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

Diagnosis: Abdominal Pain
Treatment: Continued Inpatient Hospital Admission
The insurer denied: Continued Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male who was admitted for abdominal pain. A chest x-ray was negative for acute process. A computed tomography of the abdomen and pelvis showed possible splenic infarct, renal arterial thrombosis. The patient was treated with antibiotics for possible urinary tract infection, was started on anti-coagulation and Remdesevir for positive COVID-19 (Coronavirus disease). Repeated evaluation of abdominal imaging confirmed that the patient did not have renal artery thrombosis. The patient was treated and evaluated by physical and occupational therapy and discharged in stable condition.

The proposed treatment was not medically necessary.

The patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or change in kidney function. He did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration. There was no documentation of refractory pain, and the patient was able to tolerate oral diet and did not require total parenteral nutrition.
When taking into account the patient's exam, imaging, and lab findings as well as the patient's lack of need for diagnostic testing beyond what was already done prior to the dates of service in question and the availability of any additional diagnostic testing as an outpatient, the patient had no requirements for inpatient level of care for the requested continued hospital stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea; Vomiting
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

This patient is an adult female with hypertension, diabetes, asthma, and gastritis who presented to the emergency room for severe and progressive nausea / vomiting, diarrhea, and abdominal pain. The patient was treated with Zofran and intravenous fluids and intravenous antibiotics. The patient 
presented, was admitted the next day and was discharged the following day. The records note that on arrival to the emergency room, the patient was afebrile and hemodynamically stable. Her vitals noted blood pressure 103/58, pulse 79, respiratory rate 18, and temperature 36.5 Celsius. Labs showed white blood cell count was 14.5 with left-sided shift, Plts (platelets) 248, BUN/Cr (blood urea nitrogen/creatinine) 16.0/0.43, K (potassium) 5.3, CO2 (carbon dioxide) 23, AG (anion gap) 17, B-OH (beta-hydroxybutyrate) 1.05. The patient received LR (lactated Ringer's) 1 liter, Antacid 30 ml (milliliters), Ceqriaxone 1-gram IV (intravenous), Pepcid 20mg (milligrams), Haldol 5mg (milligrams), ketorolac IV (intravenous) 15mg (milligrams), Reglan 10mg (milligrams) IV (intravenous), Flagyl 500mg (milligrams) IV (intravenous), and Zofran 4 mg (milligrams) IV (intravenous). A computed tomography (CT) scan of the abdomen / pelvis showed 3.2-centimeter x 4.1-centimeter complex appearing right adnexal mass with calcification. The patient was discharged with a diagnosis of gastroenteritis.

The Inpatient admission was not medically necessary.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. An observational level of stay would have been more appropriate for this patient. An observational level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have fevers, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Class I occlusion.
Treatment: Braces, monthly visits. 
The insurer denied Braces, monthly visits. 
The health plan's determination is upheld. 

The patient in question is a young female with a Class I occlusion with 6-millimeter (mm) overbite and 4 mm overjet. She has minor maxillary mandibular crowing. She is in the middle-mixed dentition phase of development. Her treatment provider states she has possibly impacted maxillary canines. 

Braces and monthly visits are not medically necessary for this patient.
The patient's overbite is deep but there is no indication of damage to the incisors in the photographs. Her cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient.
While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.2 This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal but her overjet would not affect oral health related quality of life unless it was greater than 6 mm. If her teeth were aligned, it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Alopecia Areata
Treatment: Xeljanz
The insurer denied Xeljanz.
The determination is overturned.


The patient has alopecia areata (AA). Her scalp is affected. She has tried and failed Olumiant 4 milligrams (mg) daily. She was previously on Xeljanz with hair regrowth. The medication under review is Xeljanz.

