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

Diagnosis: Gastric ulcer
Treatment: Esophagogastroduodenoscopy (EGD)
The insurer denied coverage for an esophagogastroduodenoscopy (EGD)
The denial is overturned

The patient was having epigastric pain and reflux for 6 months. She underwent an endoscopy and was found to have gastritis with a gastric ulcer. 

MCG (Milliman Care Guideline) ACG: A-0203 discusses indications to perform Upper GI (gastrointestinal) Endoscopy. Dyspepsia is an indication under certain listed conditions. Having persistence of symptoms for 3 months or longer is an indication to do the 
procedure. 

This patient was having epigastric pains for 6 months. Since her symptoms were present for longer than 3 months, she met the criteria for doing an endoscopy for evaluation of dyspepsia. She was diagnosed with a gastric ulcer and therefore also required a follow-up endoscopy which was subsequently performed. In view of the persistence of symptoms, she met MCG criteria for indications to do the endoscopy. The health care plan did not act reasonably or in the best interest of the patient. The EGD procedure was medically necessary.

The denial is overturned.

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

The insurer's denial of coverage for an esophagogastroduodenoscopy (EGD) procedure code 43239 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Allergic reaction.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is upheld.

The patient is a female who was admitted to the hospital for an apparent reaction to metronidazole. She had been treated and released from the ED (emergency department) 1 day prior but had recurrent symptoms. On the physical examination, there was generalized rash, but no angioedema, stridor, tachypnea, bronchospasm/wheezing or hypotension. The CXR (chest x-ray) was normal, and labs showed leukocytosis likely due to steroid administration. The patient was given treatment for anaphylaxis and allergic reaction. She was admitted with the admission note showing a rash and no angioedema. A rapid response team noted slight lip swelling and treated the patient with ketorolac and solumedrol. A critical care consultation was obtained, and they noted hand joint pain, improved swelling and advised rheumatology and dermatology consults. Joint pain improved on ketorolac. The patient had a CT (computed tomography) angiogram because of the concern of a pulmonary embolus which was normal. The ECG (electrocardiogram) was also normal. 

This patient did not have any suggestion of airway compromise. There was no suggestion of tongue or laryngeal angioedema or laryngospasm. There was no hypotension. There was in fact no lip swelling noted by the ED physician. The diagnostic criteria for anaphylaxis were in fact not met. The patient did not have a life-threatening drug hypersensitivity pattern such as DRESS (drug reaction with eosinophilia and systemic symptoms), Stevens Johnson syndrome or exfoliative dermatitis. The treatment with corticosteroids, antihistamines and NSAIDs (non-steroidal anti-inflammatory drugs) could have all been administered orally on an ambulatory basis. There was no indication that the patient had intractable pain or pain due to a life-threatening disorder. The patient could have been managed in an observation setting.

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

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

Diagnosis: Multiple Sclerosis (MS).
Treatment: Continued stay at a Skilled Nursing Facility (SNF). 
The insurer denied coverage for continued stay at a Skilled Nursing Facility (SNF).
The denial is upheld.

The patient has a history of multiple sclerosis (MS) and chronic neuropathic pain. She presented to the skilled nursing facility (SNF) after undergoing a laminectomy, posterior spinal fusion at C (cervical)3-C7.  She received physical and occupational therapy.  Under review is the medical necessity for continued stay at a skilled nursing facility.

The patient was initially appropriate for the SNF subacute rehabilitation level of care (1, 2, 3).  She had functional deficits that were potentially amenable to comprehensive rehabilitation. According to the physical and occupational therapy initial evaluation notes, she required maximal assistance to full dependence for activities of daily living (ADL), bed mobility and transfer activities. Unfortunately, the treatment notes do not document significant improvement over the subsequent month of treatment. For example the patient remained essentially at the maximal assistance to full dependent level for ADL, bed mobility and transfer activities. Wheelchair mobility also remained totally dependent. There were also no acute medical or complicated nursing issues that required continued stay at the SNF.   

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

The insurer's denial of coverage for a continued stay at a skilled nursing facility (SNF) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Gastroesophageal Reflux Disease/GERD.
Treatment: Diagnostic Testing.
The health plan denied the requested EGD as not medically necessary. 
The health plan's determination is upheld.

