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

Diagnosis: Plaque psoriasis. 
Treatment: Taltz. 

The insurer denied coverage for Taltz. 

The denial is upheld. 

This is a female patient with plaque psoriasis affecting 10% body surface area (BSA).  The patient has failed Cosentyx, topical steroids, and phototherapy. She has a history of fatty liver, diabetes, and morbid obesity. The patient has a family history of malignancy.  Her maternal grandfather had prostate cancer and her mother had breast cancer. The patient's dermatologist requested the medication Taltz for psoriasis. 

As per Menter et al. (2019), the use of tumor necrosis factor (TNF) inhibitors has relative contraindications for patients with the following: untreated hepatitis B infection; history of lymphoreticular malignancy; active infection (including tuberculosis) or sepsis; New York class III or IV congestive heart failure (CHF) or pre-existing multiple sclerosis. Absolute contraindication would be a history of allergic reaction to a therapeutic agent or vehicle. Garcia-Doval et al. (2016)'s study found that "[in] current clinical practice, treatment with anti-TNF drugs was not associated with a higher risk of serious infections than treatment with nonbiologic systemic therapy." As per Bartos et al. (2016), "Biologics are highly effective treatments for moderate-severe psoriasis with a high percentage of patients achieving 75% improvement in Psoriasis Area Severity Index (PASI75) at 12 weeks." 

Based on the review of the medical record, this is a patient with plaque psoriasis affecting 10% of BSA. The patient has a history of fatty liver and a family history of malignancy. However, the patient does not have a demyelinating disorder, CHF, lupus like syndrome or active infection. She is not immunosuppressed or immunocompromised. The patient does not have any personal history of malignancy. There is no documented relative or absolute medical contraindication to the use of the insurer's preferred medications. The patient has no documented trial and failure with any of the Food Drug Administration (FDA) approved options of Enbrel, Cimzia, infliximab, Inflectra, or Avsola. There is no exception for Taltz. Thus, the medication Taltz is not considered medically necessary for this patient at this time. 

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

The carrier's denial of the medication Taltz for psoriasis should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spastic quadriplegia cerebral palsy, Chronic respiratory failure

Treatment: Personal care assistance (PCA) services, Level ll, 36 hours per week

The insurer denied coverage for personal care assistance (PCA) services, Level ll, 36 hours per week.

The denial is upheld.

This is a male patient with multiple medical problems including chronic respiratory failure on ventilator support via tracheostomy, congestive heart failure, dysphagia with a percutaneous endoscopic gastrostomy (PEG) tube and spastic quadriplegia cerebral palsy. The patient currently has around-the-clock private duty nursing care from a licensed practical nurse (LPN) 24 hours/day, 7 days a week, as well as personal care assistance (PCA) services 30 hours/week. A request was made for an increase of PCA services to 36 hours per week which was denied by the insurer.

The clinical records do not provide a compelling case for the requested additional services. The patient is severely debilitated with poor potential for any functional improvement. The primary reason for the request of additional services is reported difficulty turning the patient due to his heavy weight and thus, risk for pressure ulcers. However, according to a recent physician office visit note, there was "no skin breakdown" noted on this patient's physical exam. The current care hours can also be rearranged to better suit this patient's custodial care needs.  

The Uniform Assessment System (UAS) report reflects the patient's debility level and service needs. The combination of the UAS and physician assessments support the extensive LPN/PCA services currently provided for the patient. However, the clinical records also demonstrate the provided quality of care, which is sufficient to meet the needs of this patient at this time.  

From a physical medicine and rehabilitation perspective, the requested coverage for PCA services Level ll, 36 hours per week is not medically necessary.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. Considerations included the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations.  

Based on the above, the medical necessity for PCA services, Level ll, 36 hours per week is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal
Physical Therapy

Diagnosis: Neck/Shoulder pain
Treatment: Physical Therapy
The insurer denied two additional physical therapy visits. The health plan's determination is upheld. 

The patient is a female with a with diagnoses of cervicalgia, strain of other muscles, fascia and tendons at shoulder and upper arm on the left. Under review is the medical necessity of 2 additional physical therapy (PT) visits.

