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

Diagnosis: Hypoxia

Treatment: Inpatient emergency admission

The insurer denied coverage for inpatient emergency admission

The denial is upheld

This is a patient with a history of chromosome 2 abnormality, developmental delay, syndromic craniosynostosis, ventriculoperitoneal (VP) shunt, Chiari decompression, deafness, and von Willebrand's disease. He presented to the hospital for a scheduled routine outpatient magnetic resonance imaging (MRI). He underwent a routine MRI of the sella and pituitary gland successfully. After the procedure he was transferred to the post anesthesia care unit (PACU). He had desaturations to the 80s and was admitted with hypoxia. He was placed initially on 2 liters (L) oxygen via nasal cannula. Oxygen was increased to 3 L. He was able to be weaned back to 2 L. A chest x-ray revealed normal lungs. The patient was discharged.   

The mild hypoxia while sleeping is due to multifactorial reasons. Patient received sedation and was intubated during the procedure. It is expected to have mild hypoxia and slight decreased respiratory effort in the immediate post sedation period. This combined with snoring and sleep disordered breathing may have contributed to the transient hypoxia that was reversible without any intervention. As per the physician note there was no distress and the hypoxia improved with sitting up. There was no work up such as arterial blood gas nor escalation of therapy to high flow nasal cannula (HFNC) nor Albuterol. Due to above reassuring factors, the patient could have been observed in the hospital overnight. 

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

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

Diagnosis: Nausea and vomiting

Treatment: Inpatient admission 	

The insurer denied coverage for an inpatient admission. 
 
The denial is upheld.

The patient has medical diagnoses of diabetes mellitus type one (DM1), gastroparesis, daily marijuana use, and cannabinoid hyperemesis syndrome. The patient presented to the emergency department (ED) with complaints of abdominal pain, nausea, vomiting, diarrhea, and decreased food intake for three days. 

"The introduction of the Sepsis-3 definition is still relatively new to the critical care literature but given the ease of SOFA calculation and high specificity of SOFA (Sequential Organ Failure Assessment) /qSOFA (Quick Sequential Organ Failure Assessment) scores, it is likely to be adopted as a consensus definition for future clinical research. However, as highlighted by Williams et al. (11), one limitation of the new definition is the poor sensitivity of the qSOFA scoring system, which likely excludes its use as a screening tool for early sepsis, the stage in which treatment is most effective. Although the SOFA score has the most prognostic accuracy for in-hospital mortality but which one SIRS (Systemic Inflammatory Response Syndrome) criteria or qSOFA score has more prognostic accuracy of mortality is not clear yet and it needs more research. In addition, many healthcare facilities currently use the previous sepsis definition as part of emergency room and ICU (intensive care unit) protocol and implementation of the new recommendations will require funding to facilitate amendment of protocols and retraining of healthcare providers." (Marik, et al., 2017). 

"Conclusions: The need for two or more SIRS criteria to define severe sepsis excluded one in eight otherwise similar patients with infection, organ failure, and substantial mortality and failed to define a transition point in the risk of death. (Funded by the Australian and New Zealand Intensive Care Research Centre.)." (Kaukonen, et al., 2015).

"Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management is key to the successful resolution of DKA and HHS. Critical components of the hyperglycemic crises' management include coordinating fluid resuscitation, insulin therapy, and electrolyte replacement along with the continuous patient monitoring using available laboratory tools to predict the resolution of the hyperglycemic crisis. Understanding and prompt awareness of potential special situations such as
DKA or HHS presentation in the comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA, and the risk of brain edema during therapy are important to reduce the risks of complications without affecting recovery from hyperglycemic crisis." (Gosmanov, et al., 2021).                                                         

The insurer's denial of coverage for inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Osteoarthritis.
Treatment: Genicular Nerve Injection (left knee). 
The health plan denied: Genicular Nerve Injection (left knee).
The denial is: overturned.

This is a female patient with a diagnosis of bilateral primary osteoarthritis of the knee and pain in the left knee. Records indicate that a request for a genicular nerve block was denied by the insurance carrier as genicular nerve blocks for knee pain are considered experimental or investigational (unproven) and not covered by the health plan. Determination is under appeal, which is the subject of this review.

