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

Diagnosis: Right Upper Belly Pain with Nausea and Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This is a female patient who was hospitalized for upper abdominal pain with known history of gallstones. This patient underwent an uncomplicated laparoscopic cholecystectomy.

Per the Appeal Decision:  We still cannot approve coverage  for a full hospital admission. Your request tells us that you developed right upper belly pain with nausea and vomiting. We did not see that you had high fevers. We did not see that you had a blockage in your bile ducts widespread signs of infection or infection in the bile ducts with fever and jaundice. People can be watched and treated in the hospital without a full admission for the type of complaint that you had. This may include an overnight stay. Surgery to remove your gallbladder was done. No problems from the surgery were noted. Our guideline states that this surgery can be done in same day surgery. Most people are able to recover in the surgery area. For these reasons, we believe that a full hospital admission was not medically necessary. We based our decision on the MCG (Milliman Care Guidelines) guideline for Gallbladder or Bile Duct Inflammation or Stone, M-555 and Cholecystectomy by Laparoscopy, S-365 

Diagnosis(es) include right upper belly pain with nausea and vomiting.

No, the proposed inpatient admission was not medically necessary.
This patient presented to the emergency department afebrile. This patient was admitted early morning with pervious history of gallstones, reportedly not being offered surgery. This patient was clinically stable without signs of sepsis or hemodynamic instability. Being clinically stable, this patient did not meet any criteria for Milliman Care Guidelines (MCG) Criteria for an Acute Inpatient Admission.  As per the Milliman Care Guidelines National criteria, the expected length of stay for an uncomplicated laparoscopic cholecystectomy is ambulatory. In keeping with that expected length of stay, allowing time for being nothing by mouth (NPO), this patient should have had her surgery in the morning early enough to be discharged same day after having an uncomplicated cholecystectomy. There is no documented medically necessary indication that this patient's cholecystectomy was delayed until the late evening so that this patient was eventually discharged morning.

Overall, observation care was appropriate.  Dates of service are denied due to delay in providing efficient, effective, timely, and safe medical care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Overall, observation care was appropriate.  Dates of service are denied due to delay in providing efficient, effective, timely, and safe medical care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer/Prostate Cancer
Treatment: Radiology Services
The health plan denied the requested proton beam therapy as not medically necessary. 
The health plan's determination is upheld.

This is a male with history of adenocarcinoma of his prostate gland, status post prostatectomy with a rising prostate-specific antigen (PSA). Axumin positron emission tomography (PET)/computed tomography (CT) showed hypermetabolic uptake in the region of the left vas deferens/seminal vesicle. He was recommended to proceed with a course of salvage external beam radiotherapy with curative intent. The request is for approval of proton beam radiation therapy.

I uphold, in whole, the health plan's determination of medical necessity.

No, the requested proton beam radiation therapy is not medically necessary for this patient. There is currently insufficient high quality prospective clinical outcomes published in the peer reviewed medical literature to allow one to make definitive conclusions regarding the relative safety/efficacy of proton radiation therapy in the patient's setting, as compared with standard of care photon-based intensity modulated radiation therapy (IMRT). The ASTRO Model Policy for proton radiation does not support its use in the patient's setting outside the context of a prospective clinical trial. The treating provider did not supply a proton/photon plan comparison to show that photon-based radiotherapy is unable to provide adequate safety/efficacy. Furthermore, the patient has not previously received pelvic radiotherapy in the past, nor do the provided clinical records indicate that he has a genetic/comorbid condition that would increase his normal tissue sensitivity to radiation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Cosentyx.
The insurer denied Cosentyx. 
The health plan's determination is upheld. 

The patient is a female with psoriasis of the scalp and nails. She also has pain in her thumbs, soles, and elbows, concerning for psoriatic arthritis. The appeal letter states she has failed diclofenac, ibuprofen, naproxen, ketoconazole, and flucoinonide. The medication under review is Cosentyx.

Cosentyx is not medically necessary for this patient. There are no comparative, controlled studies showing that Cosentyx has a superior efficacy and safety profile to all the formulary alternatives, such as methotrexate which have been shown to be effective for nail psoriasis, psoriatic arthritis, and psoriasis. 

Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, Cosentyx is not necessary. It is noted that the patient has failed topical steroids. However, there is no documentation provided that the patient has tried and/or failed methotrexate. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Cosentyx medically more appropriate than the other options.
Therefore, the administration of Cosentyx is not strongly supported for this patient, and Cosentyx is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure/Bradycardia. 
Treatment: Long Term Custodial Care. 

The insurer denied Long Term Custodial Care. The health plan's determination is upheld. 


The patient has a medical history of heart failure with left ventricular dysfunction with an ejection fraction of 45%, history of bradycardia who was hospitalized for near syncope and found to have hypotension with bradycardia with a heart rate of 39 beats per minute. She underwent an implantable loop recorder and was determined to have autonomic dysfunction as the cause of her near syncope. She was transferred to a transitional care center for further physical and occupational therapy for gait instability, muscle weakness and a decline in her transfers, toileting, and dressing. 

The requested health service/treatment of Long Term Custodial Care is not medically necessary for this patient. 

This is a patient with a medical history of heart failure who was found to have hypotension with bradycardia. She underwent an implantable loop recorder and was determined to have autonomic dysfunction as the cause of her near syncope. She was transferred to a transitional care center for further physical and occupational therapy for gait instability, muscle weakness and a decline in her transfers, toileting, and dressing. She underwent therapy and was determined to have met a majority of her physical and occupational therapy goals. She was determined to be able to fully independent in bed mobility, sit to stand & chair to bed transfer, walk 150 feet without assistance and found to have a mobility score of 11 points out of a possible 12 with 12 being the highest function. She was recommended for discharge home with a home exercise program and her prognosis was excellent to maintain her current level of function.
Custodial care is care designed to assist an individual to meet their activities of daily living such as assistance in bathing, dressing, toilet use, walking and getting in out of bed, and/or supervision of medication. Custodial care does not require the services of a trained medical or paramedical professional. Per the information enclosed, the patient is independent in her activities of daily living and has returned to her prior level of function. Per the transitional care center discharge report, she was recommended for discharge home with a home exercise program and her prognosis was excellent to maintain her current level of function. This patient has been determined to take care of all her daily needs and would not be deemed to be unsafe at home. Therefore, the requested health service/treatment of Long Term Custodial Care is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polycystic Kidney Disease
Treatment: Jynarque
The insurer denied Jynarque.
The determination is overturned.

The patient has a history of chronic kidney disease (CKD) stage 4, autosomal dominant polycystic kidney disease (ADPKD), hypertension (HTN), gout, asthma, and breast cancer status/post (s/p) lumpectomy who presented to her nephrologist for follow up. There is a positive family history of polycystic kidney disease. Her most recent estimated glomerular filtration rate (eGFR) was 22 with a creatinine of 2.37. She has a right (R) kidney volume of 504 and a left kidney volume of 730 milliliters (ml) with Mayo classification 1C disease. Her provider prescribed tolvaptan (Jynarque) in order to help slow down progression of her polycystic kidney disease. At issue is the medical necessity of Jynarque.

The medical treatment of tolvaptan (Jynarque) in this patient is medically necessary based on her history of ADPKD with class 1C disease based on imaging. This puts her at a higher risk of progression and therefore a potential greater benefit of treatment to slow down her disease progression.
A recent post hoc analysis retrospectively investigated eGFR decline in REPRISE versus an open-label, phase 3b extension trial (open-label extension [OLE] National Clinical Trial (NCT) 02251275) in subjects who received placebo in REPRISE and tolvaptan in OLE with eGFR 15 to 24 and 25 to 29 milliliters per minute (ml/min) per 1.73 square meter (m2), respectively. This study concluded that initiating of maintaining tolvaptan therapy significantly delayed eGFR decline in subjects with baseline eGFR of 15-24 and 25-29. This patient had an eGFR of 22 so it is reasonable to conclude that she would also have the same potential significant benefit. Slowing the progression of her disease would delay any possible future initiation of dialysis, provide a longer dialysis free period on a kidney transplant wait list thereby increasing her chances for a preemptive kidney transplant or ideally allowing her more time to find a living donor to ensure the best chance of a successful transplant outcome.
The use of Jynarque in this patient with ADPKD is medically necessary to prevent progression of her advanced CKD.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Stelara 90 mg every 4 weeks. 

The insurer denied Stelara 90 mg every 4 weeks. 
The determination is overturned. 