The two additional physical therapy visits are not medically necessary for this patient.
While the patient noted in the appeal that "follow-up (f/u) visit after magnetic resonance imaging (MRI) with ortho she advised I see the PT 12 more times (2/week)" neither the MRI nor the physician clinic note was provided. In addition, there as only 1 physical therapy note provided which did not present a "full picture" of the patient's rehab course especially as physical therapy had started earlier. Therapy noted that neck pain was a 0/10 at rest and a 4/10 with activity and that will initial pain was moderate to severe current level of pain was mild to moderate. In addition, therapy noted that patient had shown improvement in cervical range of motion, improved posture and decrease in radicular symptoms with, overall, improved pain. While therapy did note that patient "still has increase left shoulder elevation secondary to tightness in upper trapezius, levator scapula and weak scapular decompression" it is unclear why this patient could not have successfully continued to improve with a home exercise program as she was already independent with a home exercise program, had successfully improved cervical range of motion by 10 degrees to turn head side to side with less difficulty and had improved cervical strength by 1/2 grade in order to improve cervical stabilizer strength in order to maintain proper posture 50% of the time. She had also improved left upper extremity strength by 1/2 grade to don/doff clothes without difficulty.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory distress due to COVID-19
Treatment: Long Term Acute Care Hospital Admission
The insurer denied the Long Term Acute Care Hospital Admission. 
The denial is upheld. 

The patient is a male with coronavirus disease 2019 (COVID-19) and respiratory failure who was treated with ECMO (extracorporeal membrane oxygenation). The patient received tracheostomy. He is now being weaned off mechanical ventilation (MV). The patient is being considered to be transferred to long term acute care hospital for ventilator weaning. Per the clinical documentation, the patient is not on any invasive intravenous medications.

No, the proposed long-term acute care hospital admission is not medically necessary.

The patient is receiving pain medication as needed and is receiving nutritional support. The main active issue is ventilator weaning.  The ventilator weaning can be safely and effectively performed at a lower level of care since the patient's COVID-19 (coronavirus disease 2019) infection as well as chronic respiratory failure has improved significantly. The daily lab draws, and daily physician visit are not likely required since the patient is overall doing well. The long-term acute care hospital admission is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Grade 2 frontal astrocytoma with Isocitrate dehydrogenase type 1 (IDH1) mutation

Treatment: Tibsovo tablet

The insurer denied coverage for Tibsovo tablet.

The denial is overturned.

This is a female patient with a medical history of astrocytoma of the right frontal lobe of the brain. The patient has a diagnosis of grade 2 frontal astrocytoma with Isocitrate dehydrogenase type 1 (IDH1) mutation. She was evaluated by a physician who recommended Ivosidenib (AG120) as off-label. IDH1 mutation was found in 70 percent of these types of tumor and found to be the tumor drivers. Clinical trials for this patient's clinical scenario are closed. 

Mellinghoff et al. (2017) concluded "AG-120 monotherapy is associated with a favorable safety profile and prolonged stable disease in a previously treated non-enhancing mIDH1 [mutant isocitrate dehydrogenase] glioma patient population, and warrants further clinical evaluation."

Per Dhillon (2018), "Ivosidenib (Tibsovo) is a small molecule, orally available inhibitor of mutated cytosolic isocitrate dehydrogenase 1 (IDH1) that is being developed by Agios Pharmaceuticals for the treatment of cancer in patients with IDH1 mutations.  The mutated form of the IDH1 enzyme produces a metabolite, 2-hydroxyglutarate (2-HG), which is thought to play a role in the formation and progression of acute myeloid leukaemia (AML), gliomas and other cancers."                                                         

The health care plan did not consider that Tibsovo (ivosidenib) would be approved to this patient's tumor with IDH1 mutation in view of view of the mechanism of IDH1 mutation inhibition as an isocitrate dehydrogenase-1 inhibitor that works by decreasing abnormal production of the oncometabolite 2-hydroxyglutarate (2-HG), leading to differentiation of malignant cells.      

The requested Tibsovo is considered medically necessary for this patient. There has been concern that the gliosis crosses the corpus callosum to the other side. Therefore, the recommendation to avoid radiation and to consider AG120 as off-label treatment is appropriate. Furthermore, given the tumor driver, this tumor is targeted by the Food and Drug Administration (FDA) approved ivosidenib. Therefore, it is reasonable and in the patient's best interest to utilize ivosidenib as off-label for this patient.

The carrier's denial of Tibsovo tablet is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System/Gastrointestinal. 
Treatment:  Lab Work/Blood Tests (Prometheus Anser ADA). 

The insurer denied the medical necessity of the special lab test, Prometheus Anser ADA. 
The denial was upheld.

