Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Genitourinary/other
Pharmacy/Prescription Drugs

The patient is a male with a history of hypogonadism.
The coverage request is for Testim 50mg/5gm (1%) gel. The medication was previously denied because the patient did not meet medical necessity criteria under health plan, specifically because it is nonformulary drug and the patient has not tried a failed formulary agents (testosterone gel - generic Androgel 1.62%, testosterone solution, and Androderm).

The health plan's determination is upheld. Hypogonadism treatment in symptomatic men is recommended by the Endocrine Society 2018 guidelines, and the society does not differentiate between different types of testosterone preparations in terms of efficacy in treating hypogonadism and its symptoms. Similarly, the 2018 American Urological Association (AUA) guidelines on the topic also do not differentiate between different types of testosterone preparations in terms of treatment efficacy. Additionally, there are no high quality clinical studies showing one preparation results in improved patient outcomes versus another testosterone preparation.
All of the testosterone forms on the formulary are effective agents in treatment of hypogonadism when titrated appropriately. Thus, the patient can use formulary preferred drugs first, before requesting non-preferred agents as the Testim 50mg/5gm (1%) gel.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Asthma
Treatment:  Pharmacy/Prescription drugs

The patient is a male with a medical history of severe persistent asthma on therapy with inhaled corticosteroid (ICS), long acting beta agonist (LABA), leukotriene modifiers, albuterol and as needed prednisone.  He had a blood eosinophil level of 84 cells/mcL. The provider is seeking biologic therapy with Dupixent to treat the patient's severe persistent asthma.  This is the subject of this review.

The health plan's determination is upheld.  Dupixent 200 mg/1.14 Syringe 2.280 for 14 Days is not medically necessary for this patient.

Dupixent is indicated as an add-on maintenance treatment in patients with moderate-to-severe asthma aged 12 years and older with an eosinophilic phenotype or with oral corticosteroid dependent asthma.  Castro et al. demonstrated that patients who received Dupixent had significantly lower rates of severe asthma exacerbation than those who received placebo, as well as better lung function and asthma control.  Wenzel et al. demonstrated Dupixent increased lung function and reduced severe exacerbations in patients with uncontrolled persistent asthma.  Rabe et al. demonstrated that in patients with glucocorticoid-dependent severe asthma, Dupixent treatment reduced oral glucocorticoid use while decreasing the rate of severe exacerbations and increasing the FEV1.

Per the clinical documentation, this patient has severe persistent asthma therapy with inhaled corticosteroid (ICS), long acting beta agonist (LABA), leukotriene modifiers and albuterol.  Also, per the clinic note, the provider states the patient does not have an elevated eosinophil count (84 cells/mcL) and does not have steroid dependent asthma.  Therefore, without documentation of maximal asthma therapy with high dose inhaled corticosteroids and long acting beta agonists or steroid dependent asthma in the setting of eosinophilic asthma, Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intermittent exertional chest discomfort 

Treatment: Inpatient hospital stay 

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

This patient is a male with a history of recent tobacco use, hypertension, hyperlipidemia and coronary artery disease with percutaneous coronary intervention (PCI) in the left anterior descending (LAD) and right coronary artery (RCA). The patient's past medical history also included gastroesophageal reflux disease (GERD), asthma, arthritis and a disease of the liver. The patient's home medications included aspirin, atorvastatin, Plavix, Ranexa, amlodipine, Imdur, Symbicort, Tessalon Perles, Ventolin and Loratadine.  The patient had a two week history of intermittent exertional chest discomfort and dyspnea with some episodes at rest, similar to his symptoms prior to the PCI. The patient was noted to have a recent abnormal nuclear stress test when he was seen in the pre-procedure area for an elective coronary angiography and possible PCI.  
The patient's coronary angiography revealed an 80% proximal left anterior descending (LAD) and 80% in-stent mid-LAD stenosis, with mild diffuse dominant right coronary artery (RCA) and left circumflex disease.  The patient was treated with balloon angioplasty, atherectomy and implantation of a drug-eluting stent in the mid-LAD, and balloon angioplasty and implementation of a drug eluting stent on the proximal LAD.  The procedure was performed using right femoral artery access, and there were no access site complications.  During and after the procedure, the patient complained of chest discomfort which was treated with fentanyl and morphine, with no abnormal changes noted on the EKG during the discomfort.  The patient also complained of chest discomfort that was worse with inspiration on, which resolved with acetaminophen.  The patient was discharged to home on his home medications for outpatient management.

