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

Diagnosis: Crossbite of individual anterior teeth. 
Treatment: Orthodontic treatment (braces). 

The insurer is denied coverage for orthodontic treatment (braces). 

The denial is upheld. 

This female patient who was evaluated for orthodontic treatment. A clinical examination and analysis consisting of a dental and jaw evaluation revealed the following findings: skeletal Class I; normal vertical growth pattern; permanent dentition; Class II canines; mild maxillary spacing; mild mandibular spacing; and anterior crossbite with gingival attachment loss (mandibular right canine). The following automatic qualifier was chosen on the patient's Handicapping Labio-Lingual Deviation (HLD) Index report: crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The physician is requesting authorization for orthodontic treatment (braces) and periodic treatment visits for the patient. 

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, an HLD Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. In this case, the treating Orthodontist claims an automatic qualifying condition of 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. This reviewer concurs with the HLD index of the insurer attaining 19 points (9 overjet, 3 overbite, 3 ectopic eruption, 4 labiolingual spread). 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the orthodontic treatment (braces)  is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Cancer Screening. 
The insurer denied: Oncotype Dx testing. 
The denial is upheld.

The patient is a male who underwent a prostate biopsy for an elevated prostate-specific antigen (PSA). The biopsy showed Gleason 6 adenocarcinoma in 2 out of 29 cores. The clinical stage was T1c. An Oncotype Dx test was ordered on the biopsy specimens. The subject under review is the medical necessity for the test.

The health plan's determination is upheld.

the Oncotype Dx testing is not medically necessary for this patient. The Oncotype DX Prostate Cancer Assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS). A lower GPS score indicates more favorable biology and less aggressive disease. This test may be utilized to counsel men regarding the best course of therapy (active surveillance vs. treatment) in newly diagnosed low or low-intermediate prostate cancer.
Recent studies have suggested that Oncotype Dx can predict adverse pathology and unfavorable outcomes after radical prostatectomy. These studies have financial conflicts of interest, are recently published and need continued validation from a widespread clinical use. In addition, it is difficult to ascribe clinical utility of Oncotype Dx Prostate in patients planning to undergo active surveillance as all patients in the above studies, regardless of clinical criteria, elected radical prostatectomy within 6 months of diagnostic biopsy. Moreover, the validity of using different degrees of tumor pathology as "markers" to extrapolate the risk of progression of a tumor in vivo is unclear.
National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer 2020 state, "Several tissue-based molecular assays have been developed in an effort to improve decision-making in newly diagnosed men considering active surveillance and in treated men considering adjuvant therapy or treatment for recurrence. No randomized controlled trials have studied the utility of these tests. 

American Society for Clinical Oncology Guideline on Molecular Biomarkers in Localized Prostate Cancer, 2019 states "Tissue-based molecular biomarkers (evaluating the sample with the highest volume of the highest Gleason pattern) may improve risk stratification when added to standard clinical parameters, but the Expert Panel endorses their use only in situations in which the assay results, when considered as a whole with routine clinical factors, are likely to affect a clinical decision. These assays are not recommended for routine use as they have not been prospectively tested or shown to improve long-term outcomes-for example, quality of life, need for treatment, or survival."
While Oncotype Dx may eventually have a role in making treatment decision about patients with prostate cancer, there is limited data on clinical outcomes to currently support routine use. Hence, it is not considered a generally acceptable standard of care for management of patients with a diagnosis of prostate cancer.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Exertional Dyspnea
Treatment: Heart catheterization and ventriculography test
The insurer denied the Heart catheterization and ventriculography test.
The determination is overturned.

The patient has multiple risk factors and a strong family history of coronary artery disease who presented with increasing exertional dyspnea over a 5 month period. He underwent elective, outpatient stress testing which demonstrated a 5% reversible defect in the inferior wall. In the setting of increasing symptomatic limitation, consistent with Canadian Cardiovascular Society (CCS) class 3 angina, he was referred for catheterization which demonstrated no significant coronary artery disease and normal left ventricular (LV) function. At issue is the medical necessity of the catheterization and ventriculography test.

