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

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent.

The insurer denied the Dupixent.  The determination is overturned.

The patient has a diagnosis of atopic dermatitis.  She has a large body surface area affected.  She has failed tacrolimus, Eucrisa, and triamcinolone.  The medication under review is Dupixent.   

Given that the patient has severe atopic dermatitis uncontrolled with all conventional topical steroids, calcineurin inhibitors, and Eucrisa, the Dupixent is medically necessary.

The request for Dupixent is supported by the medical literature and specialty society guidelines.  Dupixent is the only systemic therapy approved by the FDA for the management of atopic dermatitis.  In early 2017, the Food and Drug Administration (FDA) approved Dupixent for adults with moderate-to-severe atopic dermatitis (AD) who are inadequately controlled with topical treatments, and in spring of 2019, it was approved for pediatric patients, as in this patient (1-3).  According to consensus guidelines "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe AD .... Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment ... with moderate-to-severe AD who are uncontrolled with topical therapies" (1).  Igelman et al. writes in "Off-label use of dupilumab for pediatric patients with atopic dermatitis: A multicenter retrospective review" of the efficacy and safety of Dupixent for treatment of atopic dermatitis in patients as young as 3 years old, and a different study as young as 6 months old (4-5).  Therefore, the Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Colitis.
Treatment: Stelara.
The insurer denied Stelara.
The determination is upheld.

The patient has severe ulcerative colitis (pancolitis) and a family history of cardiovascular disease in his father and brother. He has failed mesalamine, budesonide, Remicade , and Entyvio. A colonoscopy (while on Entyvio, Canasa, and Lialda) showed severe pancolitis, confirmed on biopsies. The coverage is requested for Stelara. for the treatment of ulcerative colitis. The request was not approved due to lack of attempt of or contraindication to Humira or Xeljanz.
At issue is the medical necessity of Stelara.

The medical necessity of Stelara is not met given the formulary requirement for an attempt of or contraindication to Xeljanz. Xeljanz is recommended by guidelines for the treatment of ulcerative colitis. The American Gastroenterological Association guidelines for the treatment of moderate to severe Ulcerative Colitis state "In adult outpatients with moderate to severe ulcerative colitis who have previously been exposed to infliximab, particularly those with primary nonresponse, the American Gastroenterological Association (AGA) suggests using ustekinumab or tofacitinib" [1]. Humira is not recommended by the guidelines in patients who have failed Remicade [1]. The American College of Gastroenterology guidelines for the treatment of Ulcerative Colitis also recommend Xeljanz as first-line therapy for moderate to severe disease, including in patients with prior failure of anti-tumor necrosis factor therapy such as Remicade [2]. Xeljanz is Food and Drug Administration (FDA) -approved for the treatment of Ulcerative Colitis [3,4]. Xeljanz has no listed contraindications in the FDA-approved prescribing information for Xeljanz [3]. Additionally, the cardiovascular black box warnings listed in the prescribing information are not applicable to the patient, as they only apply to patients over age 50 [3]. There is a lack of controlled head-to-head studies to show that Stelara is safer or more effective than Xeljanz, and comparison of disparate trials is not valid; a network meta-analysis did not show notable differences in safety or efficacy [5].
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: atopic dermatitis (AD)
Treatment: Dupixent 300 mg (dosed Weekly)
The insurer denied Dupixent 300 mg (dosed Weekly). 
The health plan's determination is overturned.

The patient is a female with atopic dermatitis (AD) with partial response on Dupixent every other week. The patient has tried and failed topical steroids, topical Tacrolimus, and topical Opzelura. The provider requesting Dupixent 300 milligrams (mg) (dosed Weekly). 

Dupixent 300 mg (dosed Weekly) is medically necessary for this patient.
Randomized controlled trials for Dupilumab did not find a significant difference in response to weekly dosing compared with that to every other week (EOW) dosing. The article by Gao et al performed a cohort study to examine the real-world experience for recurrence of AD prior to the next dose of dupilumab and how patients on weekly dosed dupilumab did in the cohort, all of whom were inadequately controlled on the approved dosing. This was a small study with only 23 patients. The 23 patients who had tried weekly dupilumab were called, with 17 patients completing the survey. It was observed that 12/17 patients (71%) reported recurrence prior to their next dupilumab dose, and all of them (100%) claimed that increasing EOW dosing of dupilumab to EW (every week) dosing helped control their symptoms, this benefit was worth the effort of injecting oneself twice as often, and they planned to remain on weekly dosing. From this study, weekly dosing of dupilumab may be beneficial to some patients with AD, particularly those experiencing a recurrence of AD symptoms on the standard dosing.
Therefore, given the patient's severe disease and partial response to every other week dosing, Dupixent 300 mg (dosed Weekly) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypoglycemia
Treatment: Full hospital admission

The insurer denied coverage for full hospital admission.
The denial is upheld.