The proposed health service or treatment Xeljanz is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has already failed Olumiant, and per the medical records has had previous positive response to Xeljanz.
In support of the use of Xeljanz for alopecia, Liu and others write "Ninety patients met inclusion criteria. Of 65 potential responders to therapy, defined as those with alopecia totalis or alopecia universalis with duration of current episode of disease of 10 years or less or alopecia areata, 77percent achieved a clinical response, with 58 percent of patients achieving greater than 50percentchange in the Severity of Alopecia Tool (SALT) score over 4 to 18 months of treatment. Patients with AA experienced a higher percent change in SALT score than did patients with alopecia totalis or alopecia universalis (81.9percent versus 59.0percent). Tofacitinib was well tolerated, and there were no serious adverse events" [1].
Jabbari and others writes in "An Open-Label Pilot Study to Evaluate the Efficacy of Tofacitinib in Moderate to Severe Patch-Type Alopecia Areata, Totalis, and Universalis" that "In our tofacitinib trial in 12 patients with moderate to severe AA, 11 patients completed a full course of treatment with minimal adverse events. Following limited response to the initial dose (5 mg twice a day.), the dose was escalated (10 mg twice a day) for nonresponding subjects. Eight of 12 patients demonstrated 50 percent hair regrowth, while three patients demonstrated less than 50 percent hair regrowth, as measured by Severity in Alopecia Tool scoring. One patient demonstrated no regrowth. Gene expression profiles and Alopecia Areata Disease Activity Index scores correlated with clinical response. Our open-label studies of ruxolitinib and tofacitinib have shown dramatic clinical responses in moderate to severe AA, providing strong rationale for larger clinical trials using januse kinase (JAK) inhibitors in AA" [2]. Given this patient's failure with conventional therapies, Xeljanz is warranted.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Alopecia Areata
Treatment: Xeljanz
The insurer denied Xeljanz.
The determination is upheld.

The patient has alopecia areata universalis and has lost all of the hair on her head and body. The patient also has severe eye irritation and inflammation due to her lack of eyebrow and eyelash hair. The patient has tried and failed topical, intralesional, and oral steroids. The patient has had rapid regrowth of all her hair in the past while on Xeljanz, and after she lost insurance coverage, she lost all of the hair she had gained in a short amount of time. Her condition has come to affect her livelihood and overall mental well-being. Olumiant has failed to work for this patient over the past year. Xeljanz is under review.
While it is understandable to consider Xeljanz (tofacitinib) for this patient's condition, the requested medication merits further study before being presumed acceptable for widespread clinical use. At this time, the long-term safety of this medication is not as confirmed as short-term efficacy in the use of Xeljanz for this condition.
Alopecia areata is notoriously difficult and unpredictable to treat, as well as unpredictable in its response to treatment. Oral immunosuppressants, light therapy, contact allergen treatment and related therapies have all resulted in variable and unsatisfactory outcomes, and self-resolution is often the only choice a patient has (along with hairpieces) for severe cases.
Xeljanz was denied Food and Drug Administration (FDA) approval for use in psoriasis, in large part for safety reasons, and is not without a significant risk of side effects that preclude an acceptable risk for use outside of the investigational setting for the condition of alopecia areata.
At this time, Xeljanz is only FDA-approved for rheumatoid arthritis patients who have failed methotrexate, for juvenile idiopathic arthritis, for psoriatic arthritis, for ankylosing spondylitis, and for ulcerative colitis. All five conditions have indications whereby the safety risks of not using treatment are significantly greater than treatment itself. Accordingly, the health plan policy [1] only covers Xeljanz for these four conditions. There is no significant history of rheumatoid arthritis failing methotrexate to support Xeljanz for that indication. On a related note, Xeljanz has been recommended to be used with lower dosing in rheumatoid arthritis patients because of concerns about excessive blood clotting.
The same cannot be said for Xeljanz in the treatment of alopecia areata, where physical/functional impairment and overall health impacts are relatively minimal to nonexistent, despite the social/psychological impacts that can occur in some patients. The proper dosing, anticipated side effects and long-term outcomes are not known at this time for Xeljanz in the treatment of alopecia areata, as well as short-term and long-term safety risks of relevance to this patient's overall health. There are no large, randomized, controlled, prospective trials demonstrating and proving the safe and effective treatment of alopecia areata with a specific dosing of Xeljanz.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Alopecia Areata
Treatment: Xeljanz
The insurer denied Xeljanz.
The determination is overturned.

This is a patient with alopecia universalis (AU), treated with topical, oral and intralesional steroids as well as Olumiant. She failed to improve on Olumiant. She has had full regrowth on Xeljanz, and the provider is requesting continuation of Xeljanz. The health plan denied the request as experimental.

