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

Diagnosis: Deep impinging overbite with severe soft tissue damage

Treatment: full braces and periodic orthodontic treatment visits

The insurer is denied coverage for full braces and periodic orthodontic treatment visits

The denial is overturned. 

This female patient has a history of deep impinging overbite with severe soft tissue damage

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, a Handicapping Labiolingual Deviation 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 deep impinging overbite with severe soft tissue damage.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care as on examination of the intraoral clinical images there is evidence of palatal gingival recession due to direct impingement of the teeth on the gingival soft tissues. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

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

The carrier's denial of coverage for full braces and periodic orthodontic treatment visits is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Gynecologic Issues
OB/Gyn Services


Diagnosis: Uterine Leiomyoma, Abnormal Bleeding
Treatment: Uterine Artery Embolization
The insurer denied Uterine Artery Embolization
The determination is overturned.

This is a female with symptomatic uterine fibroids over 6 months who presents for treatment. The uterus is quite large and has multiple fibroids (8 measured); these are identified on the magnetic resonance imaging (MRI) of the pelvis. The endometrial cavity is normal. An ultrasound with Doppler was also performed, noting a dominant 8.4 cm fibroid. Symptoms include menorrhagia, dysmenorrhea, and bulk complaints.
The patient is in good overall health. Past medical history notes no significant findings. Her medications were reviewed. No surgery has been planned. Treatment with medications was unsuccessful. Pertinent past medical records were reviewed. The current treatment plan is uterine fibroid embolization, as requested. What is at issue is the authorization for the treatment planned.

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

Yes, the requested health service/treatment 'uterine fibroid embolization' is medically necessary and appropriate in this particular case, for this patient. A UFE (uterine fibroid embolization) is appropriate.
This patient has a disabling condition, and the proposed uterine fibroid embolization (UFE), is an appropriate therapy. Stipulating additional procedures such as endometrial biopsy is not necessary for most patients prior to a UFE. A PAP smear was performed and was negatvie (NEG). An endometrial biopsy was not performed and is not necessary in all cases of planned UFE, such as in this case, in patients under age 45.
This is based upon the assessment of the medical literature and the submitted documentation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Ovarian Cyst. 
Treatment: Inpatient Hospitalization. 

The insurer denied coverage for inpatient hospitalization. 

The denial is upheld. 

The patient presented to the emergency room with complaint of abdominal pain, fevers and diarrhea. She was diagnosed with a 20-centimeter left ovarian cyst. She was admitted for a laparoscopic left ovarian cystectomy. Intravenous fluids and pain medication continued post-operatively. She was discharged tolerating a regular diet with oral medications for pain management. 

The patient presented with severe abdominal pain and an ovarian cyst.  She underwent an uncomplicated laparoscopy. A laparoscopy is an ambulatory procedure. 

According to Milliman Care Guidelines (MCG), Inpatient and Surgical Care, Laparoscopic Gynecologic surgery, including myomectomy, oophorectomy, and salpingectomy, laparoscopic procedures are ambulatory procedures. Inpatient stay may be needed for: -Older patients (> 65) - Conversion to abdominal procedures - Surgical complications - Comorbidities.

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. She was tolerating oral intake and voiding adequately.  Please note that a laparoscopic procedure is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. 

The patient could have been observed in the emergency department (ED) and when the pain did not improve, she could have undergone her laparoscopy which is an ambulatory procedure and discharged home thereafter. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospitalization is not considered medically necessary for this patient. 

Based on the above, the medical necessity for the inpatient hospitalization is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of Breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with history of asthma, hypertension and prediabetes. He presented to emergency room (ER) with shortness of breath.

The patient was found to have elevated troponin. The ER (emergency room) records documented diffuse anterolateral T-wave inversion. He was diagnosed with acute coronary syndrome. Additionally, he had hypoxia requiring O2 (oxygen) supplementation. Also, lactic acidosis, acute kidney injury, hypocalcemia and hypomagnesemia were found. Based on this information in the ER (emergency room), the decision was made for inpatient admission.