This is medically necessary.
This patient has a strong family history of early coronary artery disease and presented with increasing symptomatic limitation consistent with CCS Class 3 angina and a known abnormal stress test. Catheterization, including ventriculography,  is the most appropriate next step in management. While it is often reasonable to try an initial strategy of medical therapy, the high pretest probability and accelerating symptoms in this patient's case render early catheterization an appropriate and medically necessary strategy. For patients with significant symptom limiting angina and an abnormal stress test, catheterization, including ventriculography,  is a reasonable and appropriate next step in management for patients, such as this patient, with a high pretest probability and intermediate risk findings on noninvasive imaging.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Bone Fracture/Break/Rib Fractures
Treatment: Inpatient Hospital
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is overturned.

This is the case of a male unrestrained driver in a motor vehicle accident. Upon presentation, he complained of severe chest pain. He was found to have multiple bilateral rib fractures (3 on the right, 3 on the left). He also had a sternal fracture, left scapula fracture, left pneumothorax, pulmonary insufficiency and fractures of the (thoracic) T2, T3, and T4 vertebra. He was admitted to the surgical intensive care unit (SICU). He improved and was stable for transfer to the floor. The patient eloped. The issue is whether this was a medically necessary inpatient admission.

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

Yes. This is a medically necessary inpatient admission to the SICU. The patient had 6 rib fractures, a pneumothorax, vertebral fractures, a scapula fracture, and a sternal fracture. The sternal and scapula fractures are particularly notable for high impact mechanism of injury and a likelihood of cardiac contusion and other intrathoracic injuries. In general, more than 3 rib fractures are criteria for inpatient admission due to the high morbidity and mortality of rib fractures. This disposition of people with rib fractures is well discussed in an UpToDate review of the topic, "in most cases, we suggest hospitalization for patients with three or more rib fractures." The author's recommendation is consistent with widespread trauma practice. This patient was appropriately admitted to the SICU and then transferred to the floor the next day. To suggest a lower level of care is not in the best interest of the patient. This is truly a multiply injured trauma patient at great risk for rapid deterioration who required frequent vital checks, inpatient pulmonary care, and inpatient level staff trained to recognize signs of impending decompensation.
Appeal type: Medical necessity
Decision: Upheld

Digestive System
Inpatient hospital

Diagnosis: abdominal pain.
treatment; Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a woman with a history of hypertension, fibromyalgia, pituitary adenoma, and seizures who presented to the emergency department with a chief complaint of lower abdominal pain associated with diarrhea and dysuria for the past three days. She reported having a poor appetite and denied medication use for symptom relief. Review of symptoms was negative for fevers, chills, headaches, nausea, vomiting and chest pain. Vital signs showed blood pressure 103/62, heart rate 90, temperature 97.3 Fahrenheit, and respiratory rate 16. On physical exam, heart was regular, breath sounds were normal and the abdomen was soft and tender. There was no guarding. Computed tomography (CT) imaging demonstrated sigmoid diverticulitis. Labs showed glucose 89, sodium 141, potassium 4.1, creatinine 0.86, white blood cell (WBC) 6.4, hemoglobin 11.9, and platelets 139. Analysis of urine was negative for infection. The patient was admitted for acute diverticulitis.

The inpatient hospital admission was not medically necessary. Because the patient's diverticulitis was uncomplicated, she could have been treated at a lower level of care. In the absence of risk factors for an adverse outcome, uncomplicated diverticulitis may be treated as an outpatient. Some of these risk factors include advanced age, comorbidities, high fever, and other complications, all of which were absent. The patient had a repeat abdominal CT scan, but this showed improvement in the infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Bone Fracture/Break.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is overturned.

The patient is a female who was admitted to the hospital for an inpatient stay. She sustained a motor vehicle collision and presented with left sided rib pain and shortness of breath. The patient was noted to have a nondisplaced sternal fracture and multiple left sided rib fractures. She was admitted and multimodal pain management was instituted. Pulmonary toilet was also performed. She was monitored for pulmonary deterioration. She underwent a follow up chest x-ray which demonstrated clinical improvement. She was discharged.
At issue is the medical necessity of the inpatient stay.

I recommend a complete overturn of the health plan's previous denial of medical necessity.