Based on this patient's clinical presentation and uncomplicated procedure,  there was no clinical evidence that this patient was at an increased risk for short-term adverse cardiovascular events after his diagnostic coronary angiography and percutaneous coronary artery intervention that warranted inpatient monitoring and management. Based on the literature review, this procedure could have been completed at a same-day procedure level of care.

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

The carrier's denial of coverage for the inpatient hospital stay is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems
Inpatient Hospital

The patient is a female with a symptomatic right lower leg low-flow venous vascular malformation. Symptoms include swelling and pain with extension into the foot. The lesion involves lymphatic and venous components. Skin is sensitive to touch. She underwent a direct stick sclerosing embolization procedure using STS (sodium tetradecyl sulfate) foam; a powerful sclerosant under Anesthesia. She also had an arteriogram. She required medications and observation during her overnight hospital stay.

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient has a significant vascular malformation which are generally treated at only highly specialized centers by experience practitioners. This lesion required specialized treatment with powerful sclerosant agents which have many risks, side-effects and potential complications. The performed procedure in this instance required an inpatient hospitalization for this patient's recovery. Treatment of venous malformation was a significant procedure, requiring intense post-procedural evaluation. The embolization procedure would not predict how significant a complication may occur. It is appropriate to admit and observe the patient, so a complication does not cause a cascade of additional problems.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary / Kidney Disorder
Inpatient Hospital

The patient is a male with a history of end stage renal disease on dialysis, restless leg syndrome, hypertension, depression, and status/post (s/p) gastric lap band procedure. He presented to the emergency room after advising his nephrologist that he missed his dialysis two days previous. His nephrologist advised him to go to the emergency room (ER) for dialysis. The patient had no other new complaints. The vital signs and physical exam were unremarkable, and the lab studies showed the expected abnormalities considering his renal failure. The patient was admitted for further treatment and evaluation.
Upon admission, the patient underwent hemodialysis. Telemetry monitoring noted two sinus pauses while the patient was eating. Cardiology was consulted. The patient reported that this was not a new finding and was related to food passing through the banded area of his stomach. The patient was scheduled have removal of lab band due to known complications. The dialysis was uneventful, and the patient was discharged the following day.

The health plan's determination is upheld.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, or labs of an imminently life-threatening cause of the patient's complaints. The service provided - hemodialysis - was not at the acute inpatient level of care. It seems that it was provided for patient convenience. Based on the standard of care and peer reviewed literature, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class II, maxillary and mandibular crowding, excessive overjet, and deep impinging overbite 

Treatment: braces (D8080)
The insurer denied coverage for braces (D8080). The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class II, maxillary and mandibular crowding, excessive overjet, and deep impinging overbite. The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 11 points on review by internal reviewers.

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 11 points (3 points overjet, 5 points overbite and 3 points labiolingual spread).

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies. These peer reviewed articles conclude that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

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

Based on the above, the medical necessity for braces (D8080: comprehensive orthodontic treatment of the adolescent dentition) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is an unvaccinated male child. He was referred to the ED via EMS for evaluation of retractions and grunting. He had been given an albuterol treatment in the office without improvement. He had cough, congestion, and low-grade fever for two days at home. 