The admission note outlines that the patient had chest tightness for three days. During the inpatient hospital stay, the chest pain did not recur, and the patient's troponins quickly trended down, ruling out acute coronary syndrome. He was discharged following treatment for asthma exacerbation with nebulizers and inhalers.

The health plan denied coverage of full hospitalization service as not a medically necessity. This was based on the grounds that the patient's shortness of breath presentation to the ER (emergency room) required no breathing machine, in addition to absence of collapsed lung or other condition, treatment, or monitoring requiring inpatient admission. This denial is being appealed.

Yes, the Inpatient admission was medically necessary.
On ER (emergency room) presentation, the patient was found to have elevated troponin. The ER (emergency room) records have documented diffuse anterolateral T-wave inversion. He was diagnosed with acute coronary syndrome. The ER (emergency room) presentation with shortness of breath could be related to asthma or could be anginal equivalent in the setting of his cardiac risk factors. The decision for inpatient admission for ACS (acute coronary syndrome) was based on troponin elevation and documented EKG (electrocardiogram) finding in the ER (emergency room).

The standard of care for ACS (acute coronary syndrome) patients is to be admitted as inpatient for further evaluation and management. The lower level of care would not be the proper acuity given the patient's diagnosis of ACS (acute coronary syndrome) in the ER (emergency room).

Therefore, given the above, the Inpatient admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Review of entire records reveal that criteria for inpatient admission was based on suspected diagnosis of acute coronary syndrome, thus making the inpatient admission medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with history of prematurity, anemia of prematurity, and milk protein allergy. She was admitted for bronchiolitis. She had six days of URI (upper respiratory infection) symptoms and one day of increased breathing difficulty. She had a fever five days prior to admission which had resolved. She was evaluated at an urgent care the day prior to admission and tested positive for RSV (respiratory syncytial virus). Her breathing worsened, so she presented to the ED (emergency department) on the day of admission. She was noted to have decreased in oral intake but had normal urine output.

In the ED (emergency department), the patient's vital signs were T (temperature) 37.1, P (pulse) 171, R (respiration rate) 38, BP (blood pressure) 91/62, and pulse oximetry 92% on room air. She was noted to have retractions and tachypnea. Her perfusion was normal. CBC (complete blood count), BMP (basic metabolic panel), liver panel, RVP (respiratory viral panel), and rapid COVID/influenza testing were performed. She was suctioned and placed on oxygen via nasal cannula (2 liters per minute). Upon admission, she had improved work of breathing. She was placed on oral feeds, and routine vital signs were obtained. She was weaned to room air later that day. She was discharged home.

No, the Inpatient admission was not medically necessary.
The infant was admitted for bronchiolitis. Upon admission, there was no documentation of hemodynamic instability, inability to maintain oral hydration, lethargy, severe increased work of breathing or any other condition that required inpatient admission. Upon admission, the infant had no signs of respiratory distress or hypoxia and was feeding adequately. She did not require oxygen to maintain oxygen saturations above 90%, intravenous medications/fluids, frequent laboratory evaluation, frequent changes to her treatment plan, or any other service which necessitated an acute inpatient level of care. The services provided, which included monitoring of her respiratory status and supportive care measures could have been provided at a lower level of care. The requested inpatient hospital stay was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient's condition could have been treated at a lower level of care. The denial of an acute inpatient admission was appropriate in this clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tore Meniscus. 
Treatment: Surgical repair of torn structures in the right knee. 

The insurer denied coverage for surgical repair of torn structures in the right knee. 

The denial is upheld. 

This patient has a history of hypercholesterolemia, hypertension, hypokalemia, obesity, arthritis, kidney stones, and knee pain. She presented to the Orthopedic Surgeon's office for a preoperative visit for her right knee. She still reported persistent pain on the medial aspect of the knee. The physician recommended a right knee arthroscopy with partial meniscectomy versus meniscal root repair. 

The medical record was supportive for RIGHT knee surgery. The physician had provided care over period of several months. Notes refer only to the right knee. There was documentation of mechanical symptoms with correlative imaging. The woman was found to have a bucket handle tear of the meniscus (RIGHT) on the magnetic resonance imaging (MRI). A pain generator had been defined and surgery would likely provide benefit. 

