Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain
Treatment: Percutaneous laminotomy/laminectomy for 
decompression of neutral elements under indirect image guidance/ MILD (0275T)
The insurer denied: Percutaneous laminotomy/laminectomy for 
decompression of neutral elements under indirect image guidance/ MILD (0275T)
The denial is overturned.

The patient is an adult male with low back pain and neurogenic claudication. He has failed conservative treatment in the form of physical therapy, epidural steroid injections, medial branch blocks, and medications. He has severe spinal stenosis at L4-5, primarily attributed to ligamentum flavum hypertrophy. He is not a candidate or is not interested in open surgery. Minimally invasive lumbar decompression (MILD) was recommended. This was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should cover the requested health service.

The patient is an adult male with low back pain and neurogenic claudication who has failed conservative treatment in the form of physical therapy, epidural steroid injections, medial branch blocks, and medications. He has severe spinal stenosis at L4-5, primarily attributed to ligamentum flavum hypertrophy. He is not a candidate or is not interested in open surgery. The patient has severe pain with significant disability. A minimally invasive lumbar decompression (MILD)/percutaneous laminectomy was recommended. This is a fluoroscopically guided minimally invasive laminectomy that targets debulking of the ligamentum flavum in order to relieve symptoms of neurogenic claudication caused by spinal stenosis. The patient has failed typical and reasonable conservative treatments in the form of physical therapy, home exercise, medications, and epidural steroid injections. He was evaluated for spine surgery and was not found to be a candidate. He is severely limited by his pain. The options are limited. Given that one of the major contributing factors to the patient's spinal stenosis is ligamentum flavum hypertrophy, a debulking of this ligament is reasonable. Alternatives, such as open decompression or decompression with spinal fusion, are not without risks. These require general anesthesia and are considered to be significantly more invasive. Given the above, the requested MILD (minimally invasive lumbar decompression) procedure (percutaneous laminectomy/laminotomy) is medically appropriate. Therefore, the health plan should cover the requested health service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain/urinary frequency
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female without a significant past medical history who presented with left sided abdominal pain and urinary frequency for several days. She had seen an outside physician who had prescribed nitrofurantoin or Cipro without improvement. She complained of chills and subjective fevers in addition to nausea. She denied vomiting, chest pain, or shortness of breath. On exam, she was afebrile with a pulse of 68, a blood pressure of 112/77, a respiratory rate of 16 and she was not hypoxic. She was not in any acute distress, and she did not have costovertebral angle tenderness. 

The inpatient hospital stay was not medically necessary based on the documentation provided. The patient presented with symptoms of acute cystitis. She was hemodynamically stable. She did not have significant medical co-morbidities. She did not have acute kidney injury or respiratory distress. She did not have bacteremia. She did not have a renal abscess, ureteral obstruction or emphysematous pyelonephritis. She did not have a documented indication for prolonged IV antibiotic therapy. She did not require an inpatient surgical procedure or a have a complication from a procedure that required inpatient management. She could have safely been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: alcohol withdrawal seizure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.
 

This adult female was admitted to this inpatient hospital due to alcohol withdrawal symptoms including an alcohol withdrawal seizure, tremors, and a Clinical Institute Withdrawal Assessment (CIWA) score as high as 20. She reportedly had a past alcohol withdrawal seizure. It was reported that she had a history of heavy alcohol use. She reportedly had fallen and had a foot fracture. She  had other medical issues  including persistent lactic acidosis, hypokalemia, and worsened creatine phosphokinase (CPK) levels in the setting of an alcohol withdrawal seizure. She was brought in by family and was in a wheelchair unresponsive after having the seizure. She was admitted to telemetry, was given Ativan 2 milligrams (mg) intravenous (IV) for detoxification and was put on a Librium taper for alcohol detoxification treatment. She was also treated with IV Droperidol, 1 liter IV bolus times 2, Toradol, magnesium, IV potassium, thiamine, and folic acid. It was reported that the patient was critically ill with a high probability of life-threatening withdrawal. The patient reportedly was discharged when medically stable.

