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

Diagnosis: Legionella Pneumonia
Treatment: Full hospital admission

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

The patient presented to the emergency department (ED) with 1 week history of fever and diarrhea. The patient had a temperature max to 103. He was seen at an urgent care center where he was prescribed Amoxicillin for possible ear infection.  In the ED, vital signs were 102.2, Blood Pressure 119/71, Heart Rate 104, Respiratory Rate 18, and Oxygen (O2) saturations 98% (percent). The patient was noted to have Rales on right base on exam.  
White blood cell count (WBC) was 11.4 with bands of 14% hemoglobin 12.5, sodium 129 BUN (blood urea nitrogen)/Creatinine (Cr) 26/2.08 liver function tests (LFT) were also elevated urinalysis (UA) was positive for lower extremity (LE) and 5-10 WBC.  Chest x-rays (CXR) revealed right lower lobe (RLL) infiltrate consistent with Pneumonia. The patient initially received antibiotics - Cefepime/Vancomycin for treatment of Sepsis.  A computed tomography (CT) scan of the chest was done which revealed that the patient had a lobular consolidation of right lower lobe (RLL) consistent with Pneumonia.

This patient was admitted to the Hospital for treatment of pneumonia, acute kidney disease (AKI), and hyponatremia.  The patient was continued on intravenous (IV) hydration for his AKI. Antibiotics were switched to Rocephin and Azithromycin. The patient was still febrile 99-101.5 Fahrenheit (F), BUN/Cr 23/1.9. The patient was still hyponatremic. Liver function tests (LFT) were abnormal and the patient continued on hydration and antibiotics. 

Later, temperature range 99- 101.3 F blood urea nitrogen/ creatinine (BUN/Cr) 16/1.6 Sodium 136.  The patient Labs came back positive for Legionella Pneumonia. The patient was then switched to Azithromycin. Rocephin was discontinued. The patient went home on oral (PO) Azithromycin to complete course of 10 days.

This patient had Legionella Pneumonia with evidence of MOSF (multi organ system failure) - the patient had AKI, Abnormal LFT's, Hyponatremia and hypokalemia. The patient needed admission for close monitoring of all his labs, hydration and appropriate management of his renal failure and electrolyte abnormalities.  Based on these multiple issues inpatient admission was appropriate.

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 full hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems 
Treatment: Dental/Orthodontic Procedure - braces and monthly visits
The insurer denied braces and monthly visits. 
The denial is overturned.

The patient is a male with impacted tooth # (number) 27. Tooth #27 is completely blocked out, and it is contributing to the ectopic position of #26. He presents with a skeletal Class I malocclusion and significant crowding. He is treatment planned for orthodontics to address the crowding and impacted tooth, but treatment was denied due to lack of medical necessity.

The health plan's determination is overturned in whole.

The requested braces and monthly visits are medically necessary for the patient. If left untreated, the damage that will likely occur to the patient's teeth will be more time consuming and difficult to correct than the patient's existing orthodontic problem. Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisors. (2) Given the position of tooth 26 relative to tooth 27, tooth 26 will absolutely be damaged if orthodontics are not initiated. For this reason, treatment is deemed medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain. 
Treatment: Intracept Procedure (22899, C9752, C9753). 

The insurer denied the Intracept Procedure (22899, C9752, C9753). 
The denial is upheld. 

The patient is a female with a history of chronic low back pain. Her pain has not responded to home exercise and pain medication. Physical exam reveals SLR (straight leg raise) diminished range of motion of cervical and lumbar spine. An Intracept Procedure has been recommended. The procedure was denied as experimental/investigational. This was appealed. 

No, the health plan should not cover the Intracept Procedure. 

The patient is a female with a history of chronic low back pain. Her pain has not responded to home exercise and pain medication. Physical exam reveals SLR (straight leg raise) diminished range of motion of cervical and lumbar spine. An Intracept procedure has been recommended. The procedure was denied as experimental/investigational. This was appealed. 

The Intracept Procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type I or type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. Alternatives, such as spinal fusion, do not have good long-term results in the literature for axial low back pain without instability or significant spondylolisthesis such as grade 2 or more severe. 

