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

Diagnosis: Ulcerative colitis. 
Treatment: Stelara 90 mg (milligrams) every 4 weeks. 
The insurer denied coverage for Stelara 90 mg every 4 weeks. 
The denial is overturned. 

The patient has ulcerative colitis, diagnosed several years ago, and previously failed treatment with Uceris, Remicade, Entyvio, Simponi, Humira, and Xeljanz. The patient was started on Stelara. The patient had a partial response but then needed to have the dose increased to every 4 weeks. The patient has been having a good clinical response on the Stelara given every 4 weeks. The physician writes that they need to maintain this dosage to control the ulcerative colitis. 

Clinical Gastroenterology and Hepatology 2021 Jan 19 (1): 104-110 has an article titled "Effectiveness of Ustekinumab (Stelara) Dose Escalation in Patients with Crohn's Disease." Data was studied from patients who initially received ustekinurnab every 8 weeks and then had their interval shortened to every 4 weeks. The conclusion was that shortening the ustekinumab dose to every 4 weeks, in patients who did not respond to dosing every 8 weeks, improved clinical and biological indices of disease activity. It was noted that dose interval shortening was effective and safe. 

This patient has ulcerative colitis that has been refractory to multiple biologic agents. The Stelara given every 4 weeks has resulted in a positive clinical response. Dose escalation of Stelara is supported in the medical literature. 

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 Stelara 90 milligrams (mg) every 4 weeks is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite with gingival attachment loss.

Treatment: D8080 braces and D8670 monthly visit.

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

The denial is upheld.

 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present, 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 23 points on review by internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a 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 (HLD) Index Report, 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.

Based on the above, the insurer's denial must be upheld. The health care plan did 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 not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis

Treatment: Cholecystectomy

Insurer denied inpatient admission

The insurer's denial was upheld 
 

The patient presented to the emergency room (ER) with complaints of abdominal pain. White blood cell (WBC) count was elevated. Imaging revealed cholecystitis. The patient was admitted for care. The patient underwent a laparoscopic cholecystectomy and was discharged. 

Acute cholecystitis and biliary complaints are common inpatient diagnoses. Acute cholecystitis is also estimated to be attributed to millions of ambulatory visits each year and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible. [5, 8] A 50% (percent) increase in the liver function tests can be labelled as mild elevation and is considered negligible by many. [9] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6]

Per clinical documentation, this patient presented to the emergency department with abdominal pain, nausea, and vomiting. Vital signs in the ER were within normal limits. The patient was afebrile. A CT (computed tomography) scan demonstrated findings consistent with acute cholecystitis. Liver function tests were normal. White blood cell count was elevated to 19.0. The patient was transferred to a different facility for intervention. The patient underwent a laparoscopic cholecystectomy. There were no reported complications. There are no postoperative notes that indicate any further need for admission. Per MCG (Milliman Care Guidelines) criteria, laparoscopic cholecystectomy is considered an ambulatory procedure. Admission is indicated when there is conversion to an open procedure, severe infection postoperatively, care of active comorbidities, complications of the procedure, or a gallstone ileus. [7] Peer-reviewed literature and MCG criteria indicate that inpatient admission is not necessary in this circumstance. Per provided clinical documentation, inpatient admission was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status Post (s/p) Surgery for Broken Bone in Jaw. 
Treatment: Inpatient Stay. 

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

The patient is a male who was in a motorcycle accident and he did not report to the emergency room (ER) until 4 days after the accident. The patient was admitted and taken to the operating room (OR) and he was discharged the same day that he had surgery. The patient was denied an inpatient admission but received treatment at an alternate level of care for the treatment of a broken jaw. The patient had no significant medical problems or postoperative complications. 

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient. 

The inpatient stay was not medically necessary. The patient was treated with rigid fixation which meant his mouth was not wired closed. He was a healthy male and was sent home after surgery. His vital signs were stable. The patient was voiding, there were no respiratory problems, he was ambulating and tolerating his diet. The patient had stable vital signs, there were no infections and he had no difficulty breathing. 

The denial agrees with the literature. A study of patients with mandibular fractures showed that an outpatient model to treat isolated mandibular fractures was not associated with an increased risk of postoperative complications. This outpatient care model reduced the hospital length of stay without increasing the risk of postoperative complications. This surgery is no more invasive than orthognathic surgery and these cases are routinely done on an outpatient basis. 
An inpatient admission is not needed unless discharge criteria is not met within 23 hours. In the United States, it has been reported that between 46 percent (%) and 84% of patients go home the same day of surgery after an orthognathic procedure. It is rare for an orthognathic surgery patient stay to extend beyond the first postoperative day following a 3.5-hour bimaxillary surgery. 