The patient's vital signs in the ED included temperature 102.4, heart rate 167, respiratory rate 40 (range 30-42, 30s once afebrile), and oxygen saturation 99% in room air. Examination was significant for mild respiratory distress, nasal discharge, moist oral mucosa, tachypnea, belly breathing, diffuse crackles, benign abdomen, and non-focal neurologic exam. Pertinent laboratory findings included positive RSV (respiratory syncytial virus), negative influenza, unremarkable CBC (complete blood count), concentrated urine (specific gravity 1.026), lactic acidosis on venous blood gas (2.5), and mild metabolic acidosis (CO2 [carbon dioxide] 19). Chest x-ray was negative. 

The patient was given a fluid bolus for mild dehydration on labs. He was somewhat improved after an albuterol treatment, but continued to have retractions. Following suctioning, he still had mild retractions with diffuse crackles on exam. 

The patient was admitted for further management of RSV bronchiolitis and mild dehydration. Admission orders included IV fluids, respiratory monitoring, and consideration for discharge if no oxygen requirement and good oral intake. Following hospitalization, he remained afebrile with stable vital signs. He received two doses of albuterol and suctioning, with improvement in his clinical status. 

The patient continued to improve, was eating well, voiding and stooling, with no signs of respiratory distress. He was deemed stable for discharge, with a prescription for nebulized albuterol, to follow up with his primary care practitioner in one or two days.

This male infant was under one year of age when he developed RSV bronchiolitis. He was referred to the ED with cough, wheezing, retractions, grunting, and fever. He was treated with albuterol with some improvement, but continued to have signs of respiratory distress. Lab studies (CO2, lactate, urine specific gravity) were indicative of mild dehydration. He was admitted for further management. He was overall hemodynamically stable, with no oxygen requirement, no feeding refusal or inability to tolerate feeding, and no evidence of impending respiratory failure. While it was reasonable to monitor him in the hospital for adequate intake and improvement in work of breathing, he did not require acute inpatient admission and could have been safely and appropriately managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System: Other
Inpatient hospital

The patient is an infant female infant who presented to the emergency department (ED) via Emergency Medical Services (EMS) at 2 months of age for evaluation of an episode of hypotonia followed by cyanosis. The mother had fed her two ounces of chamomile tea followed by three ounces of Gentlease formula. The baby curled up as if bearing down so the mother attempted for quite a while to burp her unsuccessfully. She put the baby down after which she began sticking out her tongue and had a small spit up. She continued to do this so the mother attempted again to burp her by lying her over her lap. At this time, the baby went limp, and was noted to be purple and not breathing. The mother ran to the neighbor, an EMS worker, who performed sternal rub resulting in return of breathing and color. The entire episode lasted about five minutes. EMS was contacted and the baby was taken to the ED.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This young female infant presented with history suspicious for overfeeding with gastroesophageal reflux. There was also concern for a higher risk brief resolved unexplained event because of her age and the duration of the event. It was reasonable to observe her in the hospital pending further evaluation and monitoring. This would be consistent with management for a BRUE. She was overall hemodynamically stable, with no evidence of dehydration, impending respiratory failure, sepsis, or any other complication that would indicate need for more involved evaluation or longer hospital stay. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall, Intertrochanteric Hip Fracture 

 Treatment: Inpatient Admission

The insurer denied Inpatient Admission. The denial was upheld.   

This is a male patient with a history of substance abuse, anxiety, posttraumatic stress disorder (PTSD), right lower extremity injury and sciatic nerve damage with foot drop. He was status post right hip fracture with an ankle foot orthosis (AFO) boot in place a few days prior to this emergency department presentation. He presented to the hospital with complaints of recurrent falls and the inability to care for himself in the community. While in the hospital he received medical and pain management, physical and occupational therapy. He was discharged when he was able to ambulate with a walker.

The patient's pain level was reported to be baseline; and the patient had no problems from his surgical site. The patient's vital signs were stable. The patient's ambulatory status was limited because of his foot drop; and during inpatient stay, the patient received physical and occupational therapy, as well as a rolling walker.
The patient did not have any acute or comorbid medical conditions that required inpatient level of care. The patient received services that could have been provided as an outpatient setting (i.e. outpatient physical therapy, pain management, rehabilitation, or orthopedics). The patient's case did not have any extenuating circumstances to substantiate the inpatient admission and the length of hospital stay.  