The facts were the physician performed surgery to the LEFT side based on the operative report. Surgical indications for the left knee were not met. There was a lack of consistency in clinical record. There was no recent treatment. The magnetic resonance imaging (MRI) of the left knee was reported as showing minimal degenerative changes. Surgical intervention would not likely provide benefit based upon the above. ie. Lack of conservative treatment, lack of documentation of continual problems to left knee and associated imaging studies. 

There were no extenuating circumstances to substantiate operative intervention to her LEFT knee. 

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

Surgery is medically necessary for the RIGHT KNEE but, the physician performed surgery to the LEFT knee. There would be no indication for any operation to her LEFT KNEE. The surgical repair to LEFT knee was not medically necessary. 

Based on the above, namely that the surgical site was the left knee, the insurer denial for surgical repair of the right knee, is substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures (associated with glioblastoma)
Treatment: Epidiolex 100mg/ml Solution
The insurer denied the Epidiolex 100mg/ml Solution
The denial is upheld

The member is a male with seizure disorder secondary to glioblastoma. He was treated with levetiracetam but has cognitive side effects and was converted to levetiracetam XR (extended release). He is currently treated with levetiracetam XR (extended release). The provider is requesting Epidiolex. This was denied coverage as he does not have an FDA (Food and Drug Administration) indication for use of this medication.

No. The proposed treatment is no medically necessary.
This medication is FDA (Food and Drug Administration) approved for the treatment of seizures associated with Lennox-Gastaut syndrome (LGS), Dravet syndrome (DS), or tuberous sclerosis complex (Devinsky et al.; van der Poest Clement et al.). It is not FDA (Food and Drug Administration) indicated for this members condition. There are no high quality, prospective, randomized trials support the efficacy of Epidiolex for his condition. The manuscript provided by the AP (attending physician) is a prospective observation trial. The current medical literature is limited to retrospective studies case series and a singe, open label, uncontrolled study (Szaflarski et al,; Silvestro et al.). This level of evidence does not breach the threshold of evidence required to conclude the treatment is effective here.

Yes. The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: CHF (congestive heart failure) exacerbation

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This male patient has a history of heart failure, myocardial infarction (MI), chronic kidney disease (CKD) stage 3, deep vein thrombosis (DVT), pulmonary embolism (PE), and cocaine abuse. He presented to the emergency room (ER) with complaints of shortness of breath (SOB) and chest pain.

This patient could have been placed in Observation status while diagnostic testing and treatment were initiated. During this time MI could have been ruled out and diuresis initiated. The patient was ambulatory and tolerating oral intake. This patient remained clinically stable after admission. He could have been discharged home on oral medications after a period in observation with further close follow up in the outpatient setting.

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 inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis

Treatment: Dupixent (dupilumab) SC (subcutaneous) injection

The insurer denied coverage for Dupixent SC injection.

The denial is overturned.

The patient is a female with a past history of liver disease and anemia, who is being treated for atopic dermatitis affecting 20% (percent) total body surface area (TBSA). The patient was previously treated with topical steroids, tacrolimus, and phototherapy. The patient has multiple medical conditions, making traditional immunosuppressive therapies a non-ideal option. The requested medication is Dupixent.  

The request for Dupixent is supported by the medical literature and specialty society guidelines. Dupixent is the only systemic therapy approved by the Food and Drug Administration (FDA) for the management of atopic dermatitis (AD). The FDA approved Dupixent for adults with moderate-to-severe AD who are inadequately controlled with topical treatments. (1-2) According to consensus guidelines "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe AD... Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment... with moderate-to-severe AD who are uncontrolled with topical therapies". (1)  

The use of Dupixent is warranted and within the standard of care, given a diagnosis of moderate-severe atopic dermatitis, having a contraindication to methotrexate and cyclosporine due to liver disease and anemia.  

Based on this member's clinical history, Dupixent 300 mg (milligrams) every 2 weeks is medically necessary for the treatment of her condition.   