Treatment at an alternate level of care would have been appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Deficiency of Adenosine Deaminase, Anemia
Treatment: Ruxolitinib
The insurer denied Ruxolitinib.
The determination is upheld.

The patient has a diagnosis of hereditary adenosine deaminase 2 (ADA2) deficiency. He presented with microcytic anemia and reticulocytopenia in infancy and was diagnosed with pure red cell aplasia, requiring chronic transfusion therapy ever since. Whole exome sequencing revealed a homozygous Cat eye syndrome critical region protein 1 [CECR1] (ADA2) mutation confirming the diagnosis of hereditary ADA2 deficiency. The child has been referred for bone marrow transplant and while no matched donors have been identified, the potential for a haploidentical donor transplant is being considered. In the meantime, the care team has recommended treatment with Ruxolitinib, a janus kinase (JAK) inhibitor, with the rationale that ADA2 deficiency is caused by over-expression of Type 1 Interferon-induced genes which signal via the janus kinase/signal transducer and activator of transcription (JAK-STAT) pathway. At issue is whether Ruxolitinib is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No. Deficiency of ADA2 is a rare autosomal recessive disease resulting from loss of function mutations in the ADA2 gene manifesting in a variable phenotype that can include systemic inflammation, vasculitis, immunodeficiency and, in severe cases, bone marrow aplasia. In the past, immunosuppressive therapies, such as steroids, tacrolimus, azathioprine, and others were used in attempt to control severe systemic inflammatory symptoms with minimal effect. Case reports of treatment with interleukin agents have also been disappointing. Currently, anti-tumor necrosis factor (TNF) agents are considered the mainstay for control of severe systemic inflammatory symptoms including vasculitis and recurrent strokes. However, these agents have not been effective in treating marrow aplasia associated with this disorder. The only known definitive and potentially curative therapy for this disease is hematopoietic stem cell transplantation.
The literature does not support that Ruxolitinib would be effective in the treatment of ADA2 deficiency. The direct role of the JAK-STAT pathway in the pathogenesis of this disease has not been well established and there are no case reports to suggest that JAK inhibition is effective in reversing clinical manifestations of the disease. Additionally, there are potential known side effects of Ruxolitinib which can be detrimental to this patient. In particular, this child suffers from pure red cell aplasia which can be managed long term with chronic transfusion therapy and aggressive iron chelation. Ultimately, a stem cell transplant can be curative for this patient. Therefore, the proposed treatment of Ruxolitinib is not likely to be more beneficial than the standard treatment for this disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

The patient is an adult who presented to the emergency department (ED) with right lower extremity cellulitis. The patient had a history of uncontrolled type II (2) diabetes with neuropathy and increased erythema to the right lower extremity with associated fevers and chills was noted. He had previously undergone surgical debridement of an ulcer and application of a tissue graft for the same extremity and was followed as an outpatient while on a course of oral antibiotics. Per the records, the cellulitis was not extending from this site on the right dorsal foot. On admission, the patients White blood cell count (WBC) was 11.6. The patient exhibited tachycardia up to 106 and a fever up to 100.7 degrees Fahrenheit. During his stay the erythrocyte sedimentation rate (ESR) was elevated to 76 and the C reactive protein (CRP) to 25.043. Upon discharge the patients' elevated labs all decreased while he was on intravenous (IV) antibiotics. 

The patient was an uncontrolled diabetic with elevated inflammatory markers and white blood cell count (WBC), and he required an inpatient admission. 

Diabetic foot infections can be life threatening and patients with these infections consistently suffer from a plethora of underlying conditions that require a multi-specialty approach to treat.  As such, timing and surgical intervention is crucial, which was the case in the presentation of this patient, who had to be admitted and consulted by various specialties, thereby making this a justified admission. Furthermore, due to diabetes patients with an infection may never "mount a robust systemic response," thereby complicating factors that may be deemed as necessary for admission, which again justifies the reasoning behind the admission. 

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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient presented to the hospital for cardiac catheterization after presenting with symptoms of dyspnea on exertion. The patient had a past medical history of ischemic heart disease, coronary artery bypass grafting (CABG), hypertension, and diabetes mellitus.   Cardiac catheterization revealed a 100% (percent) mid left anterior descending (LAD) artery stenosis, 100% mid left circumflex artery stenosis, and 80-90% mid right coronary artery stenosis.  Left internal mammary artery graft to the third diagonal artery was patent and a saphenous vein graft to the right posterolateral artery was patent.  Balloon angioplasty was utilized to open the mid LAD lesion. No perioperative complications were noted, and the patient was discharged the following day.

Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference1-4). Current expert consensus from the Society of Cardiovascular Angiography and Interventions support treatment at a lower level of care (Reference 4). 