The patient has perianal fistulizing Crohn's disease status post subtotal colectomy. He has failed balsalazide, azathioprine, Remicade. The Stelara was increased to 90 milligrams (mg) every 4 weeks due to active disease symptoms, with subsequent significant improvement (from 10 bowel movements per day to 3 to 4). At issue is the medical necessity of Stelara 90 mg every 4 weeks for the treatment of Crohn's disease. 

The request for Stelara to 90 mg every 4 weeks is medically necessary in this case. The patient has moderate to severe Crohn's disease given the history of a fistula and subtotal colectomy. Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease [1-3]. Guidelines for the treatment of Crohn's disease recommend the use of Stelara [4]. In this case, the patient had initial improvement, followed by symptoms and objective evidence of active disease. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address a loss of response, and a large proportion of patients were able to maintain response [5-7]. One study showed that dose escalation was required in approximately half of patients, and successful in 61.1% (percent) of dose escalation attempts [5]. Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted [7]. Additionally, the American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should...have their medication dose adjusted in order to attempt to optimize therapy" [4]. In this case, the patient has failed Stelara every 8 weeks, with active disease symptoms; dosing every 8 weeks or discontinuation of Stelara (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this enrollee with moderate to severe disease. For all of these reasons, the use of Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of Crohn's disease in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Immunologic Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Hyqvia for medical necessity. 
The denial is overturned.

This patient is a female recommended for Hyqvia. She has chronic inflammatory demyelinating polyneuropathy (CIDP). An appeal letter indicated that she has done well on intravenous immunoglobulin (IVIG) and a switch to Hyqvia was recommended. Note indicated that she is also on treatment for Lyme's disease. She has improved with immune globulin but still has some symptoms.
At issue is the medical necessity of Hyqvia.

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

The requested health service/treatment of Hyqvia is medically necessary for this patient.
IVIG has been shown to effective for CIDP. van Schaik et al conducted a randomized, double-blind, placebo-controlled trial, with randomly allocated patients. In the intention-to-treat set, 36 (63%) patients on placebo, 22 (39% ) on low-dose slow subcutaneous immunoglobulin (SCIg), and 19 (33%) on high-dose SCIg had a relapse or were withdrawn from the study for other reasons. Absolute risk reductions were 25% (95% ) for low-dose versus placebo, 30% for high-dose versus placebo, and 6% for high-dose versus low-dose. Causally related adverse events occurred in 47 (27%) patients (ten [18%] in the placebo group, 17 [30%] in the low-dose group, and 20 [34%] in the high-dose group). Six (3%) patients had 11 serious adverse events: one (2%) patient in the placebo group, three (5%) in the low-dose group, and two (3%) in the high-dose group. Only one, who had an acute allergic skin reaction in the low-dose group, was assessed to be causally related. Therefore, the authors concluded that immunoglobulin (IG) was effective for CIDP.
The Plan's denial was due to the fact that there was no record of response to IG and that the dose was not attempted to be tapered. In this case, the notes indicated that the patient's symptoms are better with IG but incomplete. Continuation is warranted but a dose decrease would not be as she has incomplete relief.
Therefore, the requested health service/treatment of Hyqvia is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, muscle weakness, atrial fibrillation, osteoarthritis, severe protein-calorie malnutrition, stage 2 sacral pressure injury

Treatment: Consumer directed personal assistance services (CDPAS) 168 hours a week

The insurer has partially denied coverage for consumer directed personal assistance services (CDPAS) 168 hours a week as not medically necessary. They have approved 52 hours a week.

The denial is overturned

The patient has a history of oxygen-dependent congestive heart failure, hypertension, nontraumatic intracranial hemorrhage, meningioma, seizures, atrial fibrillation, muscle weakness, osteoarthritis, proctitis, severe protein-calorie malnutrition, stage 2 sacral pressure injury, constipation and fecal impaction. 

The patient recently transferred from a nursing home to the hospital. The plan was for the patient to return home. The Uniform Assessment System (UAS) and Skilled Nursing Facility Physical Therapy document maximal assistance needed for all activities of daily living (a worsening from an already poor level of function). The patient is incontinent and already has a pressure sore. She is provided with a commode but cannot manage it on her own. She is on diuretics and is prone to volume depletion, dehydration, urinary tract infection and electrolyte imbalance. Restricting her fluid intake enough to prevent the need for toileting at night is not medically appropriate. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes:

"(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse."

