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

Diagnosis: Respiratory distress.
Treatment: Inpatient admission.

The insurer is denied coverage for inpatient admission.  The denial is overturned. 

This male patient has a history of asthma, sickle cell trait, and attention deficit hyperactivity disorder. He presented to the emergency room (ER) with complaints of a one day history of shortness of breath (SOB) and a dry cough. One Albuterol treatment was given at home without improvement. The patient has been waking up at night with SOB about 2-3 times a week with a need for Albuterol 2-3 times a week. In the ER, the patient had a high respiratory rate and was not moving air. He was in significant distress. He was given 3 nebulizer treatments, magnesium sulfate, an intravenous (IV) normal saline (NS) bolus, and Prednisolone. The patient was admitted for respiratory distress. He was placed on the asthma pathway. Albuterol was given every 2 hours (Q2H) and the patient was placed on a 5 day course of oral (PO) steroids. An inhaled corticosteroid was added to the patient's medication regiment. The patient remained afebrile and hemodynamically stable during the admission. He was discharged with instructions to follow up with the physician on an outpatient basis.

In the ER, he was noted to be in significant respiratory distress with abdominal breathing, subcostal and intercostal retractions. He had increased work of breathing with abdominal retractions. He was tachypneic and his pulse oximeter was low at 93%. On physical exam he had bilateral wheezing at the lung bases with decreased air entry right greater than (>) left lung fields. He was treated with 3 inhalations of duoneb, magnesium sulfate and methyl prednisolone. He also was administered a bolus of normal saline by intravenous (IV). He had an episode of emesis following treatment and his wheezing and increased work of breathing did not improve. The decision was made to admit the child to the hospital with a diagnosis of status asthmaticus for continued treatment with albuterol every 2 hours. The patient was treated appropriately in the ER for an acute episode of wheezing and difficulty breathing. The child has a history of poorly controlled asthma with persistent symptoms of asthma and two previous ER visits in the past year. The medical record indicates that he has been followed by his pediatrician and that he was compliant with his prescribed montelukast preventive therapy. Despite his preventive therapy, he was experiencing status asthmaticus which did not respond to albuterol in the home. When he did not respond to treatment in the ER, he was appropriately admitted to the hospital with a diagnosis of status asthmaticus. He was not stable enough to be safely discharged, since he required albuterol every 2 hours.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute osteomyelitis of right foot.
Treatment: Full hospital admission. 

The insurer denied coverage for the full hospital admission.  The denial is overturned. 

This is a male patient with past medical history significant for hypertension and diabetes mellitus who presented to the Emergency Department (ED) with complaints of swelling and erythema of right second toe. The patient's vital signs on ED presentation included: Temperature 98.0, Blood Pressure 155/69, and Pulse 82, Respiratory Rate 17, and Oxygen Saturation 100% on Room Air. The patient's laboratory values were notable for the following: white blood cell (WBC) count 13.48, hemoglobin 9.4, hematocrit 31.1, glucose 126, creatinine 1.56, C-reactive protein (CRP) 95.65, and erythrocyte sedimentation rate (ESR) > (greater than) 130. The patient was empirically started on intravenous (IV) antibiotics (i.e., Zosyn) for possible osteomyelitis.  The patient's X-ray of the right foot showed comminuted pathological fracture of the second proximal phalanx suggestive of osteomyelitis.  Podiatry was consulted and they recommended surgical intervention.  The patient's magnetic resonance imaging (MRI) of the foot was consistent with acute osteomyelitis of the head and neck of the second metatarsal. The patient's wound cultures grew Klebsiella, Citrobacter, and beta- hemolytic Streptococcus Group B.  The patient underwent partial amputation of the right foot.  Infectious Diseases consulted and adjusted antibiotic coverage.  The patient remained afebrile and hemodynamically stable.  The patient was discharged to continue oral antibiotics as an outpatient (i.e., Augmentin and levofloxacin).      

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient presented with acute osteomyelitis of his right foot. The patient's laboratory results showed an elevated WBC count, as well as increased inflammatory markers. The patient's MRI abnormalities confirmed an acute infection, and if not treated in a timely manner, can be progressive and lead to sepsis.  Additionally, the patient had multiple co-morbid risk factors including diabetes mellitus.  Based on the above findings, hospital admission was medically necessary for administration of IV antibiotics and surgical intervention. 

