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

Diagnosis: Rhinoenterovirus/ Asthma
Treatment: Inpatient admission 

Summary:
The patient is a male child with medical history significant for multiple ear infections, osteomyelitis with negative immune work-up, and poorly-controlled moderate persistent asthma that presented to the ED with three day history of wheezing, cough, and difficulty breathing. Despite albuterol every three to four hours, he continued to report chest tightness and shortness of breath. He also noted congestion and runny nose, no fevers. 

Viral panel testing subsequently revealed positive Rhinoenterovirus. Admission orders included weaning albuterol from continuous to every two hours with further weaning as tolerated, enteral steroids, asthma education, IV fluids, and regular diet. Pulmonary was consulted with recommendations to start Flovent 220 mcg twice daily, continue to space albuterol (every three hours at the time of the consultation), start Flonase and Zyrtec/Claritin, outpatient allergy testing and pulmonary function testing, and creation of an asthma action plan. He remained in the PICU and then transferred to the pediatric floor. Following transfer, he was able to wean to albuterol every four hours. He was subsequently deemed stable for discharge, to complete a five-day course of steroids, slowly wean his albuterol in conjunction with his pediatrician, and follow-up with Pulmonary.

This patient presented with exacerbation of poorly controlled moderate persistent asthma and status asthmaticus secondary to Rhinoenterovirus infection. He had recent history of significant worsening of symptoms, using albuterol every day as well as low-dose inhaled steroids, and had not been seen yet by Pulmonary. Upon presentation, he required aggressive intervention in the ED, and despite bronchodilators, steroids, magnesium, and fluids, he remained on continuous albuterol necessitating PICU admission. This level of treatment, monitoring, and intervention is consistent with acute inpatient management despite the short length of stay. Lower level of care would not have been sufficient for the management of this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Exertional chest discomfort

Treatment: Inpatient admission

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

This patient is a woman had a history of hypertension and a gastric sleeve procedure. Home medications included Bystolic, hydrochlorothiazide, Lexapro, and Ranexa. She had an eight week history of increasing exertional chest discomfort, evaluated with CT angiography of the coronary arteries and was found to have evidence of a right coronary artery lesion.  Chest discomfort continued to increase with episodes at rest and she presented to the ED. Initial vital signs included blood pressure 154/77, heart rate 66 and oxygen saturation on room air 100%.  Laboratory test results at 08:06 included white blood cell (WBC) count 7.0, hemoglobin 13.9, creatinine 0.9, BNP 30, and troponin 0.01.  EKG revealed normal sinus rhythm and left ventricular hypertrophy and chest x-ray was normal.  

Her cardiologist recommended that she be admitted and arranged coronary angiography with possible intervention which was performed. This revealed a 30% ostial left anterior descending coronary artery lesion with FFR 0.94, a normal left circumflex coronary artery and a 95% eccentric mid right coronary lesion, which was treated with a drug eluting stent.  She remained hemodynamically stable during and after the procedure and had no access site complications.  She was discharged to home on her home medications plus prasugrel, aspirin and pantoprazole for outpatient management.

There is no evidence that this patient required an acute inpatient level of care to determine that her chest discomfort was not related to acute coronary syndrome or to perform coronary angiography and intervention.  The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.

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

Diagnosis: Tooth decay
Treatment: Crown, porcelain fused to high noble metal, tooth #15

The crown, porcelain fused to high noble metal, tooth #15 is not medically necessary.

Tooth #15 has an existing two surface composite restoration with recurrent decay underneath. This type of tooth would typically be restored with a new two surface composite restoration. There is no photo submitted showing a need for a crown on this tooth. If lack of solid tooth structure is the reason for placement of a crown on this tooth, then a photo would need to document this. There is no photo presented, therefore there is no way to prove medical necessity for a crown.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung cancer
Treatment: Genetic testing

The genetic testing was not medically necessary.

The patient is a male with known epidermal growth factor receptor (EGFR) mutated non-small cell lung cancer (NSCLC) on Tarceva.  The attending physician (AP) performed Guardant 360 testing. 

