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

Diagnosis: Vitiligo 

Treatment: Opzelura

The insurer denied coverage for Opzelura.

The denial is overturned.

The patient has a history of psoriasis and psoriatic arthritis and then developed generalized vitiligo affecting more than 30% (percent) TBSA (total body surface area). The patient was treated with Cosentyx for psoriasis which was noted to be ineffective and led to a worsening of her vitiligo. The patient also has an undiagnosed photo distributed cutaneous eruption of unknown etiology which was notable for an antinuclear antibodies (ANA) titer of 1/80 and positive anti-Ro antibody. The patient stopped Cosentyx due to rapid worsening of vitiligo. The patient currently has more than 30% TBSA depigmentation. The requested medication is Opzelura topical therapy.  

Vitiligo is an autoimmune disease which requires treatment and is not a cosmetic diagnosis. Opzelura is the only approved Food and Drug Administration (FDA) treatment for patients 12 years of age and older treated for vitiligo. It is noted that the patient was treated with topical steroids and tacrolimus, presumably including for the vitiligo diagnosis. Based on the documentation, it appears that the patient had vitiligo which was exacerbated by Cosentyx and/or may be related to the undiagnosed cutaneous eruption. The large surface area of involvement would suggest that systemic therapy would be most appropriate rather than topical therapy. FDA approved systemic therapy for vitiligo is available and may be appropriate, but the use of a topical agent is within the standard of care. The patient has tried and failed standard topical therapies, including topical steroids and non-steroidal tacrolimus ointment and appears to have an adverse response to excimer light therapy. The use of Opzelura is medically necessary for the treatment of this patient's vitiligo.  

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 Opzelura is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient had a history of a laparoscopic sleeve placement and chronic kidney disease and presented with epigastric pain and diarrhea. He was found to be hypertensive in the emergency room (ER). The abdominal exam was benign. There was no leukocytosis. An abdominal CAT (Computed axial tomography) scan revealed colitis. Intravenous (IV) hydration was given, and stool testing was done. The renal function improved from creatinine of 2.59 to his baseline of 2. He felt better and was discharged on an oral antibiotic. 

Clinical indications for admission for Gastroenteritis (MCG [Milliman care guidelines] M-170) include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, severe electrolyte abnormalities, or an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had a gastroenteritis. He required IV hydration and stool testing. This could have been done with observation status. The hypertension was amenable to outpatient treatment and improved. He had chronic kidney disease but responded to the IV hydration and his renal function returned to baseline. He did not meet MCG criteria for admission for Gastroenteritis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

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: Varicose veins

Treatment is CPT (Current Procedural Terminology) 36465; injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring, single incompetent extremity truncal vein

The insurer denied coverage for CPT 36465; injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring, single incompetent extremity truncal vein
 
The denial is upheld.

The patient presented to his physician complaining of lower extremity swelling, pain and discoloration of both lower extremities. A venous duplex ultrasound examination revealed bilateral saphenous vein reflux > (greater than) 600 seconds bilaterally.  The right distal great saphenous vein was injected with non-compounded foam sclerosant under ultrasound guidance. The patient was noted to have persistent symptoms and venous insufficiency despite appropriate treatment with compression stockings. He underwent successful sclerosis of the right distal great saphenous vein. The society for vascular surgery recommends endogenous thermal ablation over surgical treatment of varicose veins in patients with symptoms. Such treatment is given a class 1 recommendation. Sclerotherapy with foam injection has been recognized to be inferior to therapy such as surgical stripping, radiofrequency ablation and laser ablation therapy. (Reference 1). A meta-analysis of over 73 studies enrolling patients with treatment for varicose veins confirmed that surgical therapy resulted in similar long-term saphenous vein closure rates as endovascular laser therapy. Both modalities were superior to radiofrequency ablation and ultrasound guided foam sclerotherapy. (Reference 2). In conclusion foam sclerosis to treat varicose veins is inferior therapy as compared to endovascular laser therapy or surgical options.

