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

Diagnosis: Sialadenitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient with a history of thyroid cancer. The patient recently had multiple surgeries and radiation iodine therapy along with multiple procedures to treat cancer. The patient presented to the hospital with sialadenitis. The patient had a prior right parotidectomy and was admitted and underwent left superficial parotidectomy with an intraoperative repair of her facial nerve. The notes states that the patient had "significant pain control issues...admitted overnight". The patient was hydrated and was given pain medications. After improvement, the patient was discharged home on post-operative day (POD) # 1. The patient had lower face weakness but was able to close her eyes. During the surgery, a portion of the marginal mandibular nerve was transected and repaired. A note from the nurse in the post-anesthesia care unit (PACU) noted that the patient's pain was tolerable but a note from the surgeon, noted "complaining of severe pain in the PACU...slow emergence from anesthesia." A note on POD # 1 noted "[Left] neck pain controlled", "anticipate [discharge] today... (which was POD # 1). The discharge summary noted that the patient had "significant pain control issues in PACU, so admitted overnight". 

Based on the review of the medical record, inpatient hospital admission was not medically necessary for this patient. The patient had a total thyroidectomy with iodine radiation for thyroid cancer. The patient had repeated treatments for sialadenitis including a right total parotidectomy and on this admission, a left superficial parotidectomy with a nerve repair. The patient had oozing and severe inflammation intraoperatively. Notes indicate that in the PACU, the patient had severe pain and she was admitted for pain control. The resident physician records noted no hematoma, no bleeding, left neck pain controlled overnight. This all was indicative of an uneventful postoperative course except for this patient's day of surgery severe pain. As per literature, patients who undergo parotidectomy can typically be discharged home if they satisfy typical requirements such as: operative site and wounds acceptable; temperature status acceptable; no infection; pain managed; adequate oral intake and normal vital signs. In this case, the patient's discharge summary on POD # 1 noted; "[left] neck pain controlled", "anticipate [discharge] today... and there was no hematoma, ambulated, voiding, hemodynamically stable and pain well-controlled. All of this would appear to be consistent with an ambulatory or observational admission overnight. 

It appears that the health plan acted reasonably with sound medical judgment and in the best interest of the patient.

The medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pre- syncope

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient had a recent gynecological infection and was on oral antibiotics. She reported having nausea and episodes of lightheadedness. She had chronic lower left abdominal discomfort. She was afebrile and the vital signs were stable. The abdominal exam was benign. There was no leukocytosis. Stool for clostridium difficile toxin was negative. The oral antibiotics were continued. Benadryl was given for a possible allergic reaction. She felt better while in the hospital and was able to tolerate the oral antibiotics. 
Clinical indications for admission for dehydration (M-123) include hemodynamic instability, severe vomiting, severe hydration, persistent altered mental status, severe electrolyte abnormalities, and in inability to maintain oral hydration after observation care. The patient did not have these conditions.

Clinical indication for admission for Syncope (M-340) include hemodynamic instability, persistent altered mental status, severe cardiac disease including cardiac arrhythmias, and severe dehydration. The patient did not have these conditions.

The patient had pre-syncopal episodes associated with nausea. The provider wrote that the patient required treatment for dehydration. However, IV (intravenous) hydration and antiemetics could have been given with observation care. There was no evidence of an acute cardiac event. The oral antibiotics could have been continued as an outpatient. She did not meet Milliman Care Guidelines (MCG) criteria for admission for either dehydration or syncope. 

The healthcare plan acted reasonably and with sound medical judgement. An inpatient hospital admission was not medically necessary. 

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

Diagnosis: Abdominal Pain

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient had a history of gallstone pancreatitis and presented with abdominal pain.  She was afebrile and the vital signs were stable.  The aminotransferase (ALT) was 1677 and the aspartate aminotransferase (AST) was 2392.  The international normalized ratio (INR) was 1.1.  An abdominal computed axial tomography (CAT) scan was negative for acute findings.  A Magnetic resonance cholangiopancreatography (MRCP) was negative for choledocholithiasis.  An NAC (N-acetylcysteine) infusion was given.  The Amiodarone was held.  The Lipase went up to 3000 but then came down to 549.