According to the Level of Care for Alcohol and Drug Treatment Referral  (LOCADTR) she did require 24-hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting. She continued to drink large amounts of alcohol and had active serious withdrawal symptoms including  withdrawal seizures.  She  received and required 2 detoxification medications including Librium taper and Ativan 2 mg IV. 

This was a medically unstable patient with a current alcohol withdrawal seizure which requires hospital treatment, and she had a past alcohol withdrawal seizure. It is considered standard of care and medically necessary treatment for patients with alcohol withdrawal seizures or a history of alcohol withdrawal seizures to be treated in an inpatient medical hospital due to the high risk for life threatening withdrawal. Delirium tremens can occur 3-4 days after cessation of alcohol use, as she required the entire time in this inpatient hospital setting for detoxification treatment. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment for alcohol detoxification. 

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 an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pancreatitis
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is a female with history of alcohol abuse and pancreatitis who had initially presented to the emergency department (ED) for evaluation of abdominal pain. She was treated conservatively and sent home. She then began to have recurrent and worsening epigastric pain that was associated with vomiting. This caused her to return to the ED for further evaluation. She was unable to keep down food or water due to vomiting. She rated the pain as being 10 out of 10 in severity. She described the pain to nursing as being "unbearable". 

The inpatient hospital admission was medically necessary for this patient.
The patient crossed two midnights receiving medically necessary care for acute on chronic pancreatitis that had failed to respond both to outpatient treatment and to ED treatment on her re-presentation. The patient meets Milliman Care Guidelines (MCG) criteria for inpatient status admission for treatment of acute pancreatitis/abdominal pain for several reasons. She had severe epigastric abdominal pain and a radiologic assessment of acute pancreatitis on her CT abdomen. On her ED presentation, she had an inability to maintain oral hydration and severe pain that persisted despite initial ED treatments. According to the admission note, the patient was still having severe abdominal pain and tenderness despite having received multiple ED treatments that included IV morphine, IV fluids, and IV Reglan. Treatment of acute pancreatitis in the hospital setting typically entails several days of IV fluids, IV opioids, and IV analgesics.
She is considered high risk for complications given her history of pancreatitis and active alcohol abuse. She needed vigilant assessments in a setting that could render rapid management and intervention if she were to develop complications such as worsening pancreatitis. This could have been manifested by an infection of her pancreatic pseudocysts or progression to pancreatic necrosis. There was risk for increasing abdominal pain and ongoing exposure to IV opioids. Ongoing exposure to IV opioids on 7/24 put the patient at risk for respiratory depression, hypotension, and encephalopathy. She was at risk for ongoing nausea/vomiting which could have led to dehydration, significant electrolyte disturbances, and acute kidney injury. Her active alcohol abuse put her at high risk for alcohol withdrawal symptoms, such as hallucinations, seizure activity, or progression to delirium tremens.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: opioid use
Treatment: Suboxone
The insurer denied Suboxone. 
The health plan's determination is overturned.

The patient is a male being prescribed Suboxone 8 milligrams (mg) - 2 mg Film for the diagnosis of opioid use disorder.
The health plan denied coverage for this brand-name medication because it is not on the plan formulary. The plan requires a trial of all formulary alternatives within this drug class. Formulary alternatives available to the patient include Zubsolv, buprenorphine tablets, and buprenorphine/naloxone tablets and films. The patient's prescriber provided documentation that all of these had been tried in the past with the exception of Zubsolv. The plan requires a trial with demonstration of failure or serious side effects with Zubsolv.
The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient has tried Zubsolv and generic Suboxone films and experienced side effects from them all, including increased cravings and headaches. He has done well with brand name Suboxone. Office visit notes were provided for review which corroborate this history.
At issue is the nonformulary drug Suboxone 8mg - 2mg Film.

The health plan's determination is overturned in whole.