Yes. The inpatient stay was medically necessary based on the peer reviewed literature and the current standard of care in the General Surgery community.
The patient sustained severe blunt trauma following a motor vehicle collision. The force of the collision caused a sternal fracture and multiple left sided rib fractures. Admission based on inpatient status is strongly supported by the peer reviewed literature and the current standard of care in the Trauma and General surgery community. Multiple rib fractures cause elevated morbidity and mortality following blunt trauma. It was important to admit this patient as an inpatient to control her pain, perform pulmonary toilet and ensure that no underlying pulmonary contusion developed. Blunt chest trauma which results in multiple rib fractures is significantly related to underlying pulmonary injury and inpatient admission serves to ensure that the patient's respiratory condition does not deteriorate. It also serves to institute intravenous analgesic therapy to ensure maximal expansion of the chest wall and resolution of clinical atelectasis which may develop after severe chest trauma. In this case, the inpatient admission was medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Digestive System
Inpatient hospital

Diagnosis: cholelithiasis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. The health plan's determination is upheld. 

This is the case of a female who presented to the emergency department with right upper quadrant abdominal pain. She was diagnosed with symptomatic cholelithiasis and admitted for laparoscopic cholecystectomy. She underwent an uneventful laparoscopic cholecystectomy. She was discharged to home later that day. The issue is whether this was a necessary the inpatient admission was medically necessary.

The inpatient hospital admission was not medically necessary. The patient was admitted with evidence of mild cholecystitis. She underwent a laparoscopic cholecystectomy, which is usually an outpatient procedure. She was then discharged on post-operative day 0. There was no hemodynamic reason for admission, no need for ongoing antibiotics, her pain was controlled, and she met discharge criteria. In fact, she was discharged on the same day that she was admitted.
Outpatient cholecystectomy has been proven safe and effective. For uncomplicated cholelithiasis in a relatively healthy young patient such as this, there is no indication for an inpatient admission. In fact, laparoscopic cholecystectomy has been proven safe as an outpatient procedure since the 1990s. There are numerous studies underscoring this, with statements such as, "Ambulatory laparoscopic cholecystectomy can be performed safely for selected patients, with reduced cost and a high level of patient satisfaction." This is an appropriate patient for outpatient cholecystectomy. There is no compelling medical reason for an inpatient admission in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder-Seizures. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied clonazepam orally dissolving tablets. 
The denial is upheld.

The patient is a male with a history of Moya Moya disease with history of cerebral revascularization and seizures. His most recent seizure was the previous day. He had been off of carbamazepine and on Aptiom 1200 milligrams (mg) at night. He was seen in the emergency department that time. He was on no medications other than the Aptiom. His neurological examination was normal. A brain magnetic resonance imaging (MRI) revealed encephalomalacia and gliosis in the right frontal of compatible with old infarct. At that time, the Aptiom dose was increased to 1600 mg with a level to be checked in one to two weeks. Riboflavin was continued.
A letter of medical necessity from the physician indicated that the patient has seizures with aura and could prevent convulsions by taking clonazepam oral dissolving tablets. It was noted that avoiding convulsions would also keep him out of the emergency room and avoid unnecessary hospital admissions. The physician did not indicate why the patient could not take non-orally dissolving clonazepam.

The health plan's determination is upheld.

Clonazepam orally dissolving tablets 1 mg is not medically necessary. This is a patient with a history of seizures. It appears that clonazepam is being used for rescue. There is no evidence the peer-reviewed medical literature that clonazepam orally dissolving tablet (ODT) provides improved treatment for acute seizures compared with clonazepam (or other benzodiazepines) when provided in non-orally dissolving tablet form. A literature review fails to reveal any clinical trial supporting the superior efficacy of the orally clonazepam orally dissolving tablet preparation to other oral benzodiazepines preparations for this indication. Therefore, the specific request for clonazepam ODT is not medically necessary as there are similar drugs, including clonazepam, available to the patient without a loss of efficacy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Xifaxan. 
The denial is upheld in whole. 