Clinical indications for admission for Liver Disease Complications (M-570) include hepatic encephalopathy, hemodynamic instability, infected ascites, prolonged prothrombin time, hepatorenal syndrome, severe pain, severe vomiting, severe dehydration and acute liver necrosis.  The patient did not have these conditions.  She was given N-acetylcysteine but she did not have Tylenol induced hepatitis or acute liver failure.  The prothrombin time was normal.

Clinical indications for admission for Gallbladder or Bile Duct Stone or Inflammation (M-555) include having acute cholecystitis, acute cholangitis, or bile duct obstruction.  The patient did not have these conditions.

This patient had elevated liver enzymes.  The MRCP was negative for bile duct obstruction.  She did not have acute liver failure.  She did not meet  Milliman Care Guidelines (MCG) criteria for admission for either Liver Disease Complications or Gallbladder or Bile Duct Stone or Inflammation.  The healthcare plan acted with sound medical judgment.  An inpatient stay was not medically necessary.  

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

Diagnosis: High Blood Pressure.
Treatment: Inpatient Hospital Admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history of reflux who had been evaluated in the emergency department earlier in the day with left shoulder pain felt due to cervical radiculopathy and was discharged on gabapentin.  The patient returned to the hospital after he noted a systolic blood pressure greater than 200 at home.  

The patient's blood pressure was 167/81 on presentation to the emergency department, then was as high as 200/98, and then was 161/89 at the time of admission.  The electrocardiogram showed inferior T-wave changes with no acute ischemic changes.  Cardiac enzymes were negative.  Labs were notable for a sodium of 126.  A nitroglycerin infusion was administered in the emergency department.  At the time of admission the nitroglycerin infusion was weaned off and amlodipine was initiated.  Computed tomography angiography of the chest demonstrated no acute process.  Intravenous morphine was initially provided and was transitions to the oral route.  Occupational therapy was provided.  Neurosurgery was consulted and the gabapentin dose was increased.  The blood pressure improved with oral antihypertensive agents.

No, the proposed inpatient admission was not medically necessary.
The patient's elevated blood pressure was asymptomatic.  There was no evidence of end-organ damage related to the blood pressure elevation, such as hypertensive encephalopathy, acute myocardial ischemia, acute cerebrovascular accident, intracranial aneurysm, acute heart failure, aortic dissection, acute kidney injury, microangiopathic hemolytic anemia, seizure activity, retinal hemorrhage, or papilledema.  The blood pressure improved with oral antihypertensive agents and there was no prolonged requirement for the nitroglycerin infusion.  The patient's cervical radiculopathy was not accompanied by focal neurologic deficits.  No surgical intervention was performed and the patient did not have severe pain or requirement for frequent administration of parenteral analgesics.  The patient's hyponatremia was mildly asymptomatic; the patient did not require hypertonic saline or in antidiuretic hormone antagonist.  In summary, inpatient admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Laboratory test measurement of Infliximab and Infliximab antibodies. 

The insurer denied coverage for laboratory test measurement of Infliximab and Infliximab antibodies. 

The denial is overturned. 

This patient has a diagnosis of Crohn's disease.  The documentation indicated the patient was seen for a follow-up via telehealth.  The documentation indicated the patient did have back pain at an early age and was eventually diagnosed with ankylosing spondylitis.  He also had an onset of abdominal pain with bloody diarrhea and urgency and was diagnosed with Crohn's colitis.  The documentation does indicate his abdominal discomfort did return for a few days.  In addition, he felt unwell and had some mucus in his stools.  He did utilize prednisone with a decrease in symptoms.  Since then, he has felt back to normal.  He continues to utilize infliximab.  The physical examination was limited due to the nature of the visit.  The physician indicated the patient is being seen for a follow-up related to Crohn's disease.  The documentation indicated he had a primary non-response to Humira although drug level optimization was not performed.  He is a primary responder to infliximab and was in clinical and endoscopic remission in.  After that 6-MP (mercaptopurine) was stopped and infliximab levels dropped to 3.1.  He was advised to increase infliximab however was hesitant to do so.  Colonoscopy showed mild terminal ileitis and colitis in the cecum.  He is in clinical remission on 5 millogram pr kilogram (mg/kilogram) every 8 weeks with adequate infliximab levels of 7.5 and low-level antibodies.  It was recommended that they continue with infliximab every 8 weeks, and it was recommended he continue with laboratory studies with infliximab infusions. 

The evidence supports a result of improvement in health outcome.   The test has final approval.  The patient is a good candidate.  This is the best available treatment. 

