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

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a female with a past medical history (PMH) of smoking who was admitted to the hospital with complaints of (c/o) a one week history of intermittent shortness of breath (SOB). The patient presented to a different emergency room (ER) earlier in the day with a normal work-up and was given an albuterol inhaler. The patient's vital signs were unremarkable. The physical exam was notable for decreased breath sounds. The lab work up was unremarkable. Imaging studies that included a computed tomography (CT) chest showed no acute abnormality or pulmonary embolism (PE) and a transthoracic echocardiogram (TTE) that showed no significant findings. An electrocardiogram (EKG) showed sinus bradycardia. The patient was diagnosed with chronic obstructive pulmonary disease (COPD)/asthma exacerbation and was treated with bronchodilators, steroids, and pulmonary consultation. 

There was no requirement for intubation and carbon dioxide (CO2) narcosis with oxygen saturation was greater than (>) 90% (percent). The patient did not have symptoms of severe acidosis, concomitant cardiac disease, acute coronary syndrome, new arrhythmia or congestive heart failure exacerbation. There were no signs of pulmonary embolism, pneumonia, lobar collapse, cyanosis, depressed mental status or altered level of consciousness (LOC). The patient did not have impending respiratory failure or new ischemic electrocardiogram (ECG) changes. The patient's Dyspnoea, Eosinopenia, Consolidation, Acidemia and Atrial Fibrillation (DECAF) score is indicative of a low-risk for COPD exacerbation. This patient was treated with intravenous (IV) steroids and pulmonary nebulizers.

The patient did not exhibit hemodynamic instability, severe underlying COPD, high-risk active acute comorbidity or altered mental status (AMS). There was no acute respiratory failure, new-onset hypoxemia, worsening of pre-existing hypoxemia, hypercarbia, infection or a need for surgical intervention.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal -Back Pain.
Treatment: Surgical Services (All). 

The insurer denied Intracept Procedure. 
The denial is upheld. 

The patient is a female with a history of chronic low back pain. The magnetic resonance imaging (MRI) of the lumbar spine revealed multilevel disc displacement and facet arthrosis. She was seen by her provider, and it was noted that she had been treated with lumbar epidural steroid injections and lumbar facet ablation. She was treated with medications including anti-inflammatory, muscle relaxers and gabapentin. The physician recommended the Intracept Procedure. 
At issue is whether the Intracept Procedure is likely to be more beneficial than any standard treatment for the patient's condition. 

The health plan's determination regarding the proposed health service or treatment is upheld. 

The proposed health service or treatment Intracept Procedure 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 Intracept procedure is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. However, the evidence is insufficient to determine that the technology results in an improvement in the net health outcome. The limitation of the studies performed include unavailable long-term comparative data, lack of a sham controls and short duration of follow-up. 
Therefore, the proposed treatment of Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastric bypass
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

This patient is an adult female. She was admitted to the hospital and underwent bariatric surgery (laparoscopic roux en Y gastric bypass). She was admitted to the hospital with an inpatient status following surgery. Her pre-surgical body mass index (BMI) was 35.9 (medically complicated morbid obesity). Her obesity related comorbid conditions included hyperlipidemia, PCOS (polycystic ovarian syndrome), and metabolic syndrome.

This bariatric operation was performed under general anesthesia. The patient was treated with post-surgical IV (intravenous) fluid, antiemetic medications, analgesic medications and post-gastric bypass monitoring. On post-surgical day number one, the patient had improvement in post-surgical nausea and was tolerating a bariatric phase 1 diet. Fluid intake and output were monitored consistently. The patient's oral intake was improved and the patient was considered to be stable for discharge from the hospital.

This external review pertains to the medical necessity of the inpatient hospital admission for this patient. The medical necessity of the procedure of roux en Y gastric bypass is stipulated. The health plan denial letter notes that because surgery was performed without complication and the patient remained afebrile and hemodynamically stable and was discharged home on the next day, an observation level of care would have been appropriate. The denial is being appealed.

The inpatient hospital admission was medically necessary.

This patient underwent bariatric surgery (roux en Y gastric bypass). She had the diagnosis of medically complicated morbid obesity. Given her health condition and the planned procedure, she was at risk for thromboembolism. She was treated with DVT (deep venous thrombosis) prophylaxis. She was initially NPO (nothing by mouth) after surgery and was treated with IV fluid and antiemetic medications in addition to parenteral analgesia. Diet progression was monitored in the post-bariatric state.