This is a review for the medical necessity for an esophagogastroduodenoscopy (EGD) to evaluate for gastroesophageal reflux disease (GERD) and acute gastric ulcer.
This is a male who had an esophagogastroduodenoscopy (EGD). The esophagus appeared normal. There was evidence of erosive gastritis. There are no pre-procedure records to show that he was started on a proton pump inhibitor (PPI) or other acid suppressive therapy prior to the EGD.
At issue is the medical necessity for the requested esophagogastroduodenoscopy.

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

No, the requested health service/treatment of an EGD is not medically necessary for this patient.
According to the current American College of Gastroenterology Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease, patients presenting with typical symptoms of heartburn and regurgitation should be given empiric medical therapy with a proton pump inhibitor. The diagnosis of gastroesophageal reflux disease is made using some combination of symptom presentation, objective testing with endoscopy, ambulatory reflux monitoring, and response to antisecretory therapy. Empiric proton pump inhibitor therapy (trial) is a reasonable approach to confirm gastroesophageal reflux disease when it is suspected in patients with typical symptoms. There is no indication that the patient has had an appropriate trial and failure of a proton pump inhibitor therapy for 4-8 weeks to manage his symptoms.
Therefore, an esophagogastroduodenoscopy for this patient would not be in accordance with generally accepted standards of medical practice or clinically appropriate, in terms of type, frequency, extent, site and duration for the patient's illness. The EGD was not medically necessary in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ankylosing spondylitis. 
Treatment: Rinvoq 15mg. 

The insurer denied the Rinvoq 15mg, pre-service. 
The denial is overturned. 

This patient is a female with history of ankylosing spondylitis.  The patient also has a history of a positive ANA (anti-nuclear antibodies) and positive DsDNA (double-stranded DNA).  The patient has previously tried and failed non-steroidal anti-inflammatory drugs (NSAIDs) diclofenac, Celebrex and meloxicam.  She has also tried and failed biologic disease modifying anti-rheumatic drug (DMARD) Cosentyx.  The request for Rinvoq was initially denied due to the patient not having a diagnosis of rheumatoid arthritis, psoriatic arthritis, atopic dermatitis or ulcerative colitis.  The reason the provider is appealing the determination is because the patient had ankylosing spondylitis and Rinvoq is now approved for ankylosing spondylitis. 

Yes, the requested Rinvoq is medically necessary. 

The patient has a history of ankylosing spondylitis. The patient has previously tried and failed IL 17 (interleukin 17) inhibitor Cosentyx and had primary inefficacy. When a patient has primary inefficacy to a method of action, then guidelines typically suggest switching to an alternative method of action. Tumor necrosis factor (TNF) inhibitors are contraindicated in this individual given the positive ANA (anti-nuclear antibodies) and positive dsDNA (double-stranded DNA). Clinical studies have shown that they do pose an increased risk of causing a lupus-like reaction were drug-induced lupus in those who are susceptible. Therefore an alternative method of action would be a JAK (janus kinase) kinase inhibitor. Rinvoq was recently FDA (United States Food and Drug Administration) approved as a treatment for ankylosing spondylitis and therefore would be a reasonable appropriate option for treatment for this patient and would therefore be medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The health plan is not up-to-date with the most recent guidelines indicating that Rinvoq is now FDA (United States Food and Drug Administration) approved for the treatment of ankylosing spondylitis.
Appeal type: Medical necessity
Decision: Overturned

Skin
Inpatient hospital

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

This case involves a man admitted to the hospital for right arm swelling and erythema. The patient has psoriasis, treated with Otezla, and has developed worsening right arm suspected infection with pains with a range of motion at the wrist. The symptoms started with a pimple over 30 days before this presentation, developing into a small abscess, which was drained at an urgent care center two days before this presentation. The patient was placed on Bactrim therapy; however, he developed worsened surrounding swelling, redness, and pain on range of motion. Therefore, he came into the emergency department to be assessed. The patient denied fevers over chills. Assessment in the ED included a computed tomography (CT) scan that showed dorsal cutaneous thickening, which could reflect cellulitis, with associated focal cutaneous tract as a sequela of the drainage procedure. There is expected air in the subcutaneous tissues adjacent to the dorsal compartment musculature. The temperature was 98 C, heart rate of 72, and blood pressure 135/99. On exam, the right forearm has dorsal swelling and erythema, hot to the touch, with an incisional opening.
The medical team admitted the patient with a documented diagnosis of abscess and cellulitis with possible muscular involvement.