The patient has responded to Infliximab and did not have a response to Humira.  The optimal management using Infliximab includes monitoring of drug levels especially when response is lost and also monitoring of antibodies.  This is the appropriate step before trying to switch to a different biologic agent. There are no adverse risks. 

This testing is likely to be more beneficial than any other testing for this patient's clinical circumstance. 

The carrier's denial of coverage for laboratory test measurement of Infliximab and Infliximab antibodies should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Laboratory test measurement of Infliximab and Infliximab antibodies. 

The insurer denied coverage for laboratory test measurement of Infliximab and Infliximab antibodies. 

The denial is overturned. 

The patient has Crohn's disease of both the small and large intestine.  It was reported that the patient had a relapse of his condition.  Infliximab level and antibody level were obtained. 

A Clinical Gastroenterology and Hepatology article titled "Appropriate Therapeutic Drug Monitoring of Biologic Agents for Patients with Inflammatory Bowel Diseases"  concluded that a consensus was achieved towards the utility of therapeutic drug monitoring of biologics in inflammatory bowel disease (IBD), particularly anti-TNF (tumor-necrosis factor) therapies. 

A Gastroenterology article titled "American Gastroenterological Association Institute Guideline on Therapeutic Drug Monitoring in Inflammatory Bowel Disease"  states that the current evidence supports the use of therapeutic drug monitoring to guide treatment changes in patients with active IBD who are being treated with anti-TNF agents. 

Obtaining therapeutic drug monitoring with Infliximab levels and antibodies is more beneficial for this patient. The scientific literature supports the use of this testing and he is a good candidate since he had a relapse of his condition.  The tests have met the regulatory standards of Clinical Laboratory Improvement Amendments (CLIA).  It is the best way of providing guidance with treatment.  There are no adverse risks to obtaining these laboratory tests.  Patients on Infliximab who are having a relapse should have testing of Infliximab levels and antibody levels.  The requested testing is likely to be more beneficial than any other standard testing. 

The carrier's denial of coverage for laboratory test measurement of Infliximab and Infliximab antibodies should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient in this case is a male without prior medical history.  He presented to the emergency department with acute onset left sided chest pain that worsened with inspiration.  He complained of mild shortness of breath. 

The patient's vital signs on initial evaluation were unremarkable, with normal heart rate, blood pressure and oxygen saturation on room air.  CT (computed tomography) scan revealed multiple bilateral pulmonary emboli.  He was started on heparin in the emergency department and admitted to the hospital. 

Following hospital admission, the patient was transitioned to apixaban.  He was discharged the following day.

No, the Inpatient admission was not medically necessary.
This patient was diagnosed with pulmonary embolism and was admitted to the hospital. He had no hypoxia or hemodynamic instability. There was no identified right heart strain. He was treated with heparin and apixaban and did not require thrombolysis. He could have been safely managed in the outpatient setting with appropriate oral anticoagulation using apixaban. He did not need to start heparin before starting apixaban. He did not require any medical intervention that necessitated his admission to the hospital. Given his unremarkable vital signs and lack of any significant co-morbid medical illness, he did not require inpatient monitoring for treatment of his condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic Arthritis. 
Treatment: Enbrel SureClick injection 50 milligrams (mg)/milliliter (ml), 50 mg weekly. 

The insurer denied coverage for Enbrel SureClick injection 50 milligrams (mg)/milliliter (ml), 50 mg weekly.  The denial is overturned. 

This is a female patient with a medical history of inflammatory arthropathy. She also has a history of psoriasis.  She is seronegative.  Recent office notes note active polyarthralgias with hand synovitis.  Methotrexate did not help, and she stopped it due to pregnancy plans.  She was treated with prednisone, which helped. The clinical picture is consistent with PsA (Psoriatic Arthritis). Enbrel is requested.

The insurer has denied coverage for Enbrel SureClick injection 50 milligrams (mg)/milliliter (ml), 50 mg weekly as not medically necessary.  In their Final Adverse Determination letter, they write that for Enbrel to be covered, the patient needs to have tried and failed or been unable to take two of the following: Cimzia, Humira, Stelara or Tremfya and Cosentyx.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 
 
The request is for coverage for Enbrel for PsA.  The patient is biologic-naive.  Ordinarily an anti- tumor necrosis factor agent would be the first choice.  The anti-interleukin-17 and -12/23 agents listed by the plan are generally used after anti- tumor necrosis factor failure.  There is no difference in efficacy among the five anti- tumor necrosis factor agents, and there is no reason to prefer Enbrel over Humira on that basis.  All the anti- tumor necrosis factor agents can be used as monotherapy for PsA.  

