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

Diagnosis:  Psoriatic arthritis, psoriasis.
Treatment: Stelara.

The insurer denied Stelara.  The determination is overturned.

The patient diagnoses of psoriasis, psoriatic arthritis and Crohn's disease. Stelara was denied by the health plan as not medically necessary. The Stelara is under review for medical necessity.

The requested service/treatment of Stelara is medically necessary for this patient. The patient has psoriasis, psoriatic arthritis (PsA) and Crohn's disease, all of which can be treated with Stelara. She has tried and failed a myriad of other agents.  She has failed or had partial remission on Remicade, Humira, Cimzia, Simponi and Enbrel. Interleukin (IL)-17 inhibitors are not an option as she has inflammatory bowel disease (IBD).
There is ample data supporting the use of Stelara in psoriasis, psoriatic arthritis (PsA) and Crohn's disease. A study published in the Lancet in 2013 concluded that 'ustekinumab significantly improved active psoriatic arthritis compared with placebo, and might offer an alternative therapeutic mechanism of action to approved biological treatments'. Another study published in 2014 in Ann Rheum Dis found that 'the interleukin-12/23 inhibitor ustekinumab (45/90 milligrams (mg) every (q) 12 weeks) yielded significant and sustained improvements in PsA signs/symptoms in a diverse population of patients with active PsA, including anti-tumor necrosis factor (TNF)-experienced PsA patients'. A study published in the New England Journal of Medicine (N Engl J Med) in 2016 concluded that ' among patients with moderately to severely active Crohn's disease, those receiving intravenous ustekinumab had a significantly higher rate of response than did those receiving placebo. Subcutaneous ustekinumab maintained remission in patients who had a clinical response to induction therapy'.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Home Health Care. 
The insurer denied increase in personal care service hours to 24 hours per day split shift. 
The denial is overturned. 

The patient is a female with a past medical history of coronary artery disease, end stage renal disease, asthma, osteoarthritis, vertigo, hypertension, kidney stones, dementia, urinary incontinence, anxiety, and depression who had been assigned Personal Care Assistance (PCA) services at 42 hours/week following telephonic assessment performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and managing finances while maximum assistance with task of shopping. The patient was assessed at extensive assistance with tasks of managing medication, phone use, stairs, transportation, bathing, and dressing upper/lower body while limited assistance with tasks of personal hygiene, walking, locomotion, transfer toilet, toilet use, and bed mobility. The patient was assessed as independent with task of eating. The subject under review is the medical necessity for the increase in hours to 24 hours per day split shift.

The health plan's determination is overturned.

The requested increase in hours is medically necessary for this patient.
The patient's nephrologist and primary care physician (PCP) documented medical necessity of increased PCA services. The patient's healthcare advocate documented the patient's daughter was unable to provide informal support outside of the hours the patient had PCA services. Overnight care logs document care needs at least every 2-3 hours requiring personal care aide assistance with activities of daily living (ADLs) of transfer toilet, toilet use, walking, locomotion, and medication management. The patient's care needs in the overnight hours would not allow a personal care aide 5 hours of uninterrupted sleep. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled 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 all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, 7 days/week, split shift, 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: Formulary Exception
Decision: Upheld

Diagnosis: Infectious Disease/AIDS/HIV
Treatment: Pharmacy/Prescription Drugs - Juluca
The health plan denied the requested prescription medication as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a history of a human immunodeficiency virus (HIV) infection. Her Infectious Disease provider ordered Juluca (Dolutegravir/Rilpivirine), which the patient has reportedly been taking for the treatment of her HIV. Coverage for this medication was denied because it is considered non-formulary per the terms of her health plan.

At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, Juluca 50-25 mg (milligram) tablet or would have adverse effects.

I uphold the health plan's determination, in whole.

In this case, one of the proposed formulary alternatives to Juluca is separately prescribing its components - Dolutegravir (Tivicay) and Rilpivirine (Edurant). There is no indication that the patient has had an adverse reaction to either Dolutegravir or Rilpivirine alone, and the same dosage provided in Juluca could be achieved with one tablet each of Dolutegravir 50 mg and Rilpivirine 25 mg. Furthermore, there is no clear indication that the patient would be adversely impacted by taking one additional tablet per day for her antiretroviral treatment. Thus, separate prescriptions for Tivicay and Edurant would be equally effective compared to Juluca without an increase in risk for adverse events.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ankylosing Spondylitis of Multiple Sites in Spine. 
Treatment: Enbrel Sure Click SOAJ 50MG/ML. 