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: Diabetes mellitus, chronic obstructive pulmonary disease (COPD) and coronary artery disease

Treatment: home care / personal care HHC (home health care) - level 2 personal care services, per 15 minutes increase to 49 hours per week

The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 49 hours per week

The denial is upheld

This is an adult male with chronic medical problems including diabetes mellitus, chronic obstructive pulmonary disease (COPD) and coronary artery disease. He lives with his spouse in an apartment, can activate a personal emergency response system (PERS) or call 911 in case of an emergency and no falls were reported in the prior 90 days. He is approved for Personal Care Services (PCS) 35 hours/week and requesting 49 hours/week, which is under review.  

According to the Uniform Assessment System (UAS) report, the patient's cognitive status is described as "Independent- Decisions consistent, reasonable and safe." He requires only limited assistance for bathing, personal hygiene and dressing. He is independent for bed mobility, walking (with and without a cane), eating and toilet transfer/use. He is continent of bladder and bowel. His functional ability has slightly improved compared to prior UAS assessment. The patient's limited impairments and overall functional stability do not support the medical necessity of increasing Level 2 Personal Care Services to 49 hours/week. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the currently approved 35 PCS hours per week.  

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  

From a physical medicine and rehabilitation perspective, the requested Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 49 hours/week is not medically necessary.   

The insurer's denial of coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 49 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tachypnea.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
This patient was a child with respiratory symptoms of a cough and fast breathing that presented to the Emergency Department (ED). The patient was in no distress (in the ED physician note, it was documented "no distress"). The patient was seen in a local urgent care center earlier and was transferred. The patient had mild tachypnea at 28 breaths per minute, and no wheeze. The temperature was normal. The oxygen saturation was 97% (percent), transiently it dropped to 93%. There was no hemodynamic instability. The patient was treated with nebulization and steroids. The Chest x-ray (CXR) showed atelectasis. The clinical status improved. The patient was discharged with scheduled nebulization, steroids, and a close pediatrician follow up.

There was no persistent hypoxia and in fact the oxygen saturation was > (greater than) 93 - 97% and there was no need for continuous positive airway pressure (CPAP) or a high flow nasal canula (HFNC). There was no need for pressors or multiple boluses. There were no abnormal labs that persisted. No arterial blood gas (ABG) was done in the ED as the ED doctor did not deem the clinical status was serious enough to give intravenous (IV) steroids. Also, there was no severe dehydration as evidenced by normal physical exam and labs. Also, there was no second line treatment such as continuous albuterol nor epinephrine nor terbutaline. If one were to take the Pediatric Respiratory Assessment Measure (PRAM) score to assess the pediatric asthma, it would be in the category of mild asthma. There was no need for oxygenation. The reason for asthma exacerbation is viral illness. If one were to take the Pediatric Early Warning Score (PEWS) score, it would have been desirable also indicating an expectant and stable course in hospital. The patient was continuing in an expected clinical trajectory while in the hospital. Due to the above reasons, this child with a mild to moderate asthma exacerbation from a viral illness could have been treated in observational status.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post lumbar laminectomy
Treatment: Full Inpatient Hospital Admission
The insurer denied: Full Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male who had surgery which included a lumbar laminectomy and had an inpatient hospital admission for 2 days. The patient had surgery on the day of admission including lumbar laminectomy of L4-5 and L5-S1. The patient had leg pain with neurogenic claudication. The patient had a history of a myocardial infarction and stent placement 4 years ago. The patient had a history of bladder cancer 5 years previously. The patient had physical therapy on the second day post operatively and was able to mobilize without assistance but remained in pain. The patient was cleared from physical therapy. The patient had routine postoperative troponin levels after surgery given the cardiac history and the results were negative. The patient was mobilized immediately after surgery and physical therapy and was able to ambulate the patient 50 feet with a rolling walker. On postoperative day #1, the patient received Pepcid due to a history of gastroesophageal reflux disease (GERD). The patient had a repeat electrocardiogram (EKG), which was unchanged from admission, and troponin levels were negative. The patient was able ambulate 125 feet. The patient had 140 cubic centimeters (cc) of drainage. The patient was cleared by physical therapy on postoperative day #2 and was discharged to home. This is a review from the inpatient level of care.

The full inpatient hospital admission was not medically necessary.

The inpatient admission after this surgery would be indicated if the patient had additional diagnoses that required treatment. In this case, there were no additional diagnoses that required treatment. The patient had routine postoperative testing based on his history, but there is no evidence that the patient had any cardiac issues, excessive bleeding, or other complications that would require an inpatient level of care after the surgery. The patient received analgesics and physical therapy, which would be routine after the surgery, and did not require an inpatient level of care.