The patient is a female. She has a history of fistulizing Crohn's disease (CD). She has several draining perianal fistulas and failed treatment with metronidazole. She also tried and failed infliximab, adalimumab, and methotrexate. She is on Stelara now, but her fistulae persisted. The requested service is Xifaxan. The subject under review is the medical necessity for Xifaxan. 

Xifaxan is not medically necessary in this case. The use of antibiotics in treating perianal fistulae associated with Crohn's disease is consistent with the generally accepted practices and standards of care. The most commonly studied and used antibiotics for this indication are metronidazole and ciprofloxacin. 

According to the clinical practice guidelines "Antibiotics [ciprofloxacin or metronidazole] can be used as an adjuvant, but not as a sole treatment. Patients treated with both ciprofloxacin and anti-tumor necrosis factor (TNF) agents had better outcomes than anti-TNF agents alone. In complex fistulas, anti-TNF failure is common, with a risk for the need of a diverting ostomy." (Van Rheenen, P. F. et al). 

According to Ruemmele, F. M., et al :"In perianal disease, metronidazole/ciprofloxacin-based treatments have a good short-term response and may offer a bridge to immunosuppressive medications. Azithromycin and rifaximin may be useful for induction of remission in children with mild to moderate luminal inflammatory pediatric CD".
The intended use of Xifaxan in this case is to treat perianal fistulae, which is not well supported by the clinical practice guidelines or the available literature. Based on the standards of care, the patient has a more suitable alternative that has not been tried, therefore, medical necessity of Xifaxan cannot be established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic short stature (ISS). 
Treatment: Omnitrope. 

The insurer denied Omnitrope. 
The health plan's determination is overturned. 

The patient is a female who is seeking growth hormone (GH) treatment under the indication of idiopathic short stature (ISS). Her mid parental target height is 159.6 centimeter (cm). By history, she has always been small and growing below the growth chart for height. She is being followed in the pediatric endocrinology clinic. Her growth chart shows that she has been growing below the 1st percentile for height. Her evaluation has so far been unremarkable including normal IGF-1 (insulin like growth factor one), normal insulin-like growth factor binding protein-3 (IGFBP-3), normal female Karyotype and normal SHOX (short-stature homeobox) gene testing. This patient is seeking growth hormone (GH) treatment under the indication of ISS. 

Omnitrope is medically necessary for this patient. A meta-analysis of the efficacy of growth hormone treatment in children with idiopathic short stature including 10 controlled trials and 28 uncontrolled trials suggested an average gain in adult height of approximately 4-6 cm from GH treatment. 

This patient is quite short for her age and even though she is not from tall parents, and her mid parental height is only 61.5+/-2 inches, she is even short for her genetics. At her follow up visit, her height was 2.67 SD below the mean for age and 2.09 SD below her mid parental height. Her growth chart shows that her height has apparently dropped from -2.41 SD to -2.67 SD in the last 1.5 years. She clearly meets the definition of ISS.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left flank pain.

Treatment: Full hospital admission.

The insurer denied coverage for the full hospital admission.

The denial is upheld. 

This is a male patient with no past medical history and family history of renal stones.  The patient went to the Emergency Room (ER) for left flank pain.  The patient reported nausea and vomiting. The patient's computed tomography (CT) scan revealed mild left hydronephrosis due to a calculus in the left distal ureter.  The patient was admitted for this renal condition.  A Urology consult advised intravenous (IV) fluids and conservative management with pain control.  The patient's initial white blood cell (WBC) count was 18.2 but improved to 7.3 by the day of discharge.  The patient was deemed stable for discharge with outpatient urology follow-up.  

Per the Milliman Care Guidelines (MCG) Health (24th Edition) Renal Colic + Kidney Stones, this patient fails to meet clinical indications for admission to inpatient care.  There was no evidence of hemodynamic instability, acute renal failure, bilateral obstruction, urinary tract infection (UTI), transplanted kidney with obstruction or obstruction in a solitary functioning kidney.  Rather, the patient met clinical guidelines for Observation Care: Insufficient Pain Relief in the Emergency Department Setting.

As per review of the medical record and literature, the full hospital admission was not medically necessary for this patient.

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

The medical necessity for the full hospital admission is not substantiated. The insurer's denial should be upheld.