropriate for the patient at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Home Health Care
The health plan denied the requested increase in PCA hours. The health plan's determination is overturned.

The patient is a male with past medical history of osteoarthritis, bladder incontinence, vascular dementia, repeated falls, vision impairment, hearing loss, chronic low back pain, benign prostatic hyperplasia (BPH), and hypertension who had been assigned personal care assistant (PCA) services 8 hours/day, 7 days/week, to total 56 hours/week based on 2 assessment tools performed. On the first assessment the patient was assessed at total assistance with tasks of meal preparation, ordinary housework, and shopping, while maximal assistance with tasks of stairs, transportation, walking, locomotion, transfer toilet, and toilet use. With the tasks of managing finances, managing medication, equipment management, and bathing the patient was assessed at extensive assistance while limited assistance with tasks of phone use, personal hygiene, and dressing upper body. The patient was assessed at supervision only for the task of eating. The second assessment assessed the patient's level of assistance the same for tasks of meal preparation, ordinary housework, managing medication, stairs, shopping, transportation, bathing, personal hygiene, dressing lower body, and eating compared to the previous assessment. 

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

Yes. The patient has documented progressive and worsening medical diagnoses of osteoarthritis, chronic low back pain, and vascular dementia. The patient's PCP documented the patient's worsened medical conditions with a decline in functional abilities compared to previous assessment tools. The patient's last assessment tool underestimated the patient's current assistance needs. There is documentation that the patient needs assistance with all ADLs/ instrumental activities of daily living (IADLs) . The patient would need PCA assistance outside of the hours that he has informal help. An increase in PCA hours is not solely for supervision and safety but to assist the patient with safe completion of ADL and IADL tasks. In reviewing the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, an increase in PCA service hours is medically necessary. 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 his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient hospital stay

Diagnosis: Digestive System/Gastrointestinal-Crohn's Disease
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. The reviewer has overturned in whole the health plan determination.

The patient has a new diagnosis of Crohn's Disease admitted to the hospital. The patient was recently discharged following treatment for colitis, treated with intravenous antibiotics. The patient was discharged on oral antibiotics but was unable to tolerate these and then over a period of days stools became very loose. On the day of admit the patient developed severe left lower quadrant (LLQ) pain. On admit, vital signs and temperature were within normal range. The patient was described as in no acute distress. Abdomen was tender in the LLQ without guarding or rebound. On labs, the patient had a normal lactate and white blood cell count (WBC) although slight left shift. A computed tomography (CT)scan confirmed colitis which had not changed since 2 weeks prior. The patient was started on IV cipro/flagyl. On the eve of admit the patient vomited once. The patient underwent a flexible sigmoidoscopy and was found to have moderate to severe Crohn's colitis. The patient appeared clinically stable. Stool was ordered to be sent for Clostridioides difficile (C diff) culture as the patient had an episode of diarrhea. Patient was started on Remicade and Azathioprine which was tolerated. There were no problems during the following day and the patient was discharged the next day uneventfully.

The inpatient stay was medically necessary for this patient. The patient has severe Crohn's colitis and was admitted for a flare of the disease. Antibiotics do very little for the treatment of Crohn's and the patient experienced ongoing diarrhea and abdominal pain. Fortunately, the patient did not  progress to a perforation, obstruction, or abscess. During this hospitalization she needed to begin aggressive treatment for Crohn's This was done using the standard of care combination of infliximab with Azathioprine.[1] This could not have been accomplished appropriately as an outpatient or at a lower level of care- the patient needed to be monitored in case therapy was ineffective and the patient has progression of symptoms. The inpatient stay was medically necessary and in agreement with the guidelines put forth by the leading gastrointestinal (GI) societies which are referenced below. [2,3]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteosarcoma

Treatment: Continued admission

The insurer denied coverage for the continued admission.

The denial is upheld. 

This is a female patient who underwent resection of an osteosarcoma wing of the right ileum with arthroplasty acetabular/proximal femoral prosthetic replacement with allograft. The patient was subsequently admitted to inpatient rehabilitation. 