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

The medical necessity for the full hospital admission is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This male patient has a history of hypertension, hyperlipidemia, and diabetes.  The patient presented to the Emergency Room (ER) with complaints of worsening abdominal pain.  The patient's computed tomography (CT) scan of the abdomen revealed a sigmoid abscess.  The patient was afebrile and hemodynamically stable. The patient's white blood cell (WBC) count was 12.4.  The patient was admitted with diverticulitis.  The patient was initially kept on nothing-by-mouth (NPO) status. The patient was given 400 milligrams (mg) of intravenous (IV) ciprofloxacin every 12 hours (Q12H) and 500 mg of IV Flagyl every 8 hours (Q8H).  Infectious disease (ID) consulted over the case and they recommended cefipime. Vascular access services placed an IV midline on the patient so that IV antibiotics could be continued for 2-3 weeks at home.  The patient's pain had improved and he was able to tolerate oral (PO) intake.  The patient was discharged. IV antibiotics would be completed on an outpatient basis.

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. This patient had diverticulitis without the presence of a definitive fluid collection.  The patient could have been given intravenous (IV) antibiotics with observation care, and then, been discharged home to complete the course of antibiotics.  The patient did not meet the MCG criteria for admission for acute diverticulitis.  

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

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

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Cimzia Starter Kit for medical necessity. 
The denial was overturned in whole. 

The patient is a male with moderate to severe psoriasis (10% body surface area involvement) and arthritis. The patient was previously well-controlled on Cimzia, and because of health plan issues he had a break in therapy. The patient is experiencing generalized itching and plaques to the lower legs and behind the ears, as well as morning stiffness of the hands and ankles. The patient has tried and failed topical Duobrii, Sorilux, clobetasol, fluocinonide, triamcinolone, and Elidel, as well as oral Methotrexate. He has also tried the biologic agents Cosentyx, Stelara, Tremfya, Enbrel, and Humira. 

At issue is the medical necessity of Cimzia Starter Kit. 

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

The requested health service/treatment of Cimzia Starter Kit is medically necessary for this patient. 

Alternative biologic and oral treatments, including the Tumor Necrosis Factor inhibitors Enbrel and Humira, have been tried and failed. Cimzia is United States Food and Drug Administration (FDA) approved and literature-supported [1-4] for both moderate to severe psoriasis and psoriatic arthritis. However, the psoriasis dosing is higher, being 400 milligrams (mg) every two weeks for both induction and maintenance dosing, compared to the lower maintenance dosing of 200 mg every two weeks for psoriatic arthritis. Because this patient's psoriasis is moderate to severe in extent, the requested Cimzia dosed 400 mg every two weeks on an ongoing basis is medically necessary at this time for this patient's clinical scenario.  The patient's psoriatic arthritis and cutaneous psoriasis has responded to Cimzia, unlike Humira, Enbrel and Stelara, such that the Cimzia dosing at 400 mg every two weeks is appropriate treatment for this patient. 

Therefore, the Cimzia Starter Kit is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Amyotrophic Lateral Sclerosis (ALS) and associated upper/lower extremity weakness, urinary incontinence, vertigo, anxiety, dyspnea and fatigue.
Treatment: Increase Personal Care Aide Services to 7 Days per Week, Two 12 Hours Shifts per Day (or Split Shift).

The insurer denied the Increase Personal Care Aide Services to 7 Days per Week, Two 12 Hours Shifts per Day (or Split Shift).  The denial is overturned.

The patient is a female with a history of Amyotrophic Lateral Sclerosis (ALS) and associated upper/lower extremity weakness, urinary incontinence, vertigo, anxiety, dyspnea and fatigue. Appeal review requested for potential increase in Personal Care Aide Services to 7 Days Per Week, two 12 Hours shifts per day (or split shift) for increased activities of daily living (ADL) assistance.

Yes, the proposed treatment of 7 Days Per Week, two 12 Hours shifts per day (or split shift), Personal Assistance Services is deemed medically necessary.

The patient is a female with a history of Amyotrophic Lateral Sclerosis (ALS) and associated upper/lower extremity weakness, urinary incontinence, vertigo, anxiety, dyspnea and fatigue. 

Recent documentation from the patient's medical provider indicates that due to worsening overall functional status including worsening lower/upper extremity weakness, respiratory distress and requirement for enteral tube feeding for her nutritional support, the currently approved plan of 7 days per week live in Personal Assistance services is insufficient to meet the patient's current needs, as she currently requires 24/7 around the clock care. For these reasons, the proposed treatment of 7 Days Per Week, two 12 Hours shifts per day (or split shift), Personal Assistance Services is deemed medically necessary
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied: Cancer treatment (pembrolizumab, cyclophosphamide, pacliltaxel, carboplatin, and doxorubicin). The denial is upheld.