The insurer denied the Enbrel Sure Click SOAJ 50MG/ML. 
The denial is overturned. 

The patient is a female with ankylosing spondylitis (AS).  She failed treatment with three NSAIDs (nonsteroidal anti-inflammatory drugs), ibuprofen, naproxen, and presently Celebrex. She had a partial response to Cimzia started.  Screening for hepatitis B and C were negative, and testing for latent tuberculosis was negative and again.  At her office visit, the provider wished to switch Cimzia to Enbrel, due to the patient's incomplete response to Cimzia. 

Coverage for Cimzia was denied by the health plan due to prior lack of evidence of screening for hepatitis B and failure of more than one NSAID (nonsteroidal anti-inflammatory drug). The appeal is for Enbrel for the treatment of active AS (ankylosing spondylitis). 

Yes, the requested Enbrel is medically necessary for the treatment of AS (Ankylosing Spondylitis) in this patient. 

This patient with AS (Ankylosing Spondylitis) failed treatment with three NSAIDs (nonsteroidal anti-inflammatory drugs), ibuprofen, naproxen, and presently Celebrex. She had a partial response to the TNF (tumor necrosis factor) inhibitor Cimzia started. 

Enbrel is FDA (United States Food and Drug Administration)-approved for the treatment of AS (Ankylosing Spondylitis), as seen in this patient. Treatment with Enbrel is clinically appropriate and in accordance with standard of care in the rheumatology community for a patient with AS (Ankylosing Spondylitis) who failed multiple NSAIDs (nonsteroidal anti-inflammatory drugs) and Cimzia. This patient also recently tested negative for hepatitis B and C, as well as latent tuberculosis. 

Therefore, given the above, the requested Enbrel is medically necessary for the treatment of AS (Ankylosing Spondylitis) in this patient. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services (All). 
The insurer denied Outpatient Procedure-Genicular nerve injection. 
The denial is overturned. 

The patient is a female with a history of chronic left knee pain confirmed by x-ray and physical exam. Her provider noted in a letter that the patient was treated with physical therapy, activity modification, cortisone injections, viscosupplementation injections, and anti-inflammatories. She is not interested in surgery and has difficulty with activities of daily living (ADL)'s. A request was made for a genicular nerve block.
At issue is the medical necessity of Outpatient Procedure-Genicular nerve injection.

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

The requested health service/treatment of Outpatient Procedure-Genicular nerve injection is medically necessary for this patient.
Knee osteoarthritis (OA) pain can be managed conservatively with physical therapy and medications while joint replacements are reserved for more severe joint disease with intractable pain symptoms. Modalities like intra-articular corticosteroid injection may provide a long-term pain relief. Genicular nerve block and radiofrequency ablation were introduced to alleviate knee pain in patients with chronic knee osteoarthritis. Interruption of nociceptive pathways via genicular nerve radiofrequency is a technique that can potentially provide long-term pain relief in this group of patients. In this case the proposed treatment is a genicular nerve block, and the plan would be to perform radiofrequency ablation of the genicular nerve if the patient were to receive more than 50% (percent) relief from the block. This is a reasonable treatment plan considering the patient's diagnosis of knee osteoarthritis and her failed conservative treatments.
Therefore, the requested health service/treatment of Outpatient Procedure-Genicular nerve injection is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bloody diarrhea.
Treatment: Abdomen and Pelvis CT Scan.
The insurer denied the Abdomen and Pelvis CT Scan.
The denial is upheld.

The patient is a male with HIV (human immunodeficiency virus) and diabetes, with bloody diarrhea and urgency. His provider ordered CT (computed tomography) scan of the abdomen and pelvis to further evaluate.

No, the requested Abdomen and Pelvis CT (computed tomography) Scan is not medically necessary.
The patient has new onset bloody diarrhea.

The standard of care in the evaluation of bloody diarrhea involves stool cultures, and if negative, flexible sigmoidoscopy. There is no medical literature to support CT (computed tomography) abdomen and pelvis as initial diagnostic testing in a patient with bloody diarrhea. Therefore, the requested CT (computed tomography) abdomen and pelvis is not clinically appropriate, accepted standard of care or medically necessary in this patient.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
A CT (computed tomography) scan of the abdomen is not clinically appropriate or medically necessary in the evaluation of bloody diarrhea in a patient suspected of having acute colitis. Therefore, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Glaucoma
Treatment:  Combigan 0.2-0.5% OP SOLN, Pre-service
The insurer denied the  Combigan 0.2-0.5% OP SOLN, Pre-service.
The denial is upheld.