The patient is a male with ulcerative colitis.  The patient was previously treated with steroids and infliximab, as well as Pentasa.  At one point he was on Azathioprine monotherapy.  While having a flare of proctitis, the patient was started on Humira. Azathioprine and mesalamine were added.  The patient continued to flare despite the 3-drug regimen.

The patient's provider ordered the Anser adalimumab (ADA) as a reactive test to see whether adalimumab needed to be increased in dose or switched to another agent.  This request was denied by the plan, which considers it not medically necessary.

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

The requested service/treatment of Prometheus Anser ADA is not medically necessary for this patient.

The American Gastroenterological Association (AGA) statement remains unchanged, "In adults with active inflammatory bowel disease (IBD) treated with anti-tumor necrosis factor (TNF) agents, the AGA suggests reactive therapeutic drug monitoring to guide treatment changes." [1]  This statement was given a conditional recommendation, with a very low quality of evidence.  The principle reason for this is that the studies used to derive different target trough concentrations were cross-sectional studies of patients on maintenance therapy in various stages of clinical response or remission; they were not specifically designed to evaluate patients who had a secondary loss of response. [2,3]  Newer data suggests that proactive testing is superior to reactive testing, which has generally been disappointing as a management tool.

Therefore, based on the literature and the standard of care the requested test is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gallstones.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a man with comorbid health conditions of aortic valve replacement (not on anticoagulation), Crohn's disease, and bipolar depression, who presented to the hospital emergency department (ED) with right sided abdominal pain worsening over the past 4-days.  He also had a history of a midline laparotomy for a remote gunshot wound injury.  At the time of presentation, the patient was without fever.  He was tender in the right abdomen.  Vital signs identified normal blood pressure and heart rate.  The white blood cell (WBC) count was normal at 6 thousand (K).  The complete metabolic panel identified normal serum transaminases.  Bilirubin was normal.  Ultrasound showed gallstones in the gallbladder and a sonographic Murphy sign.

The inpatient hospital admission was not medically necessary.  There is no compelling reason why this patient could not have safely and appropriately been treated at a lower level of care.

This patient presented to the hospital ED with the diagnosis of cholelithiasis/cholecystitis.  A Cardiology evaluation was performed, due to his history of having undergone aortic valve surgery.  The patient underwent an uncomplicated laparoscopic cholecystectomy.  The patient remained stable and was discharged from the hospital.

Inpatient level of care was not medically necessary.  A lower level of care would have permitted for the pre-surgical assessment, the surgical procedure and perioperative IV fluid, IV antibiotics, IV antiemetics, and post-surgical monitoring.  The patient was clinically stable following surgery, as supported by the corresponding medical records.

The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation.  The WBC count was normal, and serum chemistries did not suggest common bile duct obstruction.  Ultrasound showed gallstones.  An Inpatient stay related to cholecystectomy may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure.  In this case, a lower level of care would have satisfied the clinical needs of this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Vascular dementia, urinary/fecal incontinence, gait ataxia and frequent falls.
Treatment:  Increase Personal Care Services To 24 Hours A Day, 7 Days A Week (live-in) For A Total Of 91 Hours A Week.

The insurer denied the Increase Personal Care Services To 24 Hours A Day, 7 Days A Week (live-in) For A Total Of 91 Hours A Week.  The denial is overturned. 

The patient is a female with a history of vascular dementia, urinary/fecal incontinence, gait ataxia and frequent falls.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  An appeal review was requested for potential approval of 24 hours for seven days a week live-in Personal Assistance Services to offer increased activities of daily living (ADL) support.

Yes, the proposed treatment of 24 hours for seven days a week live-in Personal Assistance Services is deemed medically necessary. 

This is a female with a history of vascular dementia, urinary/fecal incontinence, gait ataxia and frequent falls.  Due to impairments related to these conditions, she requires assistance for completion of the majority of his/her activities of daily living (ADLs).  Recent documentation from the patient's provider indicates that due to worsening cognitive impairment, gait ataxia and fecal/urinary incontinence, the currently approved plan of 80 hours per week of Personal Assistance Services is insufficient to meet the patient's current needs.  For these reasons, the proposed treatment of 24 hours for seven days a week live in Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory Papilloma
Treatment: Avastin
The insurer denied the Avastin
The determination is overturned.