Roux en Y gastric bypass is a complex surgical procedure that involves division of the stomach and the small bowel with creation of two enteric anastomoses. The acute risks of this procedure include intra-abdominal bleeding, enteric leak, anesthetic complications, DVT, pulmonary embolism, and other cardiopulmonary complications. It is the standard of care that these patients be appropriately monitored following surgery and an inpatient level of care is the generally accepted level of post-surgical care. While these patients can sometimes be medically stable for discharge from the hospital within 24-48-hours, this does not diminish or obviate the complexity of the surgical procedure or the need for close post-surgical monitoring.

The associated inpatient hospital admission was medically necessary based on the submitted clinical data and generally accepted standards of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis (scalp). 
Treatment: Skyrizi Pen 150MG/ML (milligrams/milliliters) Pen Injector. 

The insurer denied: Skyrizi Pen 150MG/ML (milligrams/milliliters) Pen Injector. 
The denial is overturned. 

The patient a young adult male with scalp psoriasis, 10% BSA (body surface area), treated with topical medications and intralesional steroid injections. His provider is requesting treatment with Skyrizi. The health plan requires use of systemic immunosuppressant therapy. 

The requested Skyrizi is medically necessary. 

Skyrizi is an approved, appropriate and effective medication for psoriasis.  A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. Skyrizi is among the most effective therapies for psoriasis according to current peer-reviewed literature. 

According to the meta-analysis by Sbidian et al, compared to placebo, the biologics infliximab, ixekizumab (Taltz), risankizumab (Skyrizi), bimekizumab, secukinumab (Cosentyx), guselkumab (Tremfya) and brodalumab were the most effective treatments for achieving PASI 90 (90% reduction in Psoriasis Area and Severity Index score) in people with moderate-to-severe psoriasis on the basis of moderate- to high-certainty evidence. 

Methotrexate would not be the most appropriate medication for a male of childbearing potential.  Prescribing information for methotrexate states that males must use "effective contraception during treatment and for at least 3 months after discontinuation." Acitretin and cyclosporine are not used for plaque psoriasis. 

Therefore, given the above, the requested Skyrizi is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infertility. 
Treatment: In vitro fertilization (IVF) freeze all cycle. 

The insurer denied in vitro fertilization (IVF) freeze all cycle. 
The determination is overturned. 

The patient has a history of primary infertility. She underwent an in vitro fertilization (IVF) cycle. The cycle was denied coverage due to prior ovarian reserve testing results. Prior ovarian assessment results included follicle-stimulating hormone (FSH) and estradiol levels that were discounted as they were not cycle day 3 and were in some cases elevated above specified levels in the plan policy. Anti-Mullerian hormone (AMH) levels were also below guidelines and antral follicle count was above guidelines. At issue is the medical necessity of the IVF cycle. 

The IVF freeze all cycle is medically necessary as the patient has infertility, she was able to create a chromosomally normal embryo, and fertility markers have not been met as she has reasonable embryo competence. According to the American Society of Reproductive Medicine (ASRM), Currently, "AMH and antral follicle count (AFC) are the most sensitive and reliable markers of ovarian reserve. Combined ovarian reserve test models do not consistently improve predictive ability over that of single ovarian reserve tests...Extremely low AMH values should not be used to refuse treatment in IVF....[and] AMH and AFC have only a weak association with qualitative outcomes such as oocyte quality, clinical pregnancy rates, and live birth rates." Also, "AMH and AFC are currently the simplest, most sensitive, and specific measures of ovarian reserve. Markers of ovarian reserve have been shown to be good predictors of oocyte yield, but poor independent predictors of reproductive potential. Therefore, they should not be used as a fertility test or to deny access to infertility treatment." Additionally, this IVF cycle did yield a chromosomally normal embryo. Sacchi, et.al found in their study with the average age of women of this patient's age, that live-birth rate per transferred embryo with a chromosomally normal embryo was 40.3%, well beyond the 5% chance level that determines futility.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colitis.
Treatment: Inpatient hospital admission.