The patient is a male with open-angle glaucoma, severe stage, for whom coverage of Combigan 0.2-0.5% is the subject of review. Coverage was previously approved as the patient had reported failure with individual components. Coverage was recently denied as the patient has not tried and failed the generic which is available and considered the preferred alternative. Upon appeal, the provider notes that the patient has shown improvement while under Combigan treatment in the past. No comment is provided as to why the generic equivalent would not be appropriate.

No, the proposed branded Combigan is not established as medically necessary over the generic equivalent.
A review of the peer reviewed medical literature does not identify branded Combigan as safer or more effective than the generic equivalent for the patient's condition.  No comment is provided as to why the generic equivalent would not be appropriate for this patient.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Based on the information provided, the health plan acted reasonably, with sound medical judgement and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foot Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a female with past medical history of colon cancer with colovesicular fistula, neuropathy, diabetes mellitus type 2, hypertension and asthma who presented to the emergency department after referral by her podiatrist due to a painful left foot and draining wound on the left fourth toe. The patient was admitted to inpatient level of care and continued on intravenous (IV) Ancef, blood cultures and wound cultures were obtained, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were ordered, and it was noted there was no need for urgent surgical consultation. The patient's sedimentation rate was 76 and CRP was 3.9. Due to clinical concern for osteomyelitis patient underwent an MRI of the foot showing marrow signal abnormality of the fourth distal phalanx without marrow replacement or enhancement located adjacent to the dorsal skin ulcer which may be artifactual or represent osteomyelitis, no abnormal enhancement or abscess. Wound culture came back with methicillin-resistant staphylococcus aureus (MRSA) sensitive to vancomycin. The patient was transitioned to IV vancomycin and had consultation with infectious disease who recommended transition to oral Bactrim at high dose, 2 by mouth (p.o.) twice daily for 4 to 6 weeks. The subject under review is the medical necessity for the inpatient stay. 

The patient had past medical history of diabetes with neuropathy secondary to her past chemotherapy putting her at higher risk for more serious infection and complications. Although the patient did not have an elevated white blood cell count nor fever at the time of admission given her underlying medical issues, she may not mount appropriate febrile response or leukocytosis in response to serious infection. Although the initial x-ray did not suggest osteomyelitis, the patient's sed rate and CRP were suggestive of osteomyelitis prompting MRI evaluation of the foot with concerns for osteomyelitis. The patient's culture grew MRSA and with any drug-resistant organism more care must be taken in selection of antibiotics and subsequent follow-up. The patient had infectious disease consultation urgently upon discovery of possible osteomyelitis with appropriate plan for treatment of patient's condition.
The patient's severity of illness and intensity of care were appropriate at inpatient level of care. Without proper treatment there is risk of systemic infection, limb loss, and/or death. The inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Hip Pain

Treatment hip arthroplasty

The insurer denied coverage for hip arthroplasty

The denial is overturned 

This is a female with a history of obstructive sleep apnea (OSA), gastroesophageal reflux disease (GERD), and right hip pain. She presented to the Orthopedic Surgeon's office for the evaluation of right hip pain. She had a four-year history of right hip pain. The patient has tried and failed physical therapy (PT) and anti-inflammatories. She has to use a cane because she can only walk short distances. The physician recommended hip surgery to treat symptoms. The patient had a right hip arthroplasty. 

The medical record was consistent for the diagnosis of end stage hip osteoarthritis. Subjective complaints were reported for years in duration. Documentation was submitted of visits to other physicians whose recommendations also included hip surgery. 

The patient's objective physical findings included restricted motion and requirement of cane to walk. There was documentation of physical limitations to activities of daily living. Imaging studies showed end stage degenerative disease (ie. Tonnis >3). She had received conservative treatment without improvement. 

Based upon the definition of a specific pain generator, functional limitation and poor response to non-operative management, the next step would be a total hip arthroplasty. The services provided were medically necessary and in accordance with standards of practice. 