The patient was seen complaining of pain in the left knee. It was noted she received genicular radiofrequency ablation of the right knee and reports this helped greatly by 80%. She would like the same treatment for the left knee. Right knee pain is now 2/10. The left knee was reported as 2/10 but with activity can shoot up to 10/10. Medications include levothyroxine, metformin, alprazolam, zolpidem, and Pennsaid topical solution. The patient was noted to be morbidly obese with a body mass index (BMI) of 41.20. On examination reflexes were normal, and the sensation was normal. Left knee moderate tenderness to palpation over the medial joint space. Active range of motion 10-120. Strength 5/5. There was moderate varus stability in the left knee and a positive varus stress test on the left. Negative McMurray's test. It was reported the patient has had greater than four weeks of physical therapy and home exercise, non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, and activity modification. It was noted if the patient gets more than 50% relief from the genicular nerve block, radiofrequency ablation will be considered. The provider performed a genicular nerve block.

The proposed health service or treatment Genicular nerve injection (left knee) is not likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease. The patient is noted to have complaints of chronic knee pain with osteoarthritis (although there were no imaging studies submitted for review) and reportedly has failed conservative treatment. Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended for diagnostic evaluation or treatment of osteoarthritis of the knee." The ODG by MCG regarding genicular radiofrequency ablation (RFA) states "Not recommended for treatment of osteoarthritis of the knee." Guidelines do not recommend either genicular nerve blocks or radiofrequency ablation as this treatment has not been proven to be either safe or effective and there are no high-quality long-term studies with long follow-up periods available. There are alternative guidelines-supported treatment options that can be utilized. There is no evidence to suggest that the requested treatment genicular nerve injection would be more beneficial than standard treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Osteoarthritis.
Treatment: Genicular Nerve Injection (left knee).
The health plan denied: Genicular Nerve Injection (left knee).
The denial is: upheld.

The patient is a female with a diagnosis of bilateral primary osteoarthritis of the knee and pain in the left knee. A left knee genicular nerve block was denied by the insurance carrier as experimental and investigational.
There is a progress note indicating the patient with complaints of left knee pain. Pain in the left knee was rated at 2/10 but up to 10/10 depending on activity. The provider states the patient has had greater than four weeks of conservative treatment including physical therapy and home exercise as well as medications. It was noted the patient had a genicular nerve block in the right knee that reportedly resulted in 80% relief and wants to pursue this treatment in the left knee. On examination, there was tenderness to palpation at the left knee medial joint space, limited range of motion, and 5/5 motor strength. There was noted to be varus instability in the left knee and a positive varus stress test. The patient was noted to have a body mass index (BMI) of 41.20. The patient was recommended for and underwent a left knee genicular nerve block.

Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended for diagnostic evaluation or treatment of osteoarthritis of the knee." The Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG) regarding genicular radiofrequency ablation (RFA) states "Not recommended for treatment of osteoarthritis of the knee." The patient is noted to have a history of chronic bilateral knee pain with osteoarthritis and the provider states that the patient has failed conservative treatment. The patient is noted to be obese, likely resulting in ongoing pain in the knee, and this treatment is not likely to result in any significant sustained improvement as symptoms will likely continue unless there is weight loss. The requested genicular nerve block is not recommended by the evidence-based guidelines and peer-reviewed medical literature as this treatment is considered experimental and investigational. Additional studies are needed to further evaluate the benefits and long-term safety of this type of procedure. The proposed health service or treatment genicular nerve injection (left knee) is not likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Osteoarthritis.
Treatment: Genicular Nerve Injection (left knee).
The health plan denied: Genicular Nerve Injection (left knee).
The denial is: overturned.

The patient is a female with a history of chronic bilateral knee pain secondary to osteoarthritis. She has tried and failed conservative care with therapy, anti-inflammatories, Tylenol, and steroid injections. The patient was successfully treated with a right genicular nerve block and ablation earlier in the year. A request was made for a left genicular nerve block. The subject under review is whether the Genicular nerve injection is likely to be more beneficial than any standard treatment for the patient's condition.