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

This case involves a patient who presented to the emergency room complaining of nausea, vomiting, diarrhea for 5 days with reports of a high heart rate, fever, and bandemia.  He had an elevated temperature of 101.3, elevated heart rate of 115, and right lower quadrant tenderness to palpation.  CT (computed tomography) of the abdomen noted that oral contrast remained within the small bowel and had not yet reached the cecum and nonspecific nonobstructive configuration.  There is mild air and stool-filled colon with regions of wall thickening/nonspecific colitis suggested.  The patient also had nonspecific moderate splenomegaly with spleen measuring 17 cm (centimeters) demonstrated, for which correlation was advised.  A horseshoe kidney was also incidentally noted.  Upon assessment, the patient was diagnosed with colitis.  He was subsequently admitted for treatment, placed on NPO (nothing by mouth) and was given intravenous fluids and antibiotics.  His condition improved by the following day, and he was subsequently discharged.  

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

The inpatient hospital admission was not considered medically necessary for this patient.

According to the Milliman Care Guidelines, clinical indications for admission to inpatient care include patient suspected of severe infection to include bloody diarrhea, or immunosuppression, severe abdominal pain, peritoneal signs, toxic megacolon, hemodynamic instability, vomiting that is severe or persistent, dehydration that is severe or persistent, electrolyte or metabolic abnormality that is severe or persistent despite observation care, hemolytic uremic syndrome, or the inability to maintain oral hydration that persists after observation care.  While it was noted that the patient was febrile and tachycardic on presentation to the emergency department, the evidence did not support that he required inpatient care, and he could have been treated on a lower level of service to include observational basis.  He benefited from treatment to include intravenous fluids and medications, and while he underwent testing to determine the cause of his symptoms, these measures could have been rendered on the observational basis or an outpatient basis and did not require inpatient treatment.  Therefore, it was determined that the inpatient hospital admission was not considered medically necessary for this patient.  The prior determination is upheld.

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

Diagnosis: Cancer. 
Treatment: Radiation Therapy. 
The insurer denied is proton beam therapy. 
The denial is overturned.

The patient is a female with a history of stage four (IV) breast cancer with leptomeningeal disease. She has completed whole brain radiotherapy and has been recommended to proceed with total spinal radiotherapy. The request is for approval of proton beam radiation therapy.

The proposed proton beam radiotherapy is likely to be more beneficial than any standard treatment for the patient's life-threatening condition. The treating provider supplied a proton/photon plan comparison which shows that the proton radiation plan would be associated with a significantly reduced risk for acute/late toxicity, including esophagitis, enteritis, and cardiopulmonary injury. Proton radiation for delivery of total spine irradiation is supported by numerous high-quality prospective clinical outcomes reported in the peer-reviewed medical literature and is widely utilized throughout the oncology community at specialized centers nationwide.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Radiation Therapy. 
The insurer denied is proton beam therapy. 
The denial is upheld.

This is the case of a female with metastatic breast cancer who finished whole brain radiation therapy recently. Now she needs total spine radiation therapy (RT) to complete prophylactic cranial irradiation (pCSI) using a Proton beam. This is the subject of review.

The proposed health service or treatment Proton beam therapy is not likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease.
This is an experimental/investigational treatment for a patient with widespread metastatic disease. There is no published data to support this treatment. National Comprehensive Cancer Network (NCCN) guidelines do not recommend this treatment for this clinical scenario. This is not generally accepted treatment in the USA for this clinical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Radiation Therapy. 
The insurer denied is proton beam therapy. 
The denial is overturned. 

This patient is a female with a history of stage four (IV) breast carcinoma post chemotherapy and radiation therapy to the right breast. She developed metastatic disease and has been treated with immunotherapy, chemotherapy, and liver ablation with good responses. She now has developed brain metastases and leptomeningeal metastases. She was treated with whole brain radiation down to cervical (C)7. She is recommended to have craniospinal irradiation due to the risks involved with leptomeningeal disease and the proton beam approach to deliver 3000 centigray (cGy) in 10 treatments is requested.