The documentation provided demonstrates that the alternative formulary drugs have been ineffective and/or have had adverse effects.
The patient has tried the generic equivalent of the requested medication and Zubsolv. The patient has not tolerated either of these treatments as outlined. The plan states that there was no documented trial of Zubsolv; however, the office visit notes and letter from the prescribing nurse practitioner indicate that this has been tried in the past and that it was not effective.
In an in vivo pharmacokinetic study from Santiago, brand-to-generic substitution of Suboxone resulted in different serum concentrations in patients. It is biologically plausible that the patient could have a more favorable response to brand name Suboxone and may have a lesser response to the alternative medications. Given the importance of stability and maintenance therapy in patients with opioid use disorder, the documentation supports the request for brand name Subox
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia areata. 
Treatment: Litfulo 50mg (milligrams) Capsule. 
The insurer denied Litfulo 5mg Capsule. 
The health plan's determination is overturned. 

The patient is a female with alopecia areata, treated with topical, intralesional and systemic steroids, and Tacrolimus ointment. The provider is requesting Litfulo. 

Litulfo is medically necessary. 
Alopecia areata is not a cosmetic condition. Alopecia universalis is a severe form of alopecia areata involving total body hair loss - including eyelashes, groin, etc. Regrowth of hair rarely occurs. Treatment studies for any form of alopecia areata are difficult to perform because the disease has an unpredictable course, and much investigation is still needed. 
A wide range of treatments have been used for the management of alopecia areata, most of which are not highly effective. Treatments include topical or intralesional corticosteroids, topical minoxidil (2% or 5%), topical anthralin, systemic corticosteroids, cyclosporine, and other immunosuppressants. A dependable and safe treatment for extensive disease (totalis or universalis) has yet to be found. Given the rarity of the disease, large randomized controlled trials are extremely difficult. 
JAK (Janus kinase) inhibitors such as Litfulo have now changed the landscape of treatment of alopecia areata. They are truly the only medications that can offer hair regrowth for this devastating condition. Litfulo is now Food and Drug Administration (FDA) approved in children for alopecia areata. Therefore, the request is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 
Treatment: Inpatient hospital admission. 

The insurer denied the inpatient hospital admission.  The health plan's determination is upheld. 

The patient is a female with medical history of anemia, eczema, asthma, hypertension, and pneumonia. She presented to the emergency department with abdominal pain, diarrhea, and vomiting for three days after eating a meal containing nearly raw meat. Vital signs were notable for tachycardia with pulse rate of 100/minute and low blood pressure of 110/60. Physical examination was notable for soft, protuberant abdomen with periumbilical tenderness. 

The inpatient hospital admission was not medically necessary. The patient had symptoms (nausea, vomiting, abdominal pain, and diarrhea) consistent with infection, such as gastroenteritis, without finding of complications such as abscess, colitis, or perforation on imaging. The standard of care for the evaluation of gastroenteritis was appropriately performed, including intravenous fluids, empiric antibiotics, and supportive care. No other cause for the inpatient level of care, such as inflammatory bowel disease flare, peritonitis, toxic megacolon, abscess, fistula, or other complication was documented. She had gradual improvement with antibiotics and otherwise conservative therapy. The care, which was undertaken, including observation, monitoring, labs, imaging, and empiric antibiotics, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion 
Treatment: D8080 braces and D8670 monthly visit x 12 
The insurer denied coverage for D8080 braces and D8670 monthly visit x 12 
The denial is overturned 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, and ectopic eruption among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 27 total points. 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 attaining only 11 points on the HLD index by internal reviewers. 

Upon review of the submitted documentation (study models were not provided for review) 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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. 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 completes the second portion of the index arriving at 27 points to justify orthodontic care. The reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support orthodontic care. 

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. Each of these peer reviewed articles concludes 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. 

Reverse denial as the clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval. 

Based on the above, the insurer's denial must be reversed. 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 D8080 braces and D8670 monthly visit x 12 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: substance abuse
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld.