This 37.2 week gestation, birth weight 3289 grams, female was born via Cesarian section to a mother with Type 1 insulin dependent diabetes and epilepsy.  Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.  The infant was admitted to the neonatal intensive care unit (NICU) for glucose monitoring. Documented physical examinations were normal.  All documented glucoses (including the initial 52 milligrams per deciliter [mg/dL]) were within normal limits for age. Intravenous (IV) Dextrose 10 water (W) was started and continued. Thereafter, the infant was sustained with enteral feeding and the infant was discharged.

The standard of care (Pediatrics; 127:575-579) for a 37-week gestation (term) Infant of a Diabetic Mother includes glucose screening (monitoring) for hypoglycemia.  For a well- newborn infant, this does not require admission to a NICU and may be performed in a well-newborn nursery.  Should hypoglycemia be detected, treatment (e.g., frequent feeding, by mouth and/or IV glucose) would be indicated. The location of care would depend upon the individual infant's glucose levels, presence or absence of hypoglycemic symptoms, route of treatment, response to initial treatment, and/or whether there is a co-morbidity that might necessitate a higher level of care.  Treatment of hypoglycemia with IV Dextrose would be expected to require admission to a NICU as opposed to a well-newborn nursery. 

Herein, however, it appears that IV Dextrose was initiated prophylactically because the initial glucose of 52 mg/dL was normal for age.  Based on existing recognized guidelines, the infant did not have hypoglycemia and IV Dextrose was not medically necessary.  Accordingly, this infant did not merit admission to the NICU or an intensive level of care.  

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

The insurer's denial of coverage for the full hospital admission at an intensive (NICU) level of care is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia

Treatment: inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is upheld.

The patient presented to the hospital with complaints of fever, dry cough, and some dyspnea on exertion (DOE) for 3 days duration. The patient has a history of sickle cell disease (SSD) and Covid (Coronavirus).  Vital signs (V/S) at presentation to emergency department (ED) Temperature 101. 1 Fahrenheit, Heart Rate 111, Respiratory Rate 22, Blood Pressure 102/67 mm Hg (millimeters of mercury), Oxygen (O2) saturations 100% (percent). The patient was in no acute distress (NAD). Chest x-rays revealed (CXR) revealed a L (left) sided infiltrate. White blood cell count (WBC) was 11.5, Hb (hemoglobin) 8.3, and Covid Rapid Antigen was negative. The patient was admitted to the hospital for community acquired pneumonia (CAP), rule out (R/O) COVID.

The patient was treated with Rocephin and Azithromycin for CAP.

As per history and physical (H&P), the patient was in no acute distress (NAD). The patient was not using accessory muscles of respiration, and lungs were clear to auscultation. The patient alert and oriented X 3 (person, place, and time).  White blood count (WBC) was 10.5. Vital signs were heart rate (HR) 90, blood pressure (BP) 115/69, respiratory rate (RR) 23 and oxygen saturation were 96%.

The patient denied any chest pain, had some dry cough, was in no acute distress (NAD). Shortness of breath (SOB) was better. Computed tomography (CT) revealed a small pneumonia (PNA). There was no pulmonary embolism (PE), lungs were clear, and the cardiac exam was within normal limits (WNL). The patient was tolerating oral intake (PO). Antibiotics were changed to Doxycycline.

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. Observation period could be for up to 48 hours. This patient had a mild CAP. Pneumonia severity score (PSI) score was low and CURB 65 (confusion, urea, respiration rate, blood pressure) was Zero.

This patient could have been switched to oral antibiotics. The patient was afebrile and hemodynamically stable, saturating to 100%. The patient did not have a myocardial Infarction (MI) or pulmonary embolism (PE). The patient could have been discharged home on oral antibiotics with close follow up in the outpatient setting.

