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

Diagnosis: Obesity.
Treatment: Saxenda 3mg/0.5ml Pen Injector.
The insurer denied the Saxenda 3mg/0.5ml Pen Injector.
The denial is overturned.

The patient is a female with metabolic syndrome, polycystic ovarian syndrome, obesity, and a history of gestational diabetes. The request for Saxenda is under review. The prior request for Saxenda was denied as the first request did not include submitted documentation that the patient has been enrolled in a qualified complete weight management program for at least three months, with proof of current and prior enrollment and at least monthly participation. The attending physician is appealing this determination because the patient has been attending her gym and Weight Watchers program several days per week since the delivery of her son. She has also tried and failed metformin, phentermine, Topamax, and Victoza. Her body mass index is 37.51 kg/m2 (kilograms per meters squared).


Yes, the requested Saxenda is medically necessary.
This patient is obese with a body mass index of 37.51 kg/m2 (kilograms per meters squared). This is complicated by metabolic syndrome and polycystic ovarian syndrome. The prior request for Saxenda was denied as the first request did not include documentation that the patient has been enrolled in a qualified complete weight management program such as Weight Watcher or Curves Complete for at least 3 months, with proof of current and prior enrollment and at least monthly participation. The appeal letter indicates that the patient has been actively enrolled in Weight Watchers. The appeal letter indicates that the patient has been attending her gym and Weight Watchers program several days per week. The use of Saxenda in this clinical situation is supported by the Endocrine Society guidelines on the management of obesity. Without Saxenda, this patient will be at risk of further complications of untreated obesity, including type 2 diabetes. This patient is at particular risk of type 2 diabetes as she has a history of gestational diabetes. Therefore, the requested Saxenda is medically necessary.

The requested Saxenda is medically necessary as outlined above, and it was previously denied.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ectopic pregnancy/retained product of conception. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient is an adult female who was referred to the hospital to rule out ectopic pregnancy/retained product of conception. Ultrasound was consistent with retained products of conception. The patient underwent a dilation and curettage (D&C). The procedure was uncomplicated. She remained stable, was cleared, and discharged home later that day. Estimated blood loss was 20 cc (cubic centimeters). 

This patient had an incomplete abortion necessitating a D&C. D&C are ambulatory procedures. D&C can be performed safely in the office or other outpatient setting using manual vacuum aspiration or sharp curettage. Admission to an acute level of care is not customary or medically necessary. There was no reason submitted why the patient was admitted or why the D&C was delayed. Post operatively, the patient was stable. She was not anemic, she was voiding and tolerating oral intake. 

The procedure was uncomplicated and there was no concern about a surgery complication like injury to bladder, bowel, or uterine perforation. 

Following the D&C, the patient could have been observed in the recovery room like all patients undergoing an ambulatory procedure and once the provider ascertained that she was stable, she could have been sent home. 

Based on all the information submitted, the hospital admission was not medically necessary. 

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

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

Diagnosis: Eczema

Treatment Dupixent 300 milligrams (mg)/2 milliliters (mL) quantity

The insurer denied coverage for Dupixent 300 milligrams (mg)/2 milliliters (mL)	

The denial is overturned

This is the case of a patient with a past medical history of anxiety, eczema, and endometriosis. The patient presented to an office visit with a chief complaint of flare up of eczema; recent flare due to difficulty of getting Dupixent injection. Coverage is requested for Dupixent 300 milligrams (mg)/2 milliliters (mL).

Based on the current peer-reviewed literature, Dupixent weekly is medically necessary.  The patient has tried and failed biweekly Dupixent.  There are no other systemic therapies approved for use in atopic dermatitis.  Thibodeaux et al published "A review of dupilumab in the treatment of atopic diseases." in which they demonstrated that weekly dosing of Dupixent had significant efficacy (1).  Beck et al also have reported on the efficacy of weekly Dupixent in "Dupilumab Provides Favorable Safety and Sustained Efficacy for up to years in an Open-Label Study of Adults with Moderate-to-Severe Atopic Dermatitis" (2).  Therefore, it is appropriate, based on the patient's clinical findings and refractory disease, to approve weekly Dupixent in this patient.

The unique clinical circumstances to this individual that would make it medically necessary is that the patient is not currently controlled with biweekly Dupixent.  Chronic use of oral steroids has detrimental side effects.  Therefore, weekly Dupixent is warranted in this case.  