Yes. Alopecia universalis is a severe form of alopecia areata (AA) involving total body hair loss - including eyelashes, and groin. Regrowth of hair rarely occurs. Treatment studies for any form of alopecia areata are difficult to perform because the disease has an unpredictable course, and much investigation is still needed.
A wide range of treatments have been used for the management of alopecia areata, most of which are not highly effective. Treatments include topical or intralesional corticosteroids, topical minoxidil (2 percent or 5percent), topical anthralin, systemic corticosteroids, cyclosporine, and other immunosuppressants. A dependable and safe treatment for extensive disease (totalis or universalis) has yet to be found. Given the rarity of the disease, large randomized controlled trials are extremely difficult.
The 2019 systematic review [13] performed a literature search to identify clinical trials and case reports and concluded that several clinical studies have shown very promising results in the treatment of AA with oral formulas of janus kinase inhibitors (JAKi). These agents do need chronic administration to maintain response. Topical formulations did not show satisfactory responses. The safety profile of these agents appears to be favorable.
The meta-analysis in 2021 identified a total of 1244 studies, of which only 12 studies met the inclusion criteria. Of the 346 patients in these 12 studies, 288 had received oral tofacitinib and 58 had received oral ruxolitinib. The overall Severity of Alopecia Tool50 achievement rate was 66percent (95percentconfidence interval, 54percent-76percent). Subgroup analysis revealed that drug choice, mean age, sex ratio and alopecia areata subtype ratio did not significantly affect the treatment response. Infections and laboratory abnormalities were the most common adverse events (98 and 65 cases of 319 patients, respectively).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory failure

Treatment: Inpatient admission

The insurer denied coverage for Inpatient admission.

The denial is overturned.

 
Patient is an adult male with multiple medical issues - diabetes, obesity, hypertension, and obstructive sleep apnea, amongst others. Patient had been hospitalized for an epidural cervical (C)4-C5 abscess with evidence of cord compression. Patient underwent decompression and spinal fusion. Patient underwent Tracheostomy and percutaneous endoscopic gastrostomy (PEG). His stay was complicated  by aspiration pneumonia, gastrointestinal (GI) bleeding , coagulopathy, and respiratory failure.

Patient's stay was complicated by multiple bouts of sepsis for which patient received Broad Spectrum antibiotics. Patient also received wound care for his multiple wounds. Patient had dressing changes and wound debridement. Patient was slowly progressing towards transitioning to an alternate setting.

Patient was placed on Ventilator. Patient was noted to have worsening hypoxia. Had left pneumothorax  and Pneumomediastinum. Patient had evacuation of the pneumothorax. Pneumothorax and Pneumomediastinum improved over the next few days. Patient was gradually weaned down to about 40 % oxygen. Weaning trials were initiated. Patient did not tolerate weaning. Patient was noted to become more and more hypoxic. Oxygen (O2) saturations were in the 70s. Patient was placed back on the ventilator.

Computed tomography (CT) Chest revealed Right basilar air space disease. Patient was continued on antibiotics. Patient was placed back on fraction inspired oxygen (FIO2) 100%. Patient had elevated White Blood Cell count to 17,000. Hemoglobin was 7.9. Patient was treated for sepsis with broad spectrum antibiotics .

Arterial Blood Gas revealed Respiratory acidosis - 7.26/79/284  with saturations 98%. This patient had shown recent clinical deterioration with desaturation and sepsis. Patient was not stable to be discharged from long term acute care hospital (LTACH).

Given recent deterioration with increased FIO2 requirements and broad spectrum antibiotics being  restarted it was appropriate to keep patient in LTACH.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for long term acute care hospital (LTACH) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain. 
Treatment: Trigger point injections.
The insurer denied trigger point injections. 
The health plan's determination is upheld. 

The patient is a female with complaints of neck pain. She underwent trigger point injections of the left cervical paraspinals. The following office visit reported pain 0 out of 10. Previous interventions have helped greatly, and pain improved by 100%. The patient presented for follow-up indicating she fell, broke her nose, and there has been a severe flareup of neck pain going into the cervical paraspinals. Pain is rated 9 out of 10. 