The proposed health service or treatment Genicular nerve injection (left knee) is likely to be more beneficial than any standard treatment or treatments for the patient's condition since they already failed conservative care. In this case, the proposed treatment is a genicular nerve block and the plan would be to perform radiofrequency ablation of the genicular nerve if the patient were to receive more than 50% relief from the block. As described above this is a reasonable treatment plan considering the patient's diagnosis of knee osteoarthritis and their failed conservative treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease
Treatment: Stelara SQ (subcutaneous) 90 mg (milligrams)
The insurer denied the Stelara SQ 90 mg.
The denial is upheld.

The patient is a female with moderate-to-severe Crohn's disease, status post resection. She has failed Humira and Remicade, and had some, but not a complete response to Stelara 90 mg (milligrams) every 8 weeks when starting it approximately two years ago. The health plan denied coverage of an increase of Stelara to 90 mg every 4 weeks, and she was started on Entyvio, which she now receives in the form of 300 mg every 4 weeks in combination with Stelara. A note states she is in remission on the current regimen, and does not note plans to stop Entyvio. In fact, it does note that she will be abroad for 6 weeks and will miss one dose of Entyvio while she is away. Her provider is requesting to continue Stelara 90 mg every 8 weeks.

No, the requested Stelara is not medically necessary.

While there are small case reports showing the efficacy of dual biologics in the treatment of Crohn's disease, there are no large randomized case-controlled studies, and the regimen is not FDA (United States Food and Drug Administration)-approved or supported by medical literature or guidelines. The patient has not failed dose intensified monotherapy with Stelara or Entyvio, and has not failed Skyrizi either. Therefore, the requested Stelara in combination with Entyvio is not clinically appropriate, accepted standard of care, or medically necessary.

As medical literature and ACG (American College of Gastroenterology) Guidelines do not support dual biologics, the health plan acted reasonably, with sound medical judgement, and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperlipidemia
Treatment: Icosapent ethyl (Vascepa)
The insurer denied Icosapent ethyl (Vascepa).
The determination is upheld.

The patient is a male with a history of hypertension, hyperlipidemia, and obesity. Per the information provided he has been on either rosuvastatin 10 milligrams (mg) daily or atorvastatin 20 mg daily; both are moderate intensity statins. His serum triglyceride level was 342 mg/deciliter (dl); his low-density lipoprotein (LDL) cholesterol level was 104 mg/dl. His high-density lipoprotein (HDL) cholesterol level was 30 mg/dl. He was recommended for Vascepa (icosapent ethyl).

At issue is the medical necessity of icosapent ethyl (Vascepa).

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

The requested health service/treatment of icosapent ethyl (Vascepa) is not medically necessary for this patient.

Vascepa (icosapent ethyl) is a triglyceride lowering agent that is Food and Drug Administration (FDA) approved as an adjunct to maximally tolerated statin therapy to reduce the risk of myocardial infarction, stroke, coronary revascularization, and unstable angina requiring hospitalization in adult patients with elevated triglyceride levels (150 mg/dL or greater) and established cardiovascular disease or diabetes mellitus and 2 or more additional risk factors for cardiovascular disease. It is also indicated for the treatment of severe hypertriglyceridemia (500 mg/dl or greater).

Per the National Lipid Association Scientific Statement on the use of icosapent ethyl in statin-treated patients with elevated triglycerides and high or very-high atherosclerotic cardiovascular disease (ASCVD) risk, its use is recommended for patients aged 45 years or older with clinical atherosclerotic cardiovascular disease (ASCVD), or 50 years or older with diabetes mellitus requiring medication and greater than or equal to 1 additional risk factor, with fasting triglycerides 135-499 mg/dL on high-intensity or maximally tolerated statin, with or without ezetimibe.

Based on the documentation, this patient does not have established ASCVD, diabetes or a triglyceride level greater than 500 mg/dl. Moreover, he has not been treated with a high intensity statin and the records provided do not document that he was unable to tolerate high intensity statin therapy.