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

The insurer's denial of coverage for inpatient hospital stay is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System 
Treatment: Home Health Care 
The insurer denied increase in consumer directed personal assistance program 84 hours per week.
The decision is upheld.

The patient is a female with past medical history significant for asthma/chronic obstructive pulmonary disease (COPD), osteoarthritis and ambulatory dysfunction. This review is for the medical necessity of consumer directed personal assistant program hours, 12 hours per day x (times) 7 days a week for a total 84 hours a week. The patient has been approved for a total of 63 hours, which is an increase from 52.5 hours a week. Services were denied based upon medical necessity. The subject under review is the medical necessity for the increase in hours.

No, the requested health service is not medically necessary for this patient. Additional services were denied by the patient's insurance stating the following: Additional services were requested by the patient's son because of a significant change in your mother's physical condition for quite some time. She cannot sit or get up from a chair alone, walk with a cane or walker or even stand for a minute, positioning, take medicines, pick up anything from the floor while seated, cook, hold a glass, turn pages, get dressed, clean herself, eat meals, dial phone number, or comb her hair. You stated that she needs assistance with functions of daily living. 

The Uniform Assessment System (UAS) State of New York, stated some of your mother's personal care needs stayed the same and some declined. Mother's abilities to perform daily activity is the same for dressing upper body, personal hygiene, walking, locomotion, bathing, toilet transfer, meal preparation and housework. Your mother's abilities to perform daily activities declined in dressing lower body, bed mobility, toilet use, eating, and medication management. Your mother lives with her 2 sons and daughter and her children are supportive and involved in her care. Granting additional hours for safety monitoring and supervision are not covered services and not medically necessary. The plan approved 9 hours per day x7 days a week for a total of 63 hours a week.

The services provided, 63 hours a week of consumer directed care services, are adequate to meet the patient's needs and considers the patient's functional disabilities and physical decline. Services beyond 63 hours are not medically necessary. Additional services for prevention of falls, for supervision or monitoring without services being provided, are typically not necessary. In order for services to be considered medically necessary, the aide must be performing a service such medically necessary activities of daily living (ADLs) or instrumental activities of daily living (IADLs).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status Post 2 Kidney Transplants. 
Treatment: Egg Retrieval with Fertilization of the Eggs. 

The insurer denied Egg Retrieval with Fertilization of the Eggs.  The denial is upheld.

The patient is a gravida 1, para 0, elective abortion (EAB) 1 female with a history of focal glomerulosclerosis, which has resulted in kidney failure necessitating a kidney transplant. She has had two kidney transplants. She is currently on multiple immunosuppressive medications that would need to be reduced, stopped, or switched in order for the patient to attempt pregnancy, and doing so could endanger her transplant. An evaluation from her nephrologist and a maternal-fetal medicine physician all state that they discourage the patient from conceiving and attempting to carry a pregnancy on her own due to significant health risks. These risks include renal transplant rejection, pre-eclampsia, eclampsia, fetal growth retardation and further worsening of her renal function. She also is an insulin dependent diabetic and has hypertension. She has had loop electrosurgical excision procedure (LEEP) procedure for cervical dysplasia. There are no records or testing showing the patient's fertility potential or any studies detailing evidence of her fertility status. No semen analysis was given.

The patient is requesting in vitro fertilization (IVF) which requires ovarian stimulation, egg retrieval, fertilization of oocytes to create embryos and freezing of embryos for future use. It is her intent to use a gestational surrogate to carry the pregnancy due to her multiple medical issues that make her carrying the pregnancy a significant potential risk to her health and well-being.

The request for services have been denied as the patient does not meet criteria for the use of IVF treatment. 

The health plan's determination is upheld.

The requested egg retrieval with fertilization of the eggs is not medically necessary for this patient.

There have been no studies to determine the patient's fertility status. Given her age, she may not meet criteria for starting fertility treatment. There is no evaluation of her partner to determine if there are any infertility issues. The patient does not meet standard criteria for IVF treatment.

Based on the standard of care, it is reasonable to consider IVF for this patient due to her medical condition (chronic renal failure with renal transplant).  However, there was no evidence presented to show what her fertility potential is and/or any information on her reproductive history.  Without fully evaluating this patient to even see if she is a candidate for infertility treatment, one cannot approve aggressive treatment.  Standard of care requires that a patient and her partner have an initial work-up to look for all potential infertility issues.  None of this was done.  Therefore, this patient does not meet standard criteria for IVF.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis
Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.
The denial is upheld.