This case involves a man with depression and alcohol use disorder, admitted to the hospital intoxicated with thoughts of suicide. Temperature was normal, heart rate was 97, respirations 20, and blood pressure 133/82. Examination showed an anxious individual with agitated affect. The cardiopulmonary exam was unremarkable. The abdomen was soft with no pain. He was observed ambulating to the restroom independently with a steady gait. Laboratory studies showed normal white blood cell count and hemoglobin. Electrolytes appeared stable, renal function was unremarkable, and the LFTs (liver function tests) were normal. The emergency department (ED) felt the patient would start withdrawing and admitted the patient to medicine. 

The inpatient hospital admission was not medically necessary. Based on the provided documentation, there is no evidence the patient was going through severe alcohol withdrawal. He was treated with oral Librium and a tapering dose to prevent alcohol withdrawal. No high CIWA scores are documented to suggest the patient's treatment would require an inpatient level of care. The laboratory studies showed stable electrolytes and renal function. The patient was deemed non-suicidal by psychiatry on the day of admission. After the intoxication wore off, the patient was safely released home. Criteria for inpatient admission are not met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a medical history of diverticulosis, diverticulitis, polycystic kidney disease, and hypertension. She presented to the emergency department with left-sided abdominal pain, fever, and diarrhea the prior day. The physical examination was notable for a soft, nondistended abdomen with left lower quadrant and left upper quadrant tenderness. A computed tomography scan of the abdomen and pelvis showed moderate transmural thickening of the descending colon most consistent with diverticulitis, and fluid and edema posterior to the descending colon which could represent early abscess formation. She was treated with intravenous fluids, Zosyn, Toradol, ceftriaxone, and oral metronidazole and oxycodone.
A surgery consultation concluded that she had sigmoid colon diverticulitis with at least phlegmon and possible developing abscess; there was no requirement for urgent surgery, and bowel rest and intravenous antibiotics were recommended, with computed tomography scan prior to discharge and elective colon resection.  She was discharged on cefpodoxime with metronidazole, with a plan for Primary Care and Surgery follow-up. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care is not medically necessary, and the care provided could have been provided at a lower level of care for the duration of the stay. In patients with uncomplicated diverticulitis, outpatient management or observation is the standard of care [1]. The safety and efficacy of outpatient management of acute uncomplicated diverticulitis has been demonstrated [2]. A prospective randomized trial demonstrated that patients can be given intravenous antibiotics in the emergency department and then discharged with oral antibiotics [3]. A systematic review of the literature underscored this [4]. Observation level of care can be appropriate when there are significant symptoms and contained perforation, as in this case [5]. However, there was no protracted fever or hypotension to suggest that intravenous antibiotics in the hospital were ineffective. There was no abscess requiring drainage [4-6]. The patient improved on intravenous antibiotic therapy, and was appropriately discharged on antibiotic therapy [7-11]. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, fistula, or other complication was documented. For these reasons, the inpatient level of care is not supported in this case, and the care provided could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Respiratory failure.
Treatment:  Transfer for inpatient admission.
The insurer denied a transfer for inpatient admission.
The health plan's determination is overturned. 

The patient is a male infant born at term with complex medical history. He remains critically ill, requiring cardiac surgical repair at great risk of significant and severe complications.

Transfer for inpatient admission is medically necessary.
This young male infant with Down syndrome has experienced numerous complications from the sequelae of his genetic condition. He has been hospitalized from birth, unable to undergo necessary congenital heart surgery because of intercurrent acute febrile illnesses and other complications. According to the current standard of care and specialist recommendations, for his best chance at successful outcome, he requires "expert support to manage the complications of CHD [congenital heart disease] and associated lesions"; further, "expertise is required to establish the diagnosis of PH [pulmonary hypertension], its causes, and optimal management." These infants often require management at the extremes of complexity, with inhaled gases, extracorporeal membrane oxygenation, mechanical ventilatory support. While he is currently receiving treatment at an excellent facility, for his best chances, he requires more than excellent care. He requires the most experienced practitioners that can offer years of expertise and ability to handle any and all complications. The transfer for a higher level of care is medically necessary and appropriate.