The insurer's denial of coverage for Dupixent 300 milligrams (mg)/2 milliliters (mL) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer.
Treatment: Positron Emission Tomography and Computed Tomography (PET CT) (CPT 78815).
The insurer denied the Positron Emission Tomography and Computed Tomography (PET CT) (CPT 78815).
The denial is upheld.

The patient is a male with metastatic prostate cancer, treated in the past with xofigo+docetaxel, abiraterone, prostatectomy, bicalutamide. He has progressed on most recent therapy with xofigo and docetaxel, and is now on jevtana.  His PSA (prostate specific antigen) is over 1000, and he has now metastatic disease.  His provider has requested PSMA (prostate-specific membrane antigen) PET/CT (positron emission tomography/computed tomography).

No, the requested health service is not medically necessary.
There is no role at this time for PSMA (prostate-specific membrane antigen) PET/CT (positron emission tomography/computed tomography) in the evaluation of established metastatic prostate cancer. Conventional imaging is sufficient to evaluate established metastatic prostate cancer.  While this testing may be used in the future for determining eligibility to Lu-PSMA (Lutetium prostate-specific membrane antigen), this is not a currently available therapy option.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: frontal fibrosing cicatritial alopecia

Treatment: Otezla

The insurer is denied coverage for Otezla

The denial is upheld. 

This female patient has a history of lichen planus/ lichen planopilaris.

The patient has a history of frontal fibrosing cicatritial alopecia believed to be secondary to lichen planus/lichen planopilaris.  Per the provided documentation, the patent has failed therapy with ILK [Intralesional Kenalog injections], topical steroids, hydroxychloroquine, and doxycycline.  The documentation provided does not include details regarding the length of treatment of the various medications, the dose used (with the exception of a relatively low dose of ILK of 5mg/cc [milligrams per cubic centimeters]), and any side effects experienced.  It is also unclear how long the patient has suffered from her condition (notes state "duration: a while ago.")  The patient is noted to have one new spot, but otherwise "doing better."  The provided documentation fails to provide evidence which would justify a need for an off-label medication. Furthermore, numerous topical and oral medications are available which may treat her underlying condition with no documentation provided of contraindications to these alternatives. (1-3)   Otezla is not medically necessary for the treatment of the patient's condition based on the documentation provided.  

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 Otezla is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever And Low Back Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male who was admitted with low back pain.

The patient's temperature was as high as 38.2, and the blood pressure was 105/67. Computed tomography of the abdomen/pelvis demonstrated no acute process. Magnetic resonance imaging of the thoracic and lumbar spines showed no acute process. Labs were notable for white blood cell count 12,700, potassium 3.8, and creatinine 1.0. The examination demonstrated costovertebral able tenderness.

Intravenous fluids and intravenous antibiotics were provided. As needed analgesics were ordered. The patient's white blood cell count dropped to 11,000. The patient improved and was transitioned to oral antibiotics. Blood cultures were negative.

No, the Inpatient admission was not medically necessary.
The patient had the mild degree of leukocytosis on presentation, and there was no persistence of fever beyond an observation timeframe. The patient was hemodynamically stable without altered mentation or immunocompromised state. There was no evidence of urologic abnormality; computed tomography of the abdomen/pelvis demonstrated no nephrolithiasis. There was no evidence of renal obstruction, renal or perinephric abscess, pyonephrosis, hydronephrosis, or emphysematous pyelonephritis. Blood cultures were negative. No acute finding was noted on magnetic resonance imaging of the spine; there was no evidence of epidural abscess. The patient did not have a focal neurologic process or uncontrolled pain requiring frequent administration of parenteral analgesics. In summary, inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peripheral vascular disease, necrotizing fasciitis,
diabetes mellitus
Treatment: Long Term Custodial Care
The insurer denied the Long Term Custodial Care.
The denial is upheld.

The patient is a male who resides in a long-term care facility.  He has a medical history of depression, peripheral vascular disease, necrotizing fasciitis, diabetes mellitus (DM), neuropathy, hypertension, hyperlipidemia, transmetatarsal amputation, and opioid dependence. He is dependent on a wheelchair for mobility. He has difficulty with balance and has undergone physical therapy (PT).  He has had active ulcers on his right leg for at least three years for which he has undergone debridement, VAC (Vacuum-assisted closure) therapy and various dressings. He also has chronic stasis dermatitis of his left leg. 