The patient has a history of recurrent respiratory papilloma. She has undergone multiple procedures with potassium titanyl phosphate (KTP) laser to remove the laryngeal lesions. She had improvement in a raspy voice with each procedure, however, symptoms return over a variable period of time. After a recent excision of the papilloma with the KTP laser, the patient had significant regrowth of the laryngeal lesions 5 weeks after the surgery. The recommendation at the follow up appointment was for injection of either Avastin or cidofovir serially every other week for approximately 4 to 5 injections. The request for Avastin was denied as not being medically necessary. At issue is the medical necessity of Avastin.

The requested service (Avastin) is medically necessary. The current literature shows evidence of the efficacy of Avastin in patients with persistent laryngeal papillomatosis. Standard treatments for laryngeal lesions is surgery, which this patient has undergone multiple times with decreasing improvement in disease control. There are limited options for this patient, and there is significant evidence that this patient would benefit from Avastin.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a female patient with a history of steroid dependent asthma. The patient is on daily prednisone. The patient was admitted to the hospital with complaints of shortness of breath (SOB) and wheezing. The patient denied fever but complained of greenish yellow sputum. The patient had taken steroids and nebulizer at home but had only mild improvement, prompting her to come to the Emergency Department (ED). The patient reported that she had her home fumigated and her symptoms happened after that. The patient also reported tripping and falling on her ribs. The patient complained of some left-sided rib pain. The patient's vital signs in the ED were: temperature of 98.1, heart rate of 117 respirations of 18, blood pressure of 116/77, and oxygen saturation of 96 %. The patient had trouble completing sentences. The patient's lung exam revealed bilateral wheezing. The patient was treated with intravenous (IV) steroids, albuterol, ipratropium, and magnesium. The patient clinically improved with treatment. As per the History & Physical (H&P) note written later that night around 10 p.m., the patient's temperature was 97.8, heart rate was 114, respirations 20, blood pressure 111/67 and oxygen saturation was 98%. The patient was in no acute distress. The patient was speaking in full sentences. The patient had some wheezing on lung examination but was otherwise, doing well. The patient's white blood cell (WBC) count was 9.6, and her electrolytes were within normal limits. The patient's chest X-ray showed no acute infiltrate. There was persistent right paratracheal adenopathy. There was no rib fracture noted. By day 2 of admission, the patient was clinically stable for discharge. 

Based on the review of the patient's medical record, the patient did not need acute inpatient hospitalization for her asthma exacerbation. The patient could have been placed in observation status for up to 48 hours of close monitoring and for diagnostic testing and treatment. The patient had improved with treatment in the ED.  As per the admitting H&P note, the patient did not have hypoxia or have any suspicion for pneumonia or rib fracture. The patient was afebrile and hemodynamically stable. The patient's WBC count and electrolytes were within normal limits. The patient quickly improved with treatment. The patient was able to speak in full sentences. By day 2 of admission, the patient was stable for discharge. The patient remained afebrile and hemodynamically stable, and did not require oxygen supplementation. The patient was tolerating oral intake. The patient was stable to be discharged home on oral steroid taper and maintenance medications with close follow-up in an outpatient setting. Thus, inpatient admission was not medically necessary for this patient. The health plan acted reasonably with sound medical judgment in the best interest of the patient.
 
The carrier's denial of coverage for inpatient admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Right above knee amputation

Treatment: Purchase of lower limb prosthetics and accessories

The insurer denied coverage for purchase of lower limb prosthetics and accessories.

The denial is overturned.

This is a male patient with a history of right above knee amputation. The patient has been wearing a stump shrinker and has been compliant with home stretching/exercises. The patient is currently using a wheelchair for mobility. He is ready to begin training and fitting with prosthesis. Under review is the medical necessity for purchase of lower limb prosthetics and accessories.   

The preparatory prosthesis is a custom made patient-specific item (not loaned) that is utilized for the training and eventual provision of a permanent prosthesis. The initial (thermoplastic) socket will need to be replaced as the residual limb continues to heal and mature. A permanent socket is then provided. However, the initial mechanical knee and foot components can be used for the permanent prosthesis.  

From a physical medicine & rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the prosthetic components are not loaned items. The initial (thermoplastic) socket will eventually need to be replaced with a permanent socket. However, the initial mechanical knee and foot components can be used for the eventual permanent prosthesis.

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

The insurer's denial of coverage for purchase of lower limb prosthetics and accessories should be overturned.