There is no evidence that Guardant 360 testing is of clinical benefit.  The SHIVA study has shown that the use of next generation sequencing (NGS) panel testing does not improve clinical outcomes in advanced cancer conditions.  While the National Comprehensive Cancer Network (NCCN) supports the use of NGS panel testing for evaluation of NSCLC in a first line setting, following failure of EGFR tyrosine kinase inhibitor (TKI) therapy in EGFR mutated disease, the NCCN only recognizes performance of T790M testing.  Therefore, the proposed Guardant 360 testing performed following failure of Tarceva does not conform to accepted standards of practice and would not be considered necessary care.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems - Malpositioned Teeth 
Dental/Orthodontic Procedure

The patient is a female presenting with a skeletal Class III malocclusion and mild crowding. She has an anterior open bite. She is treatment planned for 30-36 months of orthodontics to address the crowding and open bite. Premolar extractions may be required per the treatment plan. The treatment was denied due to lack of medical necessity.

The health plan's determination is overturned, in whole. 

Anterior open bite patients are among the most difficult patients to treat. One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. The orthodontist is planning to attempt non-extraction treatment due to the patient's spacing but has warned extractions may be necessary to close the open bite.

Studies have shown that patients with severe malocclusions, including anterior open bite, have significantly lower masticatory and gastrointestinal digestive function than persons with normal occlusion. However, it has also been shown that after orthodontic treatment, there was no difference in masticatory function and gastric emptying between the treated group and the control group with normal occlusion. Given the patients malocclusion and the likelihood of significantly reduced masticatory function and digestive function, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted tooth
Issue under review: Braces

Determination:
The Braces are medically necessary.

The patient is a teen-aged female. The patient has an impacted upper right permanent canine. This is an "automatic qualifying" event (i.e. impacted anterior tooth where extraction is not indicated). The upper canine is a very critical tooth that needs to be moved into its proper position. This will allow proper chewing of food as well as allow all the patient's teeth to mesh together correctly without banging into each other and causing trauma. Orthodontic treatment is necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Kidney Stones
Inpatient hospital stay

Treatment: Inpatient hospital stay
This patient was admitted to the hospital with left renal colic. Vitals were 36.6-134/85-64. The white blood cell count was 7900. The creatinine was 1.06. The computed tomography (CT) imaging demonstrated a 21 millimeter (mm) left renal calculus with severe hydronephrosis. Intravenous (IV) pain medications, nausea medications, IV antibiotics and intravenous fluids (IVF) were administered.
A  left ureteroscopy with laser lithotripsy and stent placement were performed. IV pain medications, IV antibiotics and IVF were administered. The WBC count was down to 5400. Patient was discharged home afebrile and hemodynamically stable. The health plan's determination is upheld in whole. 
The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis. Following admission, there were no unstable vital signs reported. Patient did not have a documented infection or kidney failure, a solitary kidney or a kidney transplant, or need for an open surgery. Patient did not have bilateral obstruction, acute renal failure, or severe vomiting. Pain control, IV antibiotics and IVF followed by ureteroscopy/laser/stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Obstructive Sleep Apnea (OSA)
Issue under review: Inpatient Admission

Determination:
The Inpatient admission was not medically necessary.

The patient is a young male with a history of OSA (obstructive sleep apnea).  AHI (apnea-hypopnea index) was 21 on sleep study prior to surgery.  The child was an ex-33 week preemie who underwent an adenoidectomy in 2019.  The patient was admitted as an inpatient and was discharged.

There were no intraoperative or postop complications.  There was no postop bleeding, and the patient was tolerating a liquid diet advanced to a regular diet.  There was no respiratory deterioration documented.  Vital signs were stable.  

Based on the above, the medical necessity of the inpatient admission cannot be confirmed, as the patient could have been cared for at a lower level of care, observation.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Sepsis/pneumonia/acute exacerbation of asthma

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission. The denial modified.

This patient is a male with past medical history of asthma and diabetes mellitus (DM) who presented to the Emergency Department (ED) with complaint of fever. The patient complained of non-productive cough for two days. The patient also had shortness of breath (SOB) and fatigue. The patient had a possible syncopal episode preceded by dizziness. Temperature (T) Max was 103 F, blood pressure (BP) 114/51, heart rate (HR) 87, respiratory rate (RR) 18 and oxygen saturations were 94%. The patient was noted to have wheezing on lung exam. Cardiovascular system (CVS) S1 S2 was normal.  Abdomen was soft, non-tender. White blood cell (WBC) count was elevated to 11.5 K. 85 % Polys.  BUN was 29 and creatinine (Cr) 1.2.  Lactate was 3.01; Procalcitonin was 3.7 and arterial blood gas (ABG) 7.4/37/65/24 94%. Chest x-ray showed right lower lobe infiltrate. The patient was admitted for sepsis/pneumonia/acute exacerbation of asthma. The patient was treated with intravenous (IV) fluid boluses, IV antibiotics - Rocephin and Azithromycin, IV steroids and bronchodilators. Urinary Ag was positive for Strep Pneumonia.