The patient has had weekly wound assessments in the past several months which have not indicated any infections or required any significant interventions.  A progress note indicated the patient had a 4.5 by 4.0 by 0.2 dorsal foot ulcer with granulation. Nortriptyline has been used for neuropathic pain.  A discharge planning note from the skilled facility indicated the patient is unable to care for himself due to his wounds, lack of family support, and lack of income. Shelter housing is inadequate for home care. A care plan note indicated the patient requires continued stay at Skilled Nursing Facility (SNF) for wound care.

No, the proposed Long Term Custodial Care is not medically necessary.
The patient has a chronic right foot wound that is improving. There is no indication for interventions or dressings for his legs that cannot be performed with outpatient wound care.  Although the patient may have issues with placement in a shelter or facility, dressings changes and wound assessments can also be performed using long acting dressings (1, 2, 3) and nurse visits in an outpatient clinic.

Based on the clinical information, the health plan did not see an indication for skilled services for wound care in a skilled facility or custodial care that would require daily management. In addition, the patient is able to mobilize himself with a wheelchair. As a result, outpatient resources can be utilized.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Bilateral Sacroiliac (SI) joint fusion (27279). 

The insurer denied the Bilateral Sacroiliac (SI) joint fusion (27279). 
The denial is upheld. 

The patient is a female. She has had left back pain for several years, and right low
back and buttock pain radiating to her groin and pelvis all the way down to her foot.
She had SI (sacroiliac) joint injections with reported significant relief and epidurals
and ablations in the past. She reportedly had bilateral SI joint injections a year ago
with 100% relief for a few weeks. 

Three months later, it was documented that she had recent bilateral sacroiliac joint
injections with little to no relief. She had chiropractic and physical therapy
approximately a year ago. She took NSAIDs (nonsteroidal anti-inflammatory drugs)
in the past. Her physical exam reveals a positive FABER (Flexion, Abduction and
External Rotation), Gaenslen's and compression test. She had prior facet blocks in
the lumbar spine. 

The patient's MRI (magnetic resonance imaging) of the lumbar spine shows no
significant pathology. 

The patient was taken to surgery for percutaneous SI (sacroiliac) joint fusion. 

No, the bilateral sacroiliac (SI) joint fusion (27279) was not medically necessary.
The attending physician documents that the patient tried PT (physical therapy) but
over a year ago and there was no evidence of a recent trial of conservative care.
Also, the patient apparently had a SI (sacroiliac) joint injection and minimal to no
relief was reported. Since the most recent SI(sacroiliac) joint injections did not
provide relief, that does not confirm the SI joint as a concordant pain generator.
There are also two additional provocative tests that are useful in supporting the
diagnosis of SI(sacroiliac) joint pathology. 

The patient did not have a recent trial of appropriate conservative care and typically
the diagnosis should be confirmed by concordant relief after at least two SI joint
injections.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial Fibrillation.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with a past medical history significant for hypertension (HTN), atrial fibrillation (A. fib), arthritis, facial paralysis, not on any beta-blocker due to prior history of bradycardia.  She presented to the emergency room with increasing lethargy and was found to have atrial fibrillation with rapid ventricular rate, at 147 beats per minutes. The patient was given intravenous metoprolol and started on oral metoprolol for rate control. As the patient had prior history of bradycardia and suspected tachy-brady syndrome, she was admitted to telemetry for monitoring during initiation of beta-blocker therapy. She was anticoagulated with low dose apixaban. The patient tolerated the beta-blocker therapy and was discharged home on this dose with rate control.

Yes, the proposed inpatient admission was medically necessary.

The patient presented with uncontrolled atrial fibrillation and required rate control for management of her arrhythmia. She had a prior history of bradycardia, a relative contraindication for the planned beta-blocker therapy.  It would be unsafe to initiate a beta-blocker in this patient with advance age, full anticoagulation, risk for significant bradycardia or pause on beta-blocker therapy in a lower level of care without adequate monitoring.  Therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe persistent allergic asthma
Treatment: Xolair (Pre-Service)
The insurer denied the Xolair (Pre-Service)
The denial is overturned. 

The patient is a female with allergic asthma who is prescribed Xolair. The patient has tried and failed treatment with Dulera, albuterol and Singulair. She has had severe asthma that was well controlled with Xolair in the past. The patient has positive radioallergosorbent testing (RAST) and high immune globulin E (IgE) levels. Xolair was denied because there was no documentation of recent immune globulin E (IgE) levels. The denial is being appealed.