The patient is a female with a left breast, node positive estrogen receptor (ER)-/progesterone receptor (PR)-/human epidermal growth factor receptor (HER)2- breast cancer. Neoadjuvant therapy with pembrolziumab, cyclophosphamide, paclitaxel, carboplatin, and doxorubicin has been recommended and is under review for medical necessity.

The health plan's determination is upheld.

The requested treatment is not medically necessary for this patient.
For the purposes of this review, the checkpoint inhibitor (pembrolizumab) will be evaluated separately from the cytotoxic agents (cyclophosphamide, paclitaxel, carboplatin, and doxorubicin).
Pembrolizumab
Studies are evaluating the role of immune checkpoint inhibitors in advanced triple negative breast cancer (TNBC). In a randomized trial in patients with metastatic TNBC, pembrolizumab did not improve overall survival relative to physician's choice chemotherapy in the overall group (9.9 months versus 10.8 months) or in subgroups of patients with positive programmed death ligand-one (PD-L1) expression. However, in KEYNOTE 355, among almost 850 patients with advanced TNBC, the addition of pembrolizumab to chemotherapy improved progression-free survival (7.5 versus 5.6 months), particularly among those with combined positive score (CPS) greater than or equal to (>=) 10 (9.7 versus 5.6 months). Based on these results, pembrolizumab is approved in combination with chemotherapy for patients with metastatic TNBC whose tumors express PD-L1 with a CPS >=10. This patient's CPS score is not available for review and, therefore, medical necessity cannot be established for this service.
Cytotoxic therapy
The agents recommended for this patient are not being combined in a National Comprehensive Cancer Network (NCCN)-approved regimen. There are eleven regimens recommended by the NCCN for HER2 negative breast cancer patients; with two additional variants for patients with triple negative disease. These regimens are widely accepted and also endorsed by the NCCN. The proposed combination is not part of this group. There is a paucity of randomized data demonstrating an outcomes benefit to this combination which would also carry significant toxicity. For these reasons, medical necessity cannot be established for this service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hogkin Lymphoma
Treatment: Adcetris, Pre-service
The insurer denied the Adcetris, Pre-service
The denial is overturned.

The patient is a male with history of newly diagnosed stage III Hodgkin's lymphoma. The provider is recommending treatment with Brentuximab, vinblastine, doxorubicin and dacarbazine.

Yes, the proposed treatment with Adcetris is medically necessary.
Classical Hodgkin lymphoma (cHL) is among the most common malignancies in adolescents and young adults. Brentuximab has been shown to improve the survival of adults with Hodgkin lymphoma. Recent studies in pediatric patients have confirmed this finding in younger patients. In one study, newly diagnosed Hodgkin lymphoma patients received brentuximab with chemotherapy for Hodgkin lymphoma. Seventy-seven patients enrolled in the study, 27 (35%) achieved complete remission  and did not require radiation. Patients who were irradiated received radiation to individual residual nodal tissue. At a median follow-up of 3.4 years, the three-year event-free survival (EFS) was 97.4% (SE 2.3%) and the overall survival (OS) was 98.7% (SE 1.6%).  This outcome is superior to all known therapy for pediatric Hodgkin lymphoma.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems-Teeth spacing problem
Treatment: Dental/Orthodontic procedure-Braces
The health plan denied the treatment of Braces as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient in question has an anterior crossbite on tooth 10. He presents with a skeletal Class II malocclusion with moderate crowding in the maxilla and mandible. Tooth 11 is erupted, but blocked out to the labial. He is treatment planned for orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.

This patient presents with an anterior crossbite on tooth 10, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. Orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right leg weakness
Treatment: Lumbar Vertebra Three To Four (L3/L4) Laminectomy (CPT 63047), Pre-service
The insurer denied the Lumbar Vertebra Three To Four (L3/L4) Laminectomy (CPT 63047), Pre-service.
The denial is overturned. 

The patient is a male with worsening weakness in his right leg. The patient failed chiropractic care, home exercise, pain stimulator injections, opioids, and nonsteroidal anti-inflammatory drugs (NSAIDs).

The patient's exam revealed no focal deficit except 4/5 right quadriceps. X-ray shows fourth lumbar spine vertebra (L4) through first sacral vertebra (S1) degenerative disease. Magnetic resonance image (MRI) shows third lumbar spine vertebra (L3) through fourth lumbar spine vertebra (L4) disc herniation, causing severe stenosis, per clinic note. The patient was recommended third lumbar spine vertebra (L3) through fourth lumbar spine vertebra (L4) laminectomy.