The patient's sputum culture and sensitivity (C/S) grew pseudomonas. The plan was to continue IV antibiotics. Peak expiratory flow (PEF) on a specified date was 200. Sputum revealed gram negative rods. Significant wheezing was noted. The patient was continued on IV Steroids and antibiotics. The patient was switched to Levofloxacin the day after based on sputum C/S of pseudomonas which was sensitive to Levofloxacin. This patient was afebrile and hemodynamically stable. He was tolerating oral intake.  The patient was in no acute distress. Admission was appropriate given the presentation with syncope and possible sepsis, pneumonia, asthma exacerbation and lactic acidosis.  The patient was febrile and had diffuse wheezing consistent with asthma exacerbation.  The patient also had renal insufficiency with elevated BUN/ Creatinine. However, the patient responded to treatment and by a certain date had improved sufficiently to be discharged on oral medications.  

The prior denial is modified. Admission was medically necessary from a specified date range. However continued inpatient admission thereafter was not medically necessary. 

The health plan did not act reasonably regarding inpatient admission but they did act reasonably with regard to length of stay. The carrier's denial of coverage for the inpatient admission is modified. Approve the first specified date range. Deny the date range thereafter.
Appeal type: Medical necessity
Decision: Overturned

Digestive System/Gastrointestinal Crohn's Disease
Pharmacy/Prescription Drugs

The patient is a male with severe Crohn`s disease. He has tried numerous treatments with no significant response. These treatments include Pentasa, Remicade, Humira and corticosteroids. His treating physician requested treatment with Stelara, however, his health plan denied it and recommended treatment with the preferred agent, Entyvio (vedolizumab).
The subject under review is the medical necessity for the Stelara in this case.

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

Yes. The requested medication (Stelara) is medically necessary. Stelara is Food and Drug Administration (FDA) approved for the treatment of moderate to severe Crohn`s disease in adult patients who failed anti-tumor necrosis factor alpha (TNF a) (Remicade and Humira). The safety and efficacy of Stelara are well established in the medical literature and supported by the clinical practice guidelines (Lichtenstein, Gary R., et al).
Entyvio is also approved for the treatment of Crohn`s disease, however, the available scientific evidence indicate that Stelara is superior to Entyvio in terms of efficacy. Singh, Amandeep, et al. published a retrospective comparative study between Stelara and Entyvio. The study concluded that Stelara is superior and can be used as a preferred drug over Vedolizumab for induction in moderate to severe Crohn's disease (CD).
Pacou, M., et al. published a systematic literature review comparing efficacy between biologics used for Crohn`s disease treatment. The study showed a higher likelihood of response or remission at year 1 with ustekinumab compared to vedolizumab or adalimumab. Similar results found by Biemans, V et al. and published a cohort observational study showing that after 24 weeks, 46.2% Entyvio and 57.9% Stelara patients were in corticosteroid-free clinical remission. The rate of adverse events was comparable between the two groups.
Therefore, and based on the available scientific evidence, Stelara appears to be more likely to put this patient into remission when compared to Entyvio. The treating physician chose the best treatment for his patient based on the available literature. It is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Optic neuritis
Treatment: Mayzent

The health plan should not cover the proposed treatment. 

The patient is a female with remote history of optic neuritis and no accumulation of lesions on magnetic resonance image (MRI) of the brain. The attending physician (AP) has requested Mayzent. 

First, the diagnosis of secondary progressive multiple sclerosis is not established, particularly as there is no documented relapsing remitting course. Secondly, there is no evidence of relapsing or active lesions with the context of a secondary progressive course. Therefore, Mayzent is not indicated and the health plan should not cover the proposed treatment.
Appeal type: Medical necessity
Decision: Overturned

Pharmacy/Prescription Drugs

This is a patient with urticaria who is requesting for Xolair. The patient has since taken Fexofenadine and Loratadine 4 times a day without benefit. Overturn in whole, the health plans determination. Yes, the request is medically necessary. The patient has tried Allegra 4 times a day. The patient also tried Loratadine (Claritin) 10 mg 4 times per day. This patient has an adequate trial of first line treatments for Chronic Idiopathic Urticaria (CIU) per practice guidelines.
According to practice guidelines, the first line treatment for the treatment of urticaria is high dose antihistamines. This patient has tried antihistamines in doses that exceed 4 times the normal daily dosing with continual symptoms.  Therefore, the patient meets standards of care for the treatment of hives for the step up to Xolair.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Severe overjet, speech concerns, and lip incompetence

Treatment:  D8080 braces and D8670 monthly visit

The insurer denied coverage for D8080 braces and D8670 monthly visit.  The denial reversed.