The requested trigger point injections are not medically necessary. Although efficacy was noted with previous injections, there is no documentation of the duration of the efficacy being at least 6 weeks. Furthermore, there is no documentation of noninvasive modalities, such as physical therapy being used in conjunction with injections. Therefore, the requested Trigger Point Injections are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: compression fracture of (L1) lumbar spine, coronary artery disease with angina, peripheral vascular disease with multiple stents, and major depression

Treatment: 8 hours x 7 days of Personal Care Aide-Services Level 2, 56 hours per week

The insurer denied coverage for 8 hours x 7 days of Personal Care Aide-Services Level 2, 56 hours per week

The denial is upheld
 

The patient is seeking coverage for 8 hours x 7 days of Personal Care Aide-Services level 2, 56 hours per week.

The provider requested reconsideration for the patient's 56 hours/week of personal care aide services.  The patient had multiple compression fractures and wrist fractures after multiple falls.  The patient last had a fall three months ago.  The patient had compression fracture of (L1) lumbar spine, coronary artery disease with angina, peripheral vascular disease with multiple stents, and major depression.  The patient was not able to perform any daily activities after the last fall including shopping, preparing food, and taking a shower.  The patient needed an increase in hours of home health aides.

The task-based assessment tool indicated that the patient's estimated total hours per week were 33.75 which had increased since the prior assessment.

Per the cited references, personal care services are the provision of some or total assistance with personal hygiene, dressing, and feeding and nutritional and environmental support.  The services must be essential to the maintenance of the patient's health and safety in their home, be ordered by physician or nurse practitioner, and be based on an assessment of the patient's needs for the service in accordance with guidelines.  In this case, the patient had previously been receiving 5 hours a day, 7 days a week of personal care aide services.  An increase in hours was requested, for 8 hours a day for 7 days a week for a total of 56 hours/week.  The request was modified for authorization of 42 hours a week at 6 hours a day for 7 days a week.  Based on the documentation, the remaining 14 hours were not medically necessary.  The documentation indicated that the patient had recent falls and functional deficits which supported the need for personal assistance service hours.  However, the test-based assessment tool indicated that the patient needed an estimated 33.75 hours of care to meet their needs.  The patient has already been authorized for more hours than the assessment indicated were needed.  The documentation did not support that the increased 42 hours a week would be insufficient to support the patient's care needs.  Allotment of time separate and apart from personal care tasks authorized is not required for safety monitoring.  As such, the denial of coverage for 8 hours x 7 days of Personal Care Aide-Services level 2, 56 hours per week is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 8 hours x 7 days of Personal Care Aide-Services Level 2, 56 hours per week services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stone
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is a patient with a history of Crohn's disease. The patient presented to the emergency department (ED) with acute onset right flash pain, nausea, and vomiting. On exam, the patient had right costovertebral angle (CVA) tenderness, urinalysis positive for blood, white blood cell (WBC) count 13, and creatinine 1.37. A computed tomography (CT) scan revealed a 7-millimeter (mm) obstructing stone in the right upper urethra. The patient was given intravenous (IV) fluids, antibiotics, and was admitted. The patient was taken to the operating room (OR) for cystoscopy, right retrograde, and right stent placement. The patient tolerated the procedure well, recovered uneventfully, and was discharged home. The insurer has denied coverage for the full hospital admission as not medically necessary. The appeal on behalf of the hospital is noted and read in detail.

Per Milliman Care Guidelines (MCG) Health:

1) Renal Colic + Kidney Stones - Patient fails to meet guidelines for inpatient admission. 2) Urologic Surgery or Procedure GRG (general recovery care) - Patient meets the discharge parameters within 24 hours past procedure. This procedure is considered ambulatory per MCG.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vomiting/diarrhea
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned.

This is the case of a young male who presented to the emergency department (ED) with a 3 day history of vomiting and diarrhea. Review of symptoms (ROS) was positive for fever, multiple episodes of emesis, green non-bloody diarrhea, and no known ill contacts. Past medical history is notable for poor weight gain as an infant. The patient was admitted to the hospital for further management of dehydration associated with gastroenteritis. Stool was positive for Rotavirus, E Coli (Escherichia coli), and Campylobacter. 

The inpatient hospital admission was medically necessary.
Based on the medical documentation provided, this underweight child presented to the ED with acute gastroenteritis. He was found to have moderate to severe dehydration with very low bicarb level, abnormal chloride and concentrated hematocrit. Clinical findings correlated and the child's weight was below 5% for age. Given this constellation of symptoms and findings, full inpatient admission was medically necessary to ensure adequate monitoring and treatment.