Yes, the proposed Lumbar Vertebra Three to Four (L3/L4) Laminectomy (CPT 63047) is medically necessary.

There is sufficient evidence provided of adequate trial of conservative multimodal therapies employed and the patient's imaging does demonstrate stenosis that correlates with the patient's symptoms. The patient's pain in the legs as well as the stenosis noted on imaging findings correspond, and the patient has attempted multimodal nonsurgical management, and therefore surgery in this setting is medically necessary and appropriate. Therefore, the surgery and all CPT codes are deemed medically necessary for this patient based upon standard of care and medical necessity.

Additional documentation has been provided that supports the surgery; the surgery is medically necessary based upon standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders-Dermatitis. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Rinvoq for medical necessity. 
The denial was overturned. 

The patient is a male with severe atopic dermatitis (AD), treated with dupilumab, cyclosporine and methotrexate in order to keep him out of the hospital. He continues to worsen. He has had a severe course with multiple infections and hospitalizations. He has used topical steroids and Eucrisa, antibiotics and systemic steroids. His provider is requesting Rinvoq (upadacitinib).

At issue is the medical necessity of Rinvoq Specialty Guideline Management (SGM).

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

The requested health service/treatment of Rinvoq SGM is medically necessary for this patient.

Rinvoq (upadacitinib) was evaluated in a 16-week, double-blind, placebo-controlled, parallel-group, dose-ranging portion of this 88-week trial in 8 countries. Adults with moderate to severe disease and inadequate control by topical treatment were randomized 1:1:1:1, using an interactive response system and stratified geographically, to once daily upadacitinib oral monotherapy 7.5, 15, or 30 milligrams (mg) or placebo. The trial showed a 74% improvement (achievement of primary end point) at the 30 mg dose. Half of the patients receiving the 30 mg dose of upadacitinib achieved clear or almost clear skin based on the Investigator Global Assessment (IGA) score and an improvement of at least 90% in Eczema Area and Severity Index at week 16. Improvements in signs and symptoms of AD were shown after the first week in those receiving upadacitinib (7.5, 15, 30 mg), with a significant reduction in pruritus as well as clinical efficacy end points. There was no correlation between the occurrence of adverse events and the dose of upadacitinib. Therefore, there were no safety concerns to preclude further investigation of upadacitinib for AD, and phase III trials are currently under way. These agents offer a solution for patients who do not respond to dupilumab or cannot tolerate dupilumab side effects.

Given the nature of this patient's disease and results from phase II studies with upadacitinib (Rinvoq), as well as a near total lack of other options for this patient, Rinvoq is medically necessary.

Therefore, Rinvoq is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: acute pericarditis of unclear etiology.

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned. 

This male patient has a history of  depression and gastroesophageal reflux disease (GERD) who presented to the Emergency Department (ED) for chest pain. The patient reported that the chest pain started that morning, and started as mild but progressed to 10/10, significantly worsening with deep inspiration and accompanied with diaphoresis. On arrival to the ED, the patient was noted to be diaphoretic and in severe distress secondary to pain. The patient's blood pressure was 172/91. Electrocardiogram (ECG) revealed normal sinus rhythm. The patient's troponin was negative.  Computed tomography angiography (CTA) of the chest was negative for acute aortic pathology but revealed trace heart pericardial fluid without significant pericardial thickening. Due to persistent excruciating pain, despite morphine and nitroglycerin, the patient was taken to the catheterization lab for emergent coronary angiography which found no significant coronary disease. Post-catheterization cardiac monitoring revealed PR segment depression and concave ST elevation, consistent with acute pericarditis. The patient was admitted to the Telemetry Unit for acute pericarditis of unclear etiology. During the hospital course, the patient's troponin remained negative. The patient was started on Ibuprofen and colchicine as recommended by Cardiology. Pain control was achieved with intravenous (IV) hydromorphone and the patient was discharged home with Pulmonology and Cardiology follow-up.

This patient presented with severe chest pain and was ultimately diagnosed with acute pericarditis. Following diagnostic testing, the patient required several days of treatment to manage inflammation and associated pain. In one study examining over 670,000 admissions for pericarditis, the median length of hospitalization was 4.8 days.(1) This patient's initial presentation was confounded by the lack of abnormal ECG findings on initial recording. He subsequently was noted to have concave diffuse ST elevations consistent with a diagnosis of pericarditis. The patient was appropriately treated with NSAIDs and colchicine.(2) However he also required narcotics to manage his severe pain. Given multiple reports of myopericarditis and COVID 19 infection, the patient was appropriately monitored for several days.(3) In conclusion inpatient stay was medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.
	
The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.