The patient has not failed sacroiliac (SI) joint interventions, which is a common cause of axial low back pain. In situations where all non-invasive options have failed, epidural steroid injections could also be considered, although typically used in patients with radicular symptoms. Spinal cord stimulation is also an alternative, however has not been shown to have excellent results in primarily axial mechanical/discogenic type pain. Chronic opiates are not without risk, and can lead to addiction and overdose. Therefore, while the Intracept Procedure is a reasonable option, it should be employed after all conventional and evidence proven alternatives have failed. However given the patient's MRI (magnetic resonance imaging), which does show a grade 2 spondylolisthesis, which results in severe spinal stenosis, it is unlikely that the patient's pain is related to Modic/endplate changes. 

No, the Intracept Procedure is not more beneficial. 

Alternatives to treat spinal stenosis and grade 2 spondylolisthesis could be employed and have been proven in the literature.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain. 
Treatment: Intracept Procedure (22899, C9752, C9753). 

The insurer denied the Intracept Procedure (22899, C9752, C9753). 
The denial is upheld. 

The patient is a female with low back and right knee pain. At an office visit physical examination was consistent with positive straight leg raise bilaterally and mild to moderate lumbar tenderness. Impression was lumbar radiculitis/spondylosis. Provider recommended a home exercise program, medications (Percocet, Duexis and Skelaxin), Orthopedic follow up for possible knee surgery after weight loss, lumbar radiofrequency, and consideration of Intracept for modic changes. MRI (magnetic resonance imaging) of the lumbar spine shows disc bulging, grade II anterolisthesis of L4/5 (fourth lumbar spine vertebra/fifth lumbar spine vertebra) and slight L5/S1 (fifth lumbar spine vertebra/ first sacral vertebra) retrolisthesis, marked L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) canal stenosis, facet arthropathy, and Modic changes at L4-S1 (fourth lumbar spine vertebra-first sacral vertebra). Request for Intracept was denied by the health plan as experimental/investigational. 

No, the health plan should not cover the Intracept procedure for this patient. 

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date.  However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. 

At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. 

This patient does not meet inclusion and exclusion criteria in the current published studies.  The health plan should not cover the proposed treatment for this patient. 

No, the requested Intracept is not more beneficial than any standard treatment for the insured's condition or disease. 

The patient has conditions including lumbar radiculitis and lumbar spondylosis which can be treated beneficially with standard treatments such as current medications patient is taking, other NSAIDs (nonsteroidal anti-inflammatory drugs) and muscle relaxants, other interventional procedure such as epidural steroid injections and radiofrequency ablation, and surgery.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Abdominal Pain (Crohn's disease)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned, in part.

The patient is a female with Crohn's on oral steroids and Stelara who presented with abdominal pain, weakness and vomiting. She was tachycardic in the emergency room (ER), which improved with hydration. Computed tomography (CT) revealed active Crohn's, without obstruction. She was placed on intravenous steroids. 

Day two, the patient's symptoms were noted to be improved on intravenous steroids. There was no significant vomiting, and she tolerated oral intake, and her diet was being advanced. The plan was to discharge her on oral steroids on day three. 

Day three, the patient tolerated a solid breakfast and was moving her bowels, but later in the day started experiencing vomiting and abdominal pain after each meal.  She was placed on intravenous (IV) steroids again. 

Day four, the patient's diet was again advanced on intravenous (IV) steroids, but she still had pain requiring pain medication. 

Day five, the patient felt much improved, tolerated a diet without pain, and she was discharged on prednisone.

Yes, in part; the proposed treatment, inpatient admission, was medically necessary for last three dates of service .  However, inpatient admission for first two dates of service was not medically necessary.
As the patient was hemodynamically stable, without evidence of sepsis, dehydration, electrolyte abnormalities, intractable vomiting, inability to tolerate oral intake, toxic megacolon or a need for surgical intervention, or gastrointestinal (GI) bleeding, acute inpatient stay was not medically necessary on the first two dates of service. Care could have been provided at a lower level of care. 

However, while the patient was improved and medically stable for discharge, she had recurrent abdominal pain and vomiting requiring re-induction of intravenous steroids.  Therefore, acute inpatient hospital stay was medically necessary for the remaining dates of service.

Yes, in part; the health plan did act reasonably, with sound medical judgment and in the best interest of the patient in denying the first two dates of service  as they were not medically necessary; however, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient in denying the last three dates of service as they were medically necessary.
As acute inpatient was medically necessary for the last three dates of service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia areata

Treatment: Xeljanz

The insurer denied coverage for Xeljanz

The denial is upheld

The patient is a young adult male with a diagnosis of alopecia areata. According to the appeal letter, the patient has failed therapy with topical, intralesional, and oral steroids. No documentation is provided to demonstrate which actual steroid the patient has previously tried, what dose, and the results of these treatments. Similarly, no medical documentation is provided regarding the length of time the patient has been treated with these medications. The provider is requesting Xeljanz.    