Based on the provided documentation, the inpatient hospital admission was medically necessary. The patient failed outpatient therapy with appropriate antibiotic therapy, concerning features, for rapidly spreading infection into the deep compartments based on location and somewhat immunocompromised state by Otezla. As a result, this was a high-risk infection that could not be further managed in the outpatient setting. Inpatient admission is typically indicated for these types of presentations and standards of care. It is the usual practice to involve infectious disease and surgery in these types of situations for a multidisciplinary approach to treating such an infection.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Durable Medical Equipment (DME). 
The insurer denied Durable Medical Equipment Pediatric tilt wheelchair with accessories. 
The denial is upheld. 

This patient is a female with Down Syndrome and severe developmental delays whose care team is requesting a Rodeo stroller with tilt, flip-up armrests, and other accessories. Letters from the patient's occupational therapist note that the patient has poor core stability and generalized hypotonia. Per the denial letter, the following criteria must be met to approve this service: medical records detailing the condition and medical necessity of the requested service, such as impaired ability to stand and walk.
At issue is the medical necessity of Durable Medical Equipment Pediatric tilt wheelchair with accessories.

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

The requested health service/treatment of Durable Medical Equipment-Pediatric tilt wheelchair with accessories is not medically necessary for this patient.
Based on the patient's diagnosis and documentation, it is not clear that the requested items are medically necessary, as patients with Down Syndrome can have varying degrees of hypotonia. Although the occupational therapist has provided a letter stating medical necessity, there is no documentation of current status or the degree of impairment. Based on the records provided, it is not clear that the Durable Medical Equipment - Pediatric tilt wheelchair with accessories is considered medically necessary.
Therefore, the requested health service/treatment of Durable Medical Equipment-Pediatric tilt wheelchair with accessories is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypersomnia
Treatment: Modafinil
The insurer denied Modafinil. 

The health plan's determination is overturned. 

The patient is a woman diagnosed with idiopathic (primary) hypersomnia and mild obstructive sleep apnea. The patient has excessive daytime sleepiness. Treatment with modafinil is the subject of this review. The drug was denied by the plan as off-label.

Modafinil is medically necessary for treatment excessive daytime sleepiness due to idiopathic hypersomnia and mild obstructive sleep apnea.
The effectiveness of modafinil has been demonstrated in two randomized trials in a total of 104 patients with idiopathic hypersomnia without long sleep time. In both trials, patients treated with modafinil (200 mg daily given once in the morning or as two divided doses) had improved Epworth Sleepiness Scale (ESS) and clinical global impression rating scores compared with placebo. Mean sleep latency on the maintenance of wakefulness test (MWT) improved by approximately five minutes with treatment. Headache and gastrointestinal distress were the most common.  The utility of modafinil was also illustrated by a multicenter cross-sectional study of 104 patients with idiopathic hypersomnia and 126 patients with narcolepsy, all treated with modafinil. In the subset of 63 idiopathic hypersomnia patients who completed the ESS before and after treatment, the mean improvement in the ESS score was 2.6 points, which was similar to that observed in narcolepsy patients.
Of note, Modafiinl is also on-label for treatment of excessive daytime sleepiness due to obstructive sleep apnea.

The health plan's determination is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission
The denial is upheld

The patient has a history of a gastric ulcer and presented with RLQ (right lower quadrant) abdominal pain. She was afebrile and the vital signs were stable. There were no peritoneal signs. There was no leukocytosis. A CAT (computed tomography) scan showed mild wall thickening of the appendix and an early appendicitis could not be ruled out. She was treated for ulcer disease and her diet was advanced. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG (Milliman Care Guidelines) M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient had abdominal pain but did not require any surgical interventions. The clinical presentation was not consistent with acute appendicitis. She could have had serial abdominal exams done with observation care. Pain medications and ulcer treatment could also have been given with observation care. She did not meet MCG criteria for admission for Undiagnosed Abdominal Pain. The health care plan acted reasonably and with sound medical judgment an inpatient admission was not medically necessary. The denial is upheld

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

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

Diagnosis: Digestive/Gastrointestinal System. 
Treatment: Diagnostic Testing. 
The insurer denied esophagogastroduodenoscopy. 
The denial is upheld.