The treating Rheumatologist feels that the patient is more likely to need methotrexate with Humira than Enbrel, and she cannot take methotrexate.  This consideration is addressed in the chapter "Treatment of psoriatic arthritis" in www.uptodate.com.  In this source the issue is clearer with Remicade than it is with Humira. 

The issue with Humira is stated more clearly in "2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis."

In this guideline the increased chance of needing concomitant methotrexate is stated for both Remicade and Humira.  

As there is no advantage of Enbrel over Humira in terms of potential efficacy, the choice comes down to other possible considerations that would apply in this case.  There is less of a chance of having to alter therapy with Enbrel, as adding methotrexate to Humira is more likely to be needed and is problematic in this case.  

The insurer's denial of Enbrel SureClick injection 50 milligrams (mg)/milliliter (ml), 50 mg weekly is overturned.   Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Acute Myeloid Leukemia

Treatment: Sprycel in combination with Decitabine

The insurer denied coverage for Sprycel in combination with Decitabine.

The denial is overturned.

The patient is a male with relapsed core binding factor (CBF) acute myeloid leukemia (AML) with a c-KIT [proto oncogene] mutation. The treating Hematologic Oncologist has proposed treatment with the combination of dasatinib (Sprycel) + decitabine.  Insurance coverage for this treatment has been termed by the patient's insurance company experimental/investigational and has been denied.   

The treating Hematologic Oncologist has provided evidence from the medical literature supporting his treatment recommendation. CALGB 10801 [Alliance for Clinical Trials in Oncology] is a phase 2 study of dasatinib +combination chemotherapy as initial treatment for CBF AML. The results were described as encouraging but needing confirmation in a phase 3 trial. A second study from Germany, the AMLSG 11-08 trial, also as initial treatment was similarly encouraging and awaiting results from a phase 3 trial for confirmation. The manuscript noted laboratory evidence suggesting a biologic rationale for dasatinib in this subset of AML.

The scientific evidence is sufficiently compelling to warrant approval for this patient.

Sprycel has sufficient regulatory approval to allow for treatment in this case.

This patient a good candidate for Sprycel in combination with Decitabine.

Sprycel in combination with Decitabine is the best available treatment for this patient at this time.

In this ill patient, with few therapeutic options, there is sufficient scientific evidence to support a trial of decitabine + dasatinib at this time. Adverse risks are small compared with other treatment options.

The carrier's denial of Sprycel in combination with Decitabine should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Acute Myeloid Leukemia

Treatment: Sprycel in combination with Decitabine

The insurer denied coverage for  Sprycel in combination with Decitabine.

The denial is upheld.

The patient is a male with a history of KIT-mutated core binding factor acute myeloid leukemia (CBF AML). He has been treated with chemotherapy, and multiple salvages therapies, including a clinical trial with IMGN632 with azacitidine and venetoclax. The provider has prescribed Sprycel 100mg in combination with Decitabine. Two phase II trials were referenced regarding Sprycel for L=KIT+ AML.

Ustun et all notes, "Integration of cytogenetic results with molecular genetic and epigenetic data refines the diagnosis, classification and risk-stratification of CBF AML.  Clinical studies with targeting compounds (e.g. gemtuzumab ozogamicin, dasatinib) added to intensive chemotherapy appear beneficial both in younger and older patients, albeit the latter continue to have a significantly worse outcome than the former. Regularly molecular monitoring of disease during remission may provide a strategy for early therapeutic intervention before overt relapse."      

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

Phase II trials are not usually considered sufficient to establish improvement in health outcome. A phase III trial and/or guideline recommendation is needed to do that and it is not present at this time for this patient's case.

The combination does not have final approval from the appropriate regulatory bodies for this diagnosis.     

This patient is not a good candidate for Sprycel in combination with Decitabine because this combination is not an established beneficial treatment for the patient's indication.     

Sprycel in combination with Decitabine is not the best available treatment for this patient at this time. The requested treatment is not likely to be more beneficial than any other existing standard health service.                                                      

The carrier's denial of Sprycel in combination with Decitabine should be upheld.