As a result, Xeljanz is not medically necessary for the patient's condition, alopecia areata. The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possibly improve alopecia areata, including light therapy, squaric acid, diphenylcyclopropenone (DPCP), calcipotriene, and anthralin (1-11). Although case reports have demonstrated possible efficacy of Xeljanz for alopecia areata and related conditions, further studies are needed to demonstrate the long-term efficacy and safety of Xeljanz. It is noted that the Food and Drug Administration (FDA) released a statement finding increased risk of deep vein thrombosis and pulmonary embolism in patients enrolled in a phase 4 clinical trial of Xeljanz at a dosing of 10 milligrams twice a day (1).  

The standard of care for treatment of alopecia areata would necessitate an attempt to use the above-mentioned topical options or alternative oral medications for the treatment of alopecia areata. The patient has not failed or shown to have a contraindication to numerous therapies known to possibly improve his condition, including light therapy, squaric acid, DPCP, and anthralin (9-11).

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

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

Diagnosis: Ankylosed tooth #3 and ectopically erupting teeth #'s 2 and 4.
Treatment: Full Braces.
The insurer denied the Full Braces.
The denial is overturned.

The patient is a male with ankylosed tooth#3 and ectopically erupting teeth #'s 2 and 4. The patient also has a deep overbite.

Yes, the proposed treatment is medically necessary.
The patient has a deep impinging overbite with soft tissue damage to the palatal tissue. This is an automatic qualifier according to the handicapping index scale. Also, the patient has problems with his speech due to the incorrect positioning of his upper right teeth. This problem would be called a "handicapping malocclusion" and has medical necessity to orthodontically correct.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease. 
Treatment: Rinvoq. 

The insurer denied Rinvoq. 
The health plan's determination is overturned. 

The patient is a male with fistulizing Crohn's disease and Rheumatoid Arthritis. He has failed mesalamine, 6-mercaptopurine, Humira, Remicade, and high-dose Entyvio for the treatment of Crohn's disease. He started Stelara. He has had improvement on high-dose Stelara. Fecal calprotectin was elevated at 1,860. Colonoscopy showed ileitis, a 4 millimeter (mm) fistula tract, ileocecal valve inflammation, rectal inflammation, and an anal stricture. 

Rinvoq is medically necessary for this patient. Although Rinvoq is undergoing phase 3 investigation for the treatment of Crohn's disease, it was approved by the U.S. FDA for the treatment of rheumatoid arthritis after demonstrating its safety in trials including several thousand patients. Additionally, a recent Phase 2b and Phase 3 study of high-dose (45 mg) Rinvoq in ulcerative colitis demonstrated safety findings consistent with previous studies across indications, with no new safety risks observed. Studies including thousands of patients so far have shown Rinvoq to be safe. Furthermore, Rinvoq has demonstrated both safety and efficacy for the treatment of Crohn's disease in a randomized clinical trial in a study of 220 patients, which demonstrated significant increase in efficacy of all doses tested (from 3 milligrams (mg) daily to 24 mg twice daily) compared with placebo; efficacy was maintained at 52 weeks for most endpoints. Other studies have shown safety and efficacy for the treatment of Crohn's disease. 

Rinvoq is supported as medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cerebral vascular accident (CVA).
Treatment: Personal Care Services (PCS) - Total of 168 Hours per Week.
The insurer denied the Personal Care Services (PCS) - Total of 168 Hours per Week.
The denial is upheld.

This female patient has diagnoses including status post cerebral vascular accident (CVA), quadriplegia, tracheostomy, chronic respiratory failure, and gastrostomy tube.  She lives in a one bedroom apartment.  She is appealing the denial of decrease in personal care services (PCS) to a total of 168 hours per week.  The health plan is reducing hours to 51 hours per week.  The patient has 168 hours of private duty nursing.  The patient has a hospital bed and a Hoyer lift for transfers.  