The patient is a male with gastroesophageal reflux disease (GERD). He presented with chest discomfort, belching, and acid reflux, as well as cough and throat clearing; famotidine (for unknown duration) helped, but symptoms returned when he stopped it; he denied dysphagia, nausea, vomiting, chest pain, dyspnea, loss of appetite, unintentional weight loss, change in bowel habits, and gastrointestinal bleeding; famotidine was continued, and esophagogastroduodenoscopy (EGD) was planned. Esophagogastroduodenoscopy showed Grade A esophagitis, a small hiatal hernia, gastritis, and normal duodenum; the recommendation was anti-reflux regimen and start pantoprazole 20 milligrams (mg) daily; biopsies showed gastroesophageal junction mucosa with mild chronic inflammation, gastric mucosa with mild chronic gastritis, and unremarkable duodenum. The medical necessity for the esophagogastroduodenoscopy is the subject under review.

The request for esophagogastroduodenoscopy is not supported as medically necessary by the submitted documentation. Clinical guidelines (including the American College of Gastroenterology guidelines for the treatment of gastroesophageal reflux disease, and guidelines for dyspepsia) recommend endoscopy for investigation of upper gastrointestinal symptoms when those symptoms are refractory to proton pump inhibitor taken properly for 4-8 weeks without response [1-4]. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that endoscopy is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful [3]. Current medical literature continues to support these recommendations [5-8]. In this case, there is no documented proton pump inhibitor therapy for at least 4 weeks before the endoscopy. No other guideline-supported indication for esophagogastroduodenoscopy is documented. For these reasons, medical necessity for esophagogastroduodenoscopy was not supported in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied Abdominoplasty Revision and Excision, excessive skin, and subcutaneous tissue (includes lipectomy); buttock. 
The denial is upheld.

The patient is a female with a long history of sciatica treated by medications, physical therapy, chiropractor manipulation, acupuncture, and injections (epidural and trigger point). She underwent bariatric surgery and subsequently lost 80 pounds, and then underwent abdominoplasty.  She underwent cosmetic abdominal liposuction with fat transfer to the buttocks complicated by infection and toxic shock necessitating surgical incision and drainage and prolonged hospital stay with intravenous (IV) antibiotics. This exacerbated her sciatica and a spinal column stimulator trial failed to provide relief. She is unable to sit properly or comfortably which leads to uneven weight distribution exacerbating the pain and she apparently feels further plastic surgery to remove skin and tighten abdominal muscles will resolve this. Her plastic surgeon is apparently recommending a partial or total belt lipectomy extension of a prior abdominoplasty. Coverage was denied by the health plan because the surgery was considered cosmetic.
The subject under review is whether the proposed surgery is medically necessary.

The health plan's determination is upheld.

The requested abdominoplasty revision and excision, excessive skin, and subcutaneous tissue (includes lipectomy); buttock is not medically necessary for this patient.
Per Milliman Care Guidelines (MCG) Health Ambulatory Care 25th Edition Abdominoplasty ACG: A-0497 (AC)
Abdominoplasty may be indicated when ALL of the following are present:
1) Abdominal wall laxity or skin excess interferes with activities of daily living. [NOT MET]
2) Patient has complications from a panniculus (i.e., chronic, or recurrent intertrigo,
other skin infection, ulceration, or skin irritation that has been persistent despite
nonsurgical treatment). [NOT MET]
3) Patient's weight has reached stable plateau, and 1 or more of the following:
a) Adherence to multidisciplinary nonsurgical program of weight maintenance
b) One year or more has elapsed following bariatric surgery. [MET by bariatric surgery in 2012]
The criteria are not met, and revision of the prior abdominoplasty is not medically necessary.
Given the absence of rashes or infection in the front, removal of excess mons and abdominal skin would be primarily for the improvement of appearance after an inadequate cosmetic abdominoplasty result. The surgery is cosmetic, and will not resolve her lumbar radiculopathy pain, and will not resolve her left buttock contour irregularity. Therefore, the requested health service/treatment of Abdominoplasty Revision and Excision, excessive skin, and subcutaneous tissue (includes lipectomy); buttock is cosmetic and not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Vertebral Artery Dissections

Treatment hospital admission

The insurer denied coverage for hospital admission.

The denial is overturned. 

This patient has no significant past medical history and presented to the emergency department (ED) for severe neck pain for past 6 days.  She denied any recent trauma. She had a magnetic resonance imaging (MRA) neck performed in the ED (emergency department) that revealed bilateral vertebral artery dissections.  She denied any focal neurological deficits or headaches. Neurological exam was non focal in the ED.  

Given that the patient had newly diagnosed bilateral vertebral artery dissections in the setting of new neck pain, inpatient admission was medically necessary for close neurological monitoring given the patient's high risk for posterior circulation stroke. 

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

The insurer's denial of coverage for the hospital admission is overturned. Medical Necessity is substantiated.