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

The insurer's denial of coverage for Dupixent (dupilumab) SC (subcutaneous) injection for the treatment of atopic dermatitis is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertensive Heart Disease

Treatment: Echocardiogram

The insurer denied coverage for echocardiogram.

The denial is upheld.

This is the case of a gentleman with a history of hypertension and hyperlipidemia. He was initially evaluated for hypertensive heart disease. At that time, a cardiac magnetic resonance imaging (MRI) scan revealed concentric left ventricular hypertrophy with late gadolinium enhancement that was transmural in some areas. Subsequently, an echocardiogram was performed and revealed a structurally normal heart with a preserved left ventricular ejection fraction (LVEF) and no left ventricular hypertrophy (LVH). He presented to his Cardiologist for routine follow up. Blood pressure (BP) was noted to be "120-130 mmHg (millimeters of mercury)/80s" on home readings. He had no cardiac complaints. A repeat echocardiogram was ordered that demonstrated no LVH or valvular abnormalities. 

This patient was initially diagnosed with hypertensive heart disease and LVH on cardiac MRI several years earlier. He was treated with antihypertensive agents and BP appears well controlled. An echocardiogram performed earlier documented no evidence of LVH. A finding of LVH on echocardiogram is associated with increased cardiac risk. Likewise, LVH regression has been shown to improve cardiac outcomes. (1) The American Heart Association (AHA) and American Society of Echocardiography (ASE) appropriate use criteria for echocardiography classify routine echocardiography for follow up in asymptomatic patients with hypertension and documented LVH as inappropriate and of uncertain value. (2) In fact, guidelines note that initial screening with echocardiography or cardiac MRI is considered optional. European Society of Cardiology guidelines recommend echocardiography as a IIb indication in patients with hypertension and LVH when findings will alter treatment decisions. (3) 

This patient's blood pressure was adequately controlled on oral antihypertensive therapy. In addition, LVH regression was documented on an echocardiogram one year earlier. Repeat echocardiogram was not medically necessary in this case. 

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

The insurer's denial of coverage for an echocardiogram is upheld. Medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Glaucoma
Treatment: Xen Gel Stent
The insurer denied the Xen Gel Stent.
The denial is overturned.

This is a male with primary open angle glaucoma of both eyes. The provider performed XEN stent placement on the left eye on and on the right eye.

Yes, the health plan should cover the requested health service.

Per Mansouri, et al, they evaluated the safety and efficacy of XEN gel implant as a standalone versus combined XEN-Phacoemulsification surgery (XEN+cataract) in glaucoma patients in a prospective, interventional study. One-hundred forty-nine eyes (113 patients) with open-angle glaucoma and uncontrolled intraocular pressure (IOP) despite medical treatment were enrolled at a tertiary glaucoma center and followed up for a minimum of 1 year. Approximately two-thirds of patients underwent combined XEN+cataract surgery, while the remainder had XEN alone surgery. Primary outcome was a 20% or more decrease in IOP (intraocular pressure) from medicated baseline at 1 year. They concluded that the XEN gel implant as a standalone procedure or combined with cataract surgery demonstrated safe and sustained IOP (intraocular pressure) reduction after 1 year.

In addition per Olgun, et al, they compared successes and complications of XEN GEL Stent implantation and gonioscopy-assisted transluminal trabeculotomy (GATT) surgery in patients with open-angle glaucoma (OAG). They performed a multicenter, non-randomized, comparative, interventional, retrospective chart review study that included 114 eyes undergoing XEN implantation and 107 eyes undergoing GATT (gonioscopy-assisted transluminal trabeculotomy) for treatment of OAG (open-angle glaucoma). They concluded that both procedures have good efficacy and safety outcomes in lowering IOP (intraocular pressure) and need of medication in patients with OAG (open-angle glaucoma). XEN Gel Stent implantation may be preferred in patients with lower IOP (intraocular pressure) values targeted.

Therefore, given the above, the health plan should cover the requested health service.

Yes, the requested health service is more beneficial.

The XEN stent is an an-interno glaucoma procedure, and it is considered to be safer and with a shorter recovery time than a traditional trabeculoplasty.