An appeal letter notes the patient needs trach care with inner cannula change twice daily, suctioning, oxygen level monitoring, nebulizers four times per day, medication administration via percutaneous endoscopic gastrostomy (PEG) tube, heparin injections, ophthalmic drops, percutaneous endoscopic gastrostomy (PEG) tube feeds and flushes, seizure monitoring, and turn and reposition every two to three hours.  The patient requires total assistance with all activities of daily living (ADLs).  Twenty-four hours split shift licensed practical nurse (LPN) and personal care services (PCS) care is needed due to high care and unscheduled needs.

No, the proposed treatment, Personal Care Services (PCS) - Total of 168 Hours per Week, is not medically necessary.
Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient has quadriplegia, a tracheostomy for chronic respiratory failure, and gastrostomy tube.  The patient has 160 hours of private duty nursing.  She is appealing denial of decrease in PCS a total of 168 hours per week.  The health plan is reducing hours to 51 hours per week. The patient requires care with tracheostomy, suctioning, medications, feeding, and frequent repositioning.  An appeal statements states 24-hour personal care services (PCS) are required to assist the licensed practical nurse (LPN) due to the patient's needs.  Personal care services (PCS) are indicated to provide assistance with transferring, bathing, dressing, and housework. Personal care services are not indicated to provide medical care.  The approved personal care services 51 hours per week is appropriate and medically necessary to meet the patient's needs for assistance with activities of daily living (ADLs) and personal care.  The proposed personal care services (PCS) of 168 hours per week is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Atopic Dermatitis. 
Treatment:  Dupixent 300 milligrams (MG)/2milliliter (ML) SC SOPN. 

The insurer denied Dupixent 300 milligrams (MG)/2 milliliter (ML) SC SOPN.   The denial is overturned.

The patient is a female with atopic dermatitis (AD), treated with topical steroids such as mometasone and antihistamines. The patient has 10% body surface area (BSA). Her provider is requesting Dupixent. The patient has involvement to groin/buttocks and extremities. The health plan denied the request due to a lack of trial with preferred alternatives including Tacrolimus, phototherapy and systemic immunosuppressants such as cyclosporine.

At issue is the medical necessity of Dupixent 300 milligrams (MG)/2 milliliter (ML).

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

The requested health service/treatment of Dupixent 300MG/2ML SC SOPN is medically necessary for this patient.

Given the location of disease and severity, Dupixent is medically necessary.  Phototherapy is not appropriate due to groin and buttocks involvement. Use of Dupixent meets medical necessity, as systemic immunosuppressants would not be the most clinically appropriate in light of the current pandemic. According to the multidisciplinary review (Gresham et al, 2021), vaccine efficacy may be reduced in patients receiving systemic immune-targeting therapies because of the impaired immune response in these patients. There is a trend toward a decreased immune response and vaccine immunogenicity in patients on systemic immunotherapies, particularly patients receiving azathioprine, cyclosporine, methotrexate, mycophenolate mofetil, or Janus kinase (JAK) inhibitors. Therefore, it would not be advisable to use a systemic therapy in this patient that can decrease vaccine efficacy and place this patient at higher risk of coronavirus 2019 (COVID-19) complications when a safer alternative is available.

In addition, per the review by Ungar et al., patients on dupilumab (Dupixent) experienced less severe COVID-19 manifestations and lesser symptoms compared with patients on other systemics and on limited/no treatment. These results suggest that T helper 2 (Th2) modulation with dupilumab may have a protective effect on anti-viral immune response in patients with AD.

Therefore, Dupixent 300MG/2ML SC SOPN is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis Suppurativa. 
Treatment: Humira 80 milligrams. 

The insurer denied coverage for Humira 80 milligrams. 

The denial is overturned. 

The is a patient with a diagnosis of hidradenitis suppurativa. The patient has failed many years of topical and oral antibiotics. The patient's disease state is severe with numerous painful lesions. The requested medication is Humira. 

Humira is medically necessary for the treatment of the patient's condition, hidradenitis suppurativa. The patient has severe hidradenitis suppurativa affecting the breast, arms, face, and buttocks. The patient has failed oral antibiotic therapy and it is unlikely that further treatment will result in significant further improvement. 

Humira is FDA (Food and Drug Administration) medically necessary for the treatment of Hidradenitis suppurativa and is a reasonable next step in this clinical scenario based on the appeal and notes presented. The decision is reversed and Humira is approved for the treatment of the patient's hidradenitis suppurativa at the discretion of the treating physician. 

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 medication Humira 80 milligrams is overturned. Medical Necessity is substantiated.