Therefore, the requested health service/treatment of Icosapent ethyl (Vascepa) is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara subcutaneously (SQ) 90 milligrams (mg)
The health plan denied: Stelara subcutaneously (SQ) 90 milligrams (mg)
The denial is: Overturned

The patient is a female with severe ileocolonic Crohn's disease (CD). She has previously tried and failed steroids, an anti-tumor necrosis factor (TNF) agent (adalimumab) and azathioprine. She was started on Stelara and her dose was escalated to 90 milligrams (mg) every 4 weeks due to elevated inflammatory markers and active inflammation seen on magnetic resonance (MR) enterography. Her Crohn's disease is in remission on the escalated dose of Stelara. Hence the attending gastroenterologist is requesting the continued use of Stelara 90 mg subcutaneously (SQ) every 4 weeks to treat this patient's severe Crohn's disease.

The health plan's determination is overturned.

The requested health service/treatment of Stelara SQ 90mg is medically necessary for this patient. Dose escalation is the standard of care when patents on biological therapy used to treat inflammatory bowel disease are not responding to standard dose of the medication. Meserve and colleagues showed that in real world settings, ustekinumab dose escalation was effective in achieving response in patients with CD with inadequate response, or loss of response to standard dose induction and/or maintenance therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoporosis

Treatment is Prolia

The insurer denied coverage for Prolia
 
The denial is upheld

The patient has been postmenopausal and has osteoporosis. She has not been previously treated. Treatment with Prolia is requested.

The insurer has denied coverage for Prolia as not medically necessary. In their Final Adverse Determination letter, they write that criteria for approval were not met.

The patient is appealing. In a detailed appeal letter, she writes that she previously underwent gastric bypass surgery, which can cause a high rate of bone loss. She also has a family history of osteoporosis. 

The patient has osteoporosis and treatment is medically necessary.
The treatment of osteoporosis follows the following steps:

For the initial treatment of osteoporosis in postmenopausal women, oral bisphosphonates are recommended. Oral bisphosphonates as initial therapy are preferred because of their efficacy, favorable cost, and the availability of long-term safety data. However, because of her gastric bypass, this patient should not be treated with oral bisphosphonates and can be treated instead with intravenous (IV) bisphosphonate therapy. Prolia is not considered initial therapy for most patients with osteoporosis. However, it could be used as initial therapy in certain patients at high risk for fracture, such as older patients who have markedly impaired renal function. In several trials, Prolia has been shown to improve BMD (bone mineral density) and reduce the incidence of new vertebral, hip, and nonvertebral fractures in postmenopausal women. However, emerging data have raised concern about increased risk of vertebral fracture after discontinuation of Prolia. In summary, Prolia is not medically necessary for this patient. The patient could use IV bisphosphonates.

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

Prolia is not considered medically necessary for this patient.

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

Diagnosis: Peripheral Neuropathy
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient is a male with a past medical history (PMH) of diabetes mellitus type 2 (DM2), gout, hypertension (HTN), and hyperlipidemia (HLD) who was admitted with complaints of (c/o) diffuse myalgias, generalized weakness, and leg pain. The patient's vital signs were unremarkable. The physical examination was notable for no apparent distress (NAD). The patient's laboratory work was notable for hypomagnesemia. The patient's imaging studies included a transthoracic echocardiogram (TTE) which showed an ejection fraction (EF) of 56-60%, a chest x-ray (CXR) which showed no sign of cardiopulmonary disease, and an electrocardiogram (EKG) which showed no acute changes. The patient was diagnosed with diuretic-induced electrolyte derangement and peripheral neuropathy and was treated with Gabapentin, intravenous fluids (IVF), and oral and intravenous (IV) magnesium repletion. The patient was discharged in stable condition.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o diffuse myalgias and generalized weakness. The patient received a diagnostic imaging work-up with no acute pathology identified. The patient was diagnosed with electrolyte derangement secondary to diuretic usage and peripheral neuropathy, for which Gabapentin and electrolyte repletion was provided. The patient was also found to have a Vitamin B12 deficiency, for which repletion was also provided. For the patient's neuropathy, a lower level of care allows for care coordination and discharge planning and an opportunity for assessment by a physician, physical therapist, social worker, and care manager for these types of patients. These patients receive focused interventions in mobility, gait training, and functional status improvements. Overall, this patient had neither severe acute pathology, nor the need for acute surgical intervention. The diagnostic imaging workup, non-surgical treatment modalities, including physical therapy, pain control, and electrolyte and vitamin repletions could have been safely and appropriately provided at a lower level of care.