According to occupational therapy (OT) notes 3 days prior to discharge, the patient was at the supervision level for bed mobility, transfer tasks, and upper/lower body dressing.  A similarly high functional level was documented by physical therapy (PT) notes 3 day prior to discharge. The patient was able to ambulate with axillary crutches with only supervision and was "able to maintain toe-touch weight-bearing (TTWB) of the right lower extremity (RLE) throughout all ambulation." The patient also had no pain complaints. 

The patient's blood pressure readings over the course of her stay were consistently low with blood pressures ranging from 83/47 to 102/56, and the patient was asymptomatic.  

Based on the review of the patient's medical records, the clinical records do not support that the patient required a level of medical acuity and rehabilitation intensity that necessitated the continued inpatient rehabilitation. The patient could have been safely discharged to a lower level of care such as home as of day 8 of admission and continued therapy at home or as an outpatient.  

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the clinical records do not support the medical necessity for the continued inpatient rehabilitation as of day 8 of admission.

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 continued admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Irritable Bowel Syndrom With Diarrhea (IBS-D)
Treatment: Xifaxan
The insurer denied the Xifaxan.
The denial is oveturned. 

The patient is a male with IBS-D (Irritable Bowel Syndrome with Diarrhea). He has failed treatment with hyoscyamine, loperamide, generic Librax and dicyclomine. His provider is requesting treatment with Xifaxan 550 mg (milligrams) TID (three times daily).

Yes, the treatment with Rifaximin (Xifaxan) is medically necessary.

The patient has IBS-D (Irritable Bowel Syndrome with Diarrhea). Xifaxan is medically necessary, safe and effective treatment for IBS-D (Irritable Bowel Syndrome with Diarrhea). 

Xifaxan was denied, as it was felt that the patient had only failed two preferred formulary alternatives, dicyclomine and loperamide. From the appeal letter, the patient has also failed a third formulary alternative, hyoscyamine.  Therefore, the requested Xifaxan also meets PA (prior authorization) criteria. Therefore, the proposed treatment is medically necessary, and the plan did not act reasonably, with sound medical judgment and in the best interest of the patient, by denying it.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pilocystic astrocytoma
Treatment: Continued physical therapy services 2x/week x 12 weeks 
The insurer denied the Continued physical therapy services 2x/week x 12 weeks.
The denial is overturned. 

This is a child with history of infratentorial brain tumor (pilocystic astrocytoma) with ventricular hemorrhage. The tumor was resected a few years ago. Additional surgery took place the following year due to tumor recurrence. The patient developed posterior fossa syndrome. Skilled physical therapy interventions have been initiated in order to mitigate functional complications of posterior fossa syndrome that manifest itself with prolong ataxia and balance deficits. The patient has been recommended to continue physical therapy interventions provided by skilled pediatric physical therapist beyond 6 approved PT visits for dates. The most recent clinical evidence points out on the new tumor growth, and initiation of chemotherapy interventions in the nearest future.

Yes, continued physical therapy services is medically necessary.

This case involves is a child with infratentorial brain tumor and several surgical interventions who developed significant functional decline due to symptoms of posterior fossa syndrome. The patient has been receiving outpatient rehabilitative interventions that have been disrupted by the Covid-19 pandemic that led to several setbacks, and the need for further in person physical therapy interventions. Additional physical therapy is requested by the qualified healthcare providers with the personal knowledge of this child's clinical and functional status. Continued physical therapy services 2x/week x 12 weeks have been requested; the health plan has approved 6 visits. In addition, the patient has been recently diagnosed with recurrent brain tumor.

The patient is complaint with goal-oriented physical therapy interventions provided by the skilled professional under physician guidance. In this case, medical necessity for physical therapy interventions have been established.
Appeal type: Medical necessity
Decision: Overturned

Endocrine/metabolic/nutritional
Surgical Services  (All)

Diagnosis: Obesity
Treatment: Weight Loss Surgery: Sleeve Gastrectomy with Associated Inpatient Hospital Admission
The insurer denied Weight Loss Surgery: Sleeve Gastrectomy with Associated Inpatient Hospital Admission. The health plan's determination is overturned. 