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

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

Treatment: Vascular Surgery/Femoral Vascular, 04 units and Vascular Surgery/Tibial Vascular, 06 units services 

The insurer denied coverage for Vascular Surgery/Femoral Vascular, 04 units and Vascular Surgery/Tibial Vascular, 06 units services. The denial is reversed. 

This patient is a male with a history of hypertension, hyperlipidemia, peripheral vascular disease (PVD) with claudication, peripheral artery disease (PAD), coronary atherosclerosis, status post stents and coronary artery bypass graft (CABG). Based on the review of the medical records provided, this patient underwent lower extremity arterial testing and the results identified an ankle-brachial index (ABI) of 0.88 on the right, and 1.00 on the left. The patient underwent a lower extremity arterial duplex which noted severe bilateral superficial femoral artery (SFA) disease. When the patient was seen the physician indicated that based upon the patient's ABI showing blunted pulse volume recordings (PVR) and with the ultrasound showing elevated left common femoral artery (CFA) velocity and monophasic below the knee vessels, the patient was experiencing marked claudication symptoms. The follow-up notes indicated that the patient had severe right popliteal and left SFA stenosis with severe bilateral leg claudication. It was noted that a cardiac catheterization showed patent stents and a patent graft to the right coronary artery (RCA), with an occluded graft to the diagonal. 

The patient had severe claudication, and the patient's arterial duplex revealed right superficial femoral artery (SFA) occlusive disease.  According to literature review, the arterial duplex testing is suggestive but not the gold standard imaging for distal/infra-geniculate disease.  The patient's waveforms below the knee were monophasic and thus, indicated that the arterial duplex would not comment on the distal infra-geniculate circulation. When the patient went for angiography, infra-geniculate disease was found and treated with atherectomy and angioplasty to the TP trunk.  This was an accepted standard of care and practice, and should be allowed to be performed at the same setting as the right SFA intervention.  Without this concomitant treatment, the literature indicates that the results from the angiography would be incomplete, and could result in early re-stenosis or occlusion.  Thus, based on this literature review and this patient's medical record, the requested procedures were medically necessary to treat this patient's condition.   

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

The carrier's denial of coverage for the Vascular Surgery/Femoral Vascular, 04 units and Vascular Surgery/Tibial Vascular, 06 units services is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute bladder and bowel incontinence; weakness in feet; pain
Issue under review: Surgery by out-of-network doctor

Determination:
The patient's condition was emergent in nature such that the Surgery by out-of-network doctor was medically necessary.

The patient is an adult female with history of developed acute bladder and bowel incontinence, as well as weakness in the feet at night. MRI shows diffuse degenerative changes in the lumbar spine with significant stenosis. The patient presented to the ED with ten out of ten (10/10) pain. X-ray shows anterolisthesis at L3-4 and retrolisthesis at L4-5. The patient was taken to the operating room for L3-4 fusion.

Based upon standard of care, the surgery that was performed was medically necessary and emergent in nature. The patient presented with concerning findings for cauda equina. This is a neurosurgical emergency because it can lead to permanent bowel/bladder dysfunction which can be debilitating and affect the patient for life. There is a significant urgency when patients present with cauda equina, and having an out of network surgeon perform this procedure was appropriate and medically necessary as delays can cause permanent disability and significant and devastating long term consequences.

The patient had evidence of severe stenosis on MRI that correlates with symptoms, the patient had significant right leg weakness, worsening bowel/bladder incontinence, without improvement, concerning for cauda equina, and the proposed surgery addressed the pathology in the most effective way.  

The patient did present with worsening weakness and bowel/bladder symptoms.  This is very concerning for cauda equina which is a disease process that can be permanently and severely debilitating and disabling. The emergent surgery addressed the level of concern and fusion was appropriate because the patient had spondylolisthesis.  Therefore, the surgery by the out of network doctor should be approved as it was medically necessary and emergent in nature.