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

The insurer's denial of coverage for a hip arthroplasty performed is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with a history of nephrolithiasis who presented with 2 days of left flank pain. He presented to the emergency department (ED) when the pain started as was told he had a 5 millimeter (mm) obstructing left ureteral stone and was placed on conservative therapy with outpatient follow up. He presented again after continued 9/10 pain associated with nausea and vomiting, He denied fevers, chills, hematuria, dysuria, or abdominal pain.

On exam he was well appearing with left sided costovertebral angle tenderness. Vitals showed that he was afebrile with a blood pressure of 135/95, a pulse of 60, a respiratory rate of 20 and a room air pulse oximetry of 97%. Labs showed a blood urea nitrogen (BUN) of 16, a creatinine of 1.3, a white blood cell (WBC) of 10.6, a hemoglobin of 14.5. A urinalysis showed negative leukocyte esterase, negative nitrite, negative blood, and no white blood cells (WBCs) A renal ultrasound (US) revealed mild left sided hydronephrosis and a distal ureteral echogenic structure. A computed tomography (CT) scan showed no significant change in the left ureterovesical junction (UVJ) stone compared with prior study and persistent mild left hydronephrosis. The patient was admitted for further management. The patient felt better per the progress note without pain, nausea or vomiting. The patient was seen by urology and desired extracorporeal shock wave lithotripsy (ESWL) rather than decompression with a ureteral stent. He was discharged home in stable condition with outpatient follow up for lithotripsy.

The subject under review is the medical necessity for inpatient stay.

The inpatient stay is not medically necessary in this case based on the documentation provided. The patient presented due to a distal left ureteral stone that had not responded initially to conservative management. The patient was hemodynamically stable. The patient did not have a documented complicated urinary tract infection or bacteremia. The patient did not have persistent nausea, vomiting or pain beyond what could be managed in a lower level of care setting. The patient did not have bilateral ureteral obstruction or unilateral obstruction of a solitary kidney. He did not require intravenous (IV) hydration despite observation care. He did not have documented acute renal failure. He did not require an inpatient procedure or have a complicated of a procedure that required inpatient management. Placement of a ureteral stent can be safely done at a lower level of care and does not necessitate inpatient admission. The patient could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate cancer

Treatment: Positron emission tomography (PET) scan

The insurer denied coverage for the positron emission tomography (PET) scan

The denial is upheld

This male patient with history of prostate cancer, presented for evaluation of his prostate cancer. The patient decided to proceed with prostate surgery and a positron emission tomography (PET) scan was advised to best guide the course of treatment. This patient newly diagnosed prostate cancer with prostate-specific antigen (PSA) 16.2 nanograms per milliliter (ng/ml) and Gleason 8 prostate cancer. Magnetic resonance imaging (MRI) was highly suspicious for extra capsular extension. Per current American Urological Association (AUA) guidelines, National Comprehensive Cancer Network (NCCN) guidelines; imaging recommended in this situation remains computed tomography scan abdominal/pelvis and radionuclide bone scanning. Prostate-Specific Membrane Antigen (PSMA) positron emission tomography (PET)/ computed tomography (CT) is not standard of care for newly diagnosed prostate cancer, as per the guidelines, but may be considered in cases where patients have negative conventional imaging but are at high suspicion for metastatic disease. MRI is very useful in identifying extra prostatic extension (as in this case) and if conventional imaging shows no evidence of metastatic disease; the next step would be consideration of curative therapy; either with robotic prostatectomy or possible external beam radiation. PSMA PET/CT is not standard of care yet in this situation, and not recommended by guidelines.

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

The patient already had Gleason 8 prostate cancer which was diagnosed before he had his MRI.  A prostate imaging reporting and data system (PI-RADS) 5 lesion is a finding that is obtained only from an MRI.  This patient already had a history of high-grade prostate cancer Gleason 8, so a PI-RADS 5 lesion on MRI probably does not need to be biopsied as you already know he has high-grade prostate cancer which needs treatment.  The question is, is a PET CT scan indicated for the initial staging of prostate cancer. It is not.  While the current AUA guidelines are probably somewhat dated, they still recommend a CT scan and a bone scan for the initial staging of high-grade prostate cancer.  An MRI is done to evaluate for local invasion which in this case raises a high risk of extracapsular extension.  However, this will only be found out at the time of surgery which is the treatment that the patient is having. 

PET scan is not considered medically necessary for this patient.

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

The insurer's denial of coverage for a positron emission tomography (PET) scan is upheld. Medical necessity is not substantiated.