This patient is a woman under consideration for bariatric surgery. She was 61 inches tall and weighed 190.2 lbs. This corresponds to a body mass index (BMI) of 36 kg/m2. She has comorbid health conditions of hypertension and hyperlipidemia for which medication has been prescribed. She also has the condition of sleep apnea confirmed by polysomnography for which continuous positive airway pressure (CPAP) is recommended. The patient has attempted weight loss with conventional weight loss programs as detailed in the surgical assessment. Unfortunately, she has not been successful with significant sustained weight loss.

Given this patient's diagnosis, her current health condition and generally accepted guidelines for patient selection, the proposed sleeve gastrectomy procedure and the associated inpatient hospital admission is medically necessary for this patient. Laparoscopic sleeve gastrectomy (LSG) is medically necessary for this patient per widely accepted guidelines as her BMI is in excess of 35 kg/m2 in association with weight related illness of hypertension. There is serial documentation of active participation in a nonsurgical weight reduction regimen. The patient has undergone evaluation by a multidisciplinary bariatric program. The patient has been cleared for the proposed surgery from a mental health standpoint per the enclosed psychological consultation and clearance. The patient has undergone a preoperative medical consultation and is felt to be an acceptable candidate. Finally, the treatment plan includes pre and post op dietary / nutritional counseling.
From the available data it can be expected that laparoscopic sleeve gastrectomy and the associated inpatient hospital stay would be health beneficial for her and that she meets generally accepted National Institutes of Health (NIH) and American Society for Metabolic and Bariatric Surgery (ASMBS) criteria for the proposed bariatric operation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic Urothelial Carcinoma. 
Treatment: Radiation Therapy to Metastases. 

The insurer denied Radiation Therapy to Metastases. 
The determination is overturned. 

This patient has a history of acute lymphocytic leukemia (ALL) as a child treated with chemotherapy and low dose radiation who developed a locally advanced urothelial carcinoma of the bladder with pelvic nodal metastases. He was treated with chemotherapy followed by a cystectomy and node dissection. He then had a recurrence in the pelvis. He underwent a clinical trial with systemic therapies with complete response (CR). He then developed two retroperitoneal and pelvic nodal metastases. Radiation therapy was recommended to treat these two lesions with stereotactic body radiation therapy (SBRT) 700 centigray (cGy) times (x) 5 treatments to each lesion and this is under review for medical necessity. 

The requested treatment of radiation therapy for metastases is considered medically necessary for this patient. This patient has oligometastases with only two small sites of progressing disease. The patient is not a good surgical candidate and has had extensive systemic therapy, now with progression. There are excellent data published in peer reviewed journals supporting the use of SBRT with ablative radiation dosing with up to 90% control rates with minimal risk of side effects. There are some studies that have shown an increase in survival with this approach of treatment for oligometastatic disease. The Stereotactic Ablative Radiotherapy (SABR) study is a randomized trial that has shown these benefits and supports the use of SBRT in these clinical scenarios. This treatment is considered medically appropriate and necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/ Gastrointestinal
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He has history of hypertension, DM (diabetes mellitus), CAD (coronary artery disease) with stent placement done in the past, on Plavix, history of CVA (cerebrovascular accident), peptic ulcer disease on Nexium, and seizure disorder. He presented to the ED (emergency department) with left-sided chest pain with radiation to the left arm, and left lower quadrant pain and epigastric pain, vomiting blood for two days, and dizziness and lightheadedness. He has recent history of visits to other hospitals with similar complaints.

In the ED (emergency department), the patient was hemodynamically stable and afebrile. His EKG (electrocardiogram) revealed normal sinus rhythm and left ventricular hypertrophy. The CBC (complete blood count) revealed Hb/HCT (hemoglobin/hematocrit) 10.9/34. His glucose was 216, and BUN/Cr (blood urea nitrogen/creatinine) was 14/0.84. Troponin was less than 0.010. His chest X-ray was normal. 