The proposed treatment of proton beam therapy is likely to be more beneficial than any standard treatment for the insured's life-threatening or disabling condition or disease.
The recommended proton beam radiation therapy for this patient and her metastatic breast carcinoma is considered medically appropriate and not investigational nor experimental. This recommended treatment for her at-risk spinal canal with leptomeningeal metastases is the best and safest approach of treatment in a setting of previous radiation to the right chest and to match the C7 level of the spinal canal from the previous whole brain radiation therapy. There are excellent studies published in peer-reviewed journals supporting the use of proton beam radiation therapy for craniospinal irradiation. It has been shown to decrease the high doses of radiation to critical vital structures such as the spinal cord, esophagus, heart, and lung as compared to the photon intensity modulated radiation therapy (IMRT) approach of treatment. Due to the physical characteristics of proton radiation with its Bragg peak, the edges of the beam and depth of the beam are much sharper and able to improve the dosimetry of these vital structures. This is also supported by National Comprehensive Cancer Network (NCCN) guidelines with category 2a support as well as the American Society for Radiation Oncology (ASTRO) Model Policy on proton radiation as a group 1 diagnosis with excellent data supporting its use in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder - Anemia
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with dizziness, lightheadedness, and weakness who presented to the emergency room. The patient was found to have a hemoglobin of 3.8 grams per deciliter (g/dL). The patient was transfused 3 units of packed red blood cells (pRBC) and received parenteral iron. The patient left the hospital against medical advice. At issue is the medical necessity of the inpatient admission.

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

The requested health service/treatment of inpatient admission is not medically necessary for this patient. This patient had severe, symptomatic anemia, but given the hemodynamic stability of the patient and her relatively minor complaints, the patient could likely have received the same treatment without requiring the inpatient level of care. The patient was not grossly bleeding, had otherwise normal laboratory studies, and a known cause for her anemia (menstrual losses). Data demonstrating the benefit of inpatient care in this clinical scenario is scant. For these reasons, medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Upheld.

The patient is a male with a past medical history of Crohn's disease on treatment with Humira and prednisone who presented to the emergency room with abdominal pain and bloody stools. He was hemodynamically stable and afebrile. He had tenderness to palpation of the abdomen in the periumbilical region without rebound, guarding or rigidity. He had mild leukocytosis but no anemia, the rest of his labs were unremarkable. He was started on analgesics and a clear liquid diet. Gastroenterology was consulted, recommended supportive care, and computed tomography (CT) enterography which did not reveal inflammation of his bowels. Inflammatory markers - C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were normal. His symptoms gradually resolved, his diet was advanced, and he was discharged to home with outpatient follow up.

The health plan's determination is upheld.

The requested inpatient admission is not medically necessary for this patient.
As many as 15-25% (percent) with inflammatory bowel disease may require hospitalization related to a flare of their disease. The goals of hospitalization are to assess disease severity, exclude infection, administer rapidly acting and highly effective medication regimens, and determine response.
This patient had no evidence of hemodynamic instability and had benign abdominal examination without peritoneal signs. He did not have evidence of dehydration or electrolyte derangements. He did not have evidence of massive gastrointestinal blood loss. Therefore, he could have been managed at a lower level of care status rather than acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: coronary artery disease and Alzheimer's dementia

Treatment is for PCW (personal care worker) services 7 days/week; 24 hours/day; continuous care by more than 1 person

The insurer denied coverage for PCW services 7 days/week; 24 hours/day; continuous care by more than 1 person
 
The denial is overturned.

This is an elderly female with chronic medical problem including coronary artery disease and Alzheimer's dementia. She lives alone in a private residence. The insurer approved PCW 24 hours/day, 7 days/week (live-in) and the request is for PCW services 7 days/week; 24 hours/day; continuous care by more than 1 person. 

The Uniform Assessment System (UAS) assessment report. The patient's cognition is described as moderately impaired. She is totally dependent for bathing, dressing, bed mobility and toilet use. She is bowel and bladder incontinent. Maximal assistance is needed for personal hygiene and extensive assistance for eating. She is "bed bound" and non-ambulatory. The patient has significant cognitive and functional impairments that have further declined when compared to the previous UAS report. The patient's condition and functional needs are at a level or unpredictable as to require the requested increase PCW services 7 days/week, 24 hours/day, continuous care by more than 1 person: 168 hours/week. Of particular concern is her lack of bed mobility, total bowel/bladder incontinence, need for intermittent bed repositioning and risk of developing pressure ulcers. The patient's health and safety can be appropriately provided and maintained by the requested increase PCW 7 days per week, 24 hours per day, continuous care by more than 1 person: 168 hours per week.

From a physical medicine and rehabilitation perspective, PCW services 7 days/week, 24 hours/day, continuous care by more than 1 person; 168 hours/week is medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care worker (PCW) services 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week services is substantiated.