The provision of diapers and durable medical equipment such as alternate pressure beds is not by itself adequate for prevention of pressure sores.  Changing diapers regularly and positioning are also necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Given her degree of impairment, pressure sore and incontinence she should have 24-hour care. 

Based on the above, the medical necessity for the consumer directed personal assistance services (CDPAS) 168 hours a week is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Osteomyelitis of the Left Ankle. 
Treatment: Inpatient hospital admission. 
The insurer denied coverage for inpatient hospital admission. 
The denial is overturned. 

This is an adult male patient with a history of a left ankle injury, chronic osteomyelitis of the left ankle, cellulitis, tobacco abuse, and gastroesophageal reflux disease (GERD). He presented to the hospital for a left tibiotalocalcaneal (TTC) fusion. The patient was admitted to Orthopedics. He underwent the procedure without complications and was transferred to the post anesthesia care unit (PACU). Pain was well controlled with medications and the patient's diet was advanced. Standard postoperative antibiotics were given. Deep vein thrombosis (DVT) prophylaxis was provided with Lovenox. The patient worked with physical therapy and occupational therapy (PT and OT). He was stable for discharge. 

The records show the patient underwent complex reconstructive surgery to his left lower extremity. This included arthrodesis of the tibia, talus, and calcaneus. The operative time was approximately 6 hours. This type of operation would be expected to be result in a high degree of post-surgical pain. His post-surgical course was complicated by inadequate pain relief despite a regional block. It was not an isolated ankle operation. 

He required intravenous (IV) Toradol on at least two occasions. 

Based upon the type of surgery completed and difficult post-surgical course, the admission and length of stay should be approved. 

The level of service could not have been provided at a lower level of care. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The inpatient hospital admission is considered medically necessary for this patient. 

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite.
Treatment: Braces (D8080) and Monthly Visit x12 (D8670), Pre-service.
The insurer denied the Braces (D8080) and Monthly Visit x12 (D8670), Pre-service.
The denial is overturned.

The patient is a male with skeletal class III growth pattern, mild maxillary spacing and mild mandibular crowding.

Yes, the proposed braces and 12 monthly visits are medically necessary.
The patient's lower canines, teeth #'s 22 and 27, are in anterior crossbite. This means they are outside of the upper teeth, which is reverse of normal. The lower canines should be inside of his upper teeth. The teeth also have attachment (gum) loss. This is an automatic qualifying condition according the handicapping index scale.  Orthodontic treatment is needed to correct these problems. Orthodontic treatment is medically necessary as are the follow up visits to insure the treatment is progressing properly.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis

Treatment: Inpatient Hospital Stay

The insurer denied coverage for inpatient hospital stay

The denial is upheld

The patient was having ongoing episodes of abdominal pain and vomiting. She was afebrile and the vital signs were stable. The abdominal exam was benign. The liver enzymes were elevated. A magnetic resonance cholangiopancreatography (MRCP) showed common bile duct (CBD) dilation and stones. There was no leukocytosis. An endoscopic retrograde cholangiopancreatography (ERCP) was done with sphincterotomy and removal of stones. After the procedure the lipase went up to 896 but then came down to 47. 

Clinical indications for Gallbladder or Bile Duct Inflammation or Stone (M-555) include having evidence of acute cholangitis or acute cholecystitis. There need to be both systemic signs of inflammation for acute cholangitis such as fever and leukocytosis as well as evidence of common bile duct disease. In this case, she did not have systemic signs of inflammation. If there is a calculus of the bile duct, indications for admission include hemodynamic instability, severe vomiting, severe dehydration, bacteremia, or severe pain not responding to analgesics. The patient did not have these conditions. 

The patient required an ERCP for common bile duct stones. She did not have systemic signs of inflammation or acute cholangitis. The procedure could have been performed with observation status. There was a rise in the lipase after the procedure but it rapidly resolved. She did not meet Milliman Care Guidelines (MCG) Criteria for admission for Gallbladder or Bile Duct Inflammation or Stone. 

The healthcare plan acted reasonably and with sound medical judgement in the best interest of the patient. An inpatient stay was not medically necessary.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.