This patient is a female child with a Class II occlusion.  She has space in the maxillary arch, excessive overjet, and a deep bite.  The treatment planned is orthodontics with 8-10 months of Class II headgear followed by braces to correct her malocclusion. 
 
At issue is whether D8080 Braces and D8670 Monthly Visit are medically necessary for this patient.  The patient's protrusive incisors (both the high incisal angle and the 7mm overjet) are at an increased risk of trauma.  Orthodontic treatment can reduce the risk of trauma. (1)

The requested treatment of braces is medically necessary for this patient.  Her significant overjet increases the risk of dental trauma that will be more invasive to correct than the orthodontic problem she currently has.

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest of the patient. 

Based on the above, the medical necessity for D8080 braces and D8670 monthly visit is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Primary diagnosis:Dental Problems Missing tooth /teeth
Primary treatment :Dental /Orthodontic Procedure 
Summary:
The patient  presenting with a skeletal Class I malocclusion and mild spacing. The patient  has a 100% deep bite. The patient  is missing teeth 7, 10, 20, 28 and 29. Primary teeth C, H, K and T are retained. The patient  has treatment planned for 18-24 months of orthodontics to address the crowding and a palatally impinging deep bite.  The photographs clearly show the patient with a 100% deep bite. The orthodontist is planning to maintain primary teeth C, H, K and T, but prosthetic replacement for missing #28 will be necessary. The health plans determination of medical necessity is overturned in whole.
The patient presents with hypodontia. Hypodontia, or tooth agenesis, is the most prevalent craniofacial malformation in humans. Excluding third molars, the reported prevalence of hypodontia ranges from 1.6 to 6.9%, depending on the population studied. Hypodontia individuals often present a significant clinical challenge for orthodontists because, in a number of cases, the treatment time is prolonged, and the treatment outcome may be compromised. (1)
This patient's cephalometric radiograph confirms a palatally impinging deep bite. Palatal tissue damage is a known side effect of deep bite malocclusions.(2) If his deep bite is not corrected it will likely lead to soft tissue damage in the palate that will worsen with time if left untreated and can lead to periodontal problems in the future(3) that will be more invasive to correct than the orthodontic problem he currently has.
The patient's malocclusion will not correct itself; the only way to create the space for prosthetic teeth is to do orthodontics. This treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sarcopenia, dementia, tracheostomy
Treatment: Personal Care Aide Level II - 24 hour Live in 

The proposed treatment of personal care aide level II - 24 hour Live in is deemed medically necessary. 

This is a male with a history of sarcopenia, thrombocytopenia, chronic gastrocutaneous fistula, CHF, COPD, dementia and tracheostomy. Due to impairments related to his multiple medical comorbidities, he requires assistance with the majority of his activities of daily living (ADLs). Recent documentation from the patient's Attending Physician indicates that the patient is wheelchair and bedbound, requires total assistance with all activities of daily living (ADLs) and personal care including bathing, transferring, transporting including reminders and assistance with medications. for these reasons, the proposed treatment of personal care aide level II - 24 hour Live in (the health plan approved 28 hours/week) is deemed medically necessary for improved assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck and back pain
Treatment: Continued chiropractic care

The continued chiropractic care was not medically necessary.

Documentation presented for this review fails to support the necessity of chiropractic care/treatment in question.

The patient is a female. According to the documentation, it is noted that the patient has a history of neck and mid-back pain. According to the documentation, it is noted that the patient presented to the chiropractor in which the patient was diagnosed with cervical as well as cervical/thoracic radiculopathy as well as segmental dysfunction to the cervical and thoracic spine. Treatments incorporated by the attending chiropractor consisted of ultrasound therapy, traction as well as manual manipulation.

According to the documentation, the patient was treated consisting of approximately 38 visits. At that point it was noted that the patient continued to treat at the same chiropractic facility.

Documentation presented by the attending chiropractor is substandard at best and fails to contain any evidence supporting the treatment in question. This would consist of daily progress notes, examinations, outcome measures, treatment plan as well as treatment goals with time-frame to achieve such goals. As outlined previously, according to corresponding records it was indicated that the patient treated extensively through to the point in question consisting of approximately one year of treatment with approximately 40 visits provided within that time-frame. The clinical rationale to support the treatment in question has-not been supported through records submitted by the attending chiropractic practitioner.