The patient had a history of diverticulitis and presented with left lower quadrant (LLQ) abdominal pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The white blood cell (WBC) count was 13.1. A computed tomography (CT) scan was read as acute sigmoid diverticulitis. There was no fluid collection. Intravenous (IV) antibiotics were given. No surgical interventions were advised. She was then switched to oral antibiotics.

Clinical indications for admission for Acute Diverticulitis (MCG (Milliman Care Guidelines) M-150) include hemodynamic instability, peritoneal signs, persistent gross bleeding, and a significant abnormality on imaging studies. This imaging abnormality can be a fistula, obstruction, perforation, or an abscess. The patient did not have these conditions. She also did not have bacteremia, severe vomiting, severe dehydration, or need an inpatient surgical intervention.

This patient had diverticulitis that was not complicated by an abscess or perforation. She did not meet MCG criteria for admission for Acute Diverticulitis. She could have been managed with observation status and then been discharged on a course of oral antibiotics. 

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

The insurer's denial of coverage for inpatient hospital stay is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: elbow pain
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

This is a case of a male admitted for diagnosis of gout with positive crystals in fluid and negative cultures. The patient presented with right elbow pain, swelling and redness for seven days prior to admission. Orthopedic surgery treated the patient with clindamycin on an outpatient basis, but after two days, the patient had worsening redness and the patient was sent to the emergency department. Physical exam showed swelling, hyperemia, and tenderness in the right elbow. There was distress due to pain. 

The inpatient hospital admission was not medically necessary.
The patient in this case was initially treated for cellulitis but was ultimately diagnosed with a gout flair. He responded to the treatments given and did not have a resistant case requiring intraarticular glucocorticoids, or interleukin one inhibition. There was no evidence of infection and cultures remained negative. There was no septic joint.
According to Milliman Care Guidelines (MCG) Health Cellulitis and the documentation submitted, there was no hemodynamic instability, altered mental status, failed outpatient treatment given the lack of infection, limb threatening infection, significant immunosuppression, bacteremia, necrotizing infection, oral cellulitis, surgical procedure, gangrene, orbital infection, preseptal infection, severe pain requiring inpatient management, inability to maintain oral hydration or compartment syndrome.
Although the patient had needs best addressed in the hospital setting the monitoring, the diagnostic workup and therapeutic interventions prescribed could have been safely administered at a lower level of care. Therefore, the inpatient admission was not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems/Other/Orthodontic Needs
Treatment: Dental/Orthodontic Procedure

The health plan denied the requested orthodontic braces and monthly visits x4 as not medically necessary. 
The health plan's determination is upheld, in whole.

The patient is a male with Skeletal Class II malocclusion, mild mandibular crowding and mild maxillary crowding, moderate overjet, and moderate overbite.
The subject to be determined is the medical necessity for braces and monthly visits (x4).

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

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 14 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, braces, and monthly visits (x4) are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myocardial infarction

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.

The patient had a history of hypertension (HTN), bowel disease and diverticulitis colitis, status post bowel resection, restless leg and daily cocaine use. The patient presented to the emergency department (ED) via ambulance with complaints of constant mid-sternal chest pain radiating to the left arm for hours. He had last used cocaine two days prior to admission. Troponin was elevated at 1.33 (normal 0-0.08). His electrocardiogram (ECG) did not show definite ischemic changes. Cardiology was consulted and the patient was diagnosed with a non-ST elevated myocardial infarction (NSTEMI). The patient was admitted for further management and monitoring. The patient had computed tomography (CT) coronary angiography which showed 50-70 percent (%) left anterior descending (LAD), circumflex, and right coronary arteries. Ejection fraction was 55%. The following day, he left against medical advice (AMA).

The hospital admission was medically necessary. The patient had evidence of an NSTEMI. The patient presented with prolonged chest pain and had a troponin in the ED that was elevated, compatible with a non-ST segment elevation myocardial infarction. Such patients require in-hospital care as they are more prone to fatal arrhythmias and hemodynamic instability. After admission it was found by CT angiography which was appropriate. The patient then signed out against medical advice. The short in- hospital stay is considered medically necessary as patient had a myocardial infarction which required in-hospital monitoring.

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

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.