Yes, the proposed Xolair is medically necessary.
The patient has severe persistent allergic asthma. She has tried and failed treatment with Dulera, albuterol and Singulair. The patient has had severe asthma that was well controlled with Xolair in the past. Recent testing shows positive radioallergosorbent testing (RAST) and high immune globulin E (IgE) levels. Xolair is medically necessary as it is the standard of clinical practice as the patient has uncontrolled asthma which was better controlled with Xolair in the past.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with history of chronic obstructive pulmonary disease (COPD) who presented to the emergency department with worsening shortness of breath and wheezing. The patient was found to have chronic obstructive pulmonary disease (COPD) exacerbation. 

In the emergency department, the patient was not able to speak in full sentences and was hypoxic. The patient was treated with multiple nebulization treatments, intravenous steroids and intravenous antibiotics. Despite emergency department care, the patient continued to have shortness of breath and wheezing. The patient was admitted to the hospital for steroids, antibiotics and oxygen as well as nebulizations.  

The patient continued to have worsening shortness of breath / dyspnea on exertion; systemic steroids were changed to intravenous steroids as well as intravenous antibiotics were started. Day two, the patient's systemic steroids dose was increased due to worsening shortness of breath / dyspnea on exertion.  The patient continued to have significant shortness of breath / dyspnea on exertion and required high doses of intravenous steroids, as well as intravenous antibiotics, frequent Duonebs and supplemental oxygen.

Yes, the proposed inpatient admission was medically necessary.
The patient had difficult to treat chronic obstructive pulmonary disease (COPD) exacerbation. The patient had worsening respiratory symptoms compare to baseline. The patient's oxygen levels dropped below 88% and he was started on supplemental oxygen. Despite stating with oral steroids and oral antibiotic, duonebs and supplemental oxygen, the patient continued to have difficulty breathing. The steroids and antibiotics were switched from oral to intravenous and then steroid doses were increased indicating difficult to treat chronic obstructive pulmonary disease (COPD) exacerbation. The inpatient admission was medically necessary as it was the current standard of practice and generally accepted standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis. 
Treatment: Hospital admission. 

The insurer denied coverage for hospital admission. 

The denial is upheld. 

This female patient has a history of appendectomy and anemia. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone (M-555) include having acute cholecystitis or acute cholangitis. The patient did not have these conditions. She had gallstones but did not have hemodynamic instability, severe vomiting, severe dehydration, or bacteremia. 

This patient had elevated liver enzymes. There was no evidence of acute liver failure. She had gallstones but did not have acute cholecystitis or systemic signs of inflammation. The liver enzymes could have been monitored as an outpatient. She did not meet Milliman Care Guideline (MCG) criteria for admission for Gallbladder or Bile Duct Inflammation or Stone. 

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 hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obstructing right mid-ureteral stone. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This male patient has a history of kidney stones with a right ureteral stent placement. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. They noted the procedure performed and the lack of any post-surgical complications. The appeal on behalf of the hospital was noted and read in detail. 

Per Milliman Care Guideline (MCG) Health (25th): 

1) Renal colic and kidney stones - the patient fails to meet clinical indications for admission to inpatient care. 2) Urologic surgery or procedure General Recovery Care (GRG) - the patient is noted to meet the discharge parameter within 24 hours post procedure.

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: tachycardia.
Treatment: hospital admission.
The insurer is denied coverage for hospital admission.
The denial is overturned. 

This male patient has a history of hypertension (HTN), hyperlipidemia, obesity, diabetes (DM), anxiety and stroke with residual left-sided weakness.

According to current literature a patient may be admitted to inpatient services when there is evidence of hemodynamic instability or altered mental status. Additionally, if there is sustained or symptomatic tachycardia a patient may be admitted for further monitoring. The submitted documentation indicated the patient admitted after being seen in the ED (emergency department) following a syncopal episode. The documentation indicated he had residual left-sided weakness and remained tachycardic with a heart rate of 123 beats per minute. Additionally, his blood pressure was 183/86. The short admission is appropriate to correctly monitor the patient at the appropriate level of care given the presenting symptoms and vital signs in setting of a prior stroke.

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 hospital admission is overturned.  The medical necessity is substantiated.