In the ED (emergency department), the patient was started on IV (intravenous) fluids and given IV (intravenous) Pepcid, Protonix, and Maalox. He continued to complain of chest pain, and he was therefore, admitted to telemetry bed. Acute coronary syndrome was ruled out. He continued to complain of epigastric pain, and he demanded to have an EGD (esophagogastroduodenoscopy) to evaluate for UGI (upper gastrointestinal) bleed. He had no recurrence of vomiting or hematemesis during his entire hospitalization, and he tolerated diet. His Hb/HCT (hemoglobin/hematocrit) remained stable over three days. He was discharged home and advised to follow up with GI (gastroenterology) clinic.

No, the Inpatient admission was not medically necessary. 

The patient was admitted to the hospital with chest pain and radiation to the left arm, and epigastric and left lower quadrant pain and vomiting blood. He was admitted to telemetry bed and acute coronary syndrome was ruled out. During his hospital stay, he had no episodes of hematemesis, and he tolerated the diet well. His Hb/HCT (hemoglobin/hematocrit) remained stable. He was discharged home and was given the appointment with the GI (gastroenterology) clinic. Given this clinical scenario, he could have been safely managed under a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mitral Regurgitation
Treatment: Echocardiogram
The insurer denied the echocardiogram
The determination is upheld.

The patient underwent an echocardiogram which showed normal right and left ventricular size and function. There was mild mitral, pulmonic and tricuspid regurgitation and trace aortic regurgitation. The left atrial pressure was estimated at 14 millimeters of mercury (mmHg). Compared to a prior study, the right ventricular systolic pressure had increased slightly (31 mmHg versus 25 mmHg). On the earlier study there was trace mitral, aortic and pulmonic regurgitation and mild tricuspid regurgitation. The listed indication for the study was "murmur". Limited information was provided; the only medical records provided were echocardiogram results. Additional information was requested but not received. At issue is the medical necessity of echocardiography.

The information provided is insufficient to determine that this service was medically necessary. This patient was found to have mild tricuspid regurgitation and trace mitral, pulmonic and aortic regurgitation by echocardiogram. Per the most recent appropriate use criteria routine echocardiography for surveillance of trace valvular regurgitation is not appropriate; routine surveillance at less than three year intervals of mild valvular regurgitation without a change in clinical status or cardiac exam is inappropriate. Without medical records it cannot be determined if this patient had new symptoms or physical findings that would have warranted an echocardiogram, months after her prior echocardiogram.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Nutritional Supplement. 
The insurer denied Similac Total Control. 
The denial is overturned in whole.

The patient is a male with family history of dilated cardiomyopathy, who was diagnosed with dilated cardiomyopathy with severely depressed cardiac function at 5 weeks of age when he presented to the Emergency room with vomiting, respiratory distress and tachycardia. He also had ectopic atrial tachycardia. He was medically managed on milrinone, amiodarone, digoxin and listed for heart transplantation.  When a suitable heart became available, the parents rejected and chose to continue medical management. He has shown progressive improvement on medical management and was discharged home. However, he still had moderate to severely depressed cardiac function with an ejection fraction of 39% on the day of discharge. Since patient has congestive heart failure, he was started on high calorie formula for better nutrition.
The subject under review is the medical necessity for Similac Total Control for this patient.

The health plan's determination is overturned.

The requested health service of Similac total control is medically necessary for this patient. He continues to be in moderate to severe heart failure and needs formula with concentrated high calorie formula as per nutritional guidelines in these patients. Pediatric heart failure is well documented to cause malnourishment if appropriate nutrition is not given. Patients in heart failure tend to have higher caloric needs as they are in high basal metabolic rates and they need more concentration of feeds so as to reduce the amount of fluid given to the child. It is therefore established that heart failure patients need concentrated formula and is a standard practice in pediatric heart failure management. Malnourishment in the heart failure patient is well documented with a 23.7% prevalence among patients with dilated cardiomyopathy.
In summary, the requested Similac total control is medically necessary for this patient.