The insurer's denial of coverage for the CPT 36465; injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring, single incompetent extremity truncal vein is upheld. 

Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: nausea and vomiting

Treatment is an inpatient admission 

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

This patient reportedly was admitted to the inpatient hospital due to nausea and vomiting while at the Methadone clinic. He reportedly had several episodes of diarrhea, had body aches, abdominal pain, weakness, and fatigue. His heart rate was low at 35. He reportedly was given Atropine on the way to the hospital. He reportedly was homeless and left AMA (against medical advice).
  
The medical records did not provide enough specific evidence to support the need for only 24-hour hospital treatment then. The MCG (Milliman Care Guidelines) Substance Related Disorder criteria report that if in opioid withdrawal one needs around the clock care with all of the following: vomiting or diarrhea due to opioid withdrawal with marked dehydration or electrolyte abnormalities. Also, if one has acute toxicity or instability from substance use requiring inpatient treatment and a lower level of care is not feasible, or one is an imminent danger to self or others, if there is severe dysfunction in ADLs (activities of daily living), or one is in a delirium. It also states that one meets criteria if there is an inadequate response to pharmacotherapy in the ED (emergency department) or an appropriate lower level of care or a lower level of care is not feasible or appropriate. In this case, the medical records provided did not report that he was in opioid withdrawal or that he had opioid toxicity. 

There were no reports of persistent vital sign instability, severe withdrawal symptoms requiring inpatient substance detoxification treatment, or acute psychiatric symptoms then. There were no reports of a heart rate over 120, dehydration, excessive vomiting with marked dehydration or electrolyte abnormalities, and there was no reported history of withdrawal seizures of delirium tremens. The chart notes did not provide specific evidence that the patient required only inpatient detoxification protocol medication treatment or treatment for acute toxicity of substances. 

Also, there were no reports of suicidal intent or plan, psychosis, or evidence that the patient was considered an imminent danger to self or others. There were no reports of specific evidence that he could only be treated in this 24-hour hospital setting or that he could not be treated in a less restrictive level of care. Notes reported that he remained asymptomatic and that he was not in withdrawal.  

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: Overturned

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 monthly visit

The insurer denied coverage for D8080 braces and D8670 monthly visit

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified anterior crossbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of cross bite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index attaining 22 points by internal reviewers when 26 points are required for approval. The provider is appealing on behalf of the patient.

Upon review of the submitted documentation, it is evident that the patient exhibits a significant 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 met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

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

The insurer's denial of coverage D8080 braces and D8670 monthly visit is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma. 
Treatment: Inpatient Hospital Stay. 

The health plan denied the inpatient hospital stay as not medically necessary. The health plan's determination is overturned. 

The patient is a male who was admitted to the hospital for an asthma exacerbation that did not respond to appropriate home therapy. The emergency department course showed improvement with bi-level positive airway pressure (BiPAP) and medications. The decision was made to admit the patient due to previous intensive care unit (ICU) admissions and intubation for an asthma exacerbation. 

At issue is the medical necessity of the inpatient admission. 

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

Yes, the requested health service/treatment of an inpatient admission was medically necessary for this patient. 

Prior severe exacerbations necessitating Intensive Care Unit (ICU) stay and intubation warrant hospital observation per Milliman Care Guidelines (MCG) criteria. 
The patient has had three severe asthma exacerbations in the past year with ICU stay and two intubations. This is a fragile asthmatic who benefited from emergency department treatment and observation. Hospital admission with every three hours Albuterol need to ensure improvement prior to home discharge was appropriate.
As referenced in the Leung et al 2021 article, appropriate and safe discharge planning of the pediatric asthmatic patient in the emergency department is paramount to maintaining the standard of care: "For children in an emergency department (ED), indications for hospitalization and ICU consultation can vary considerably. In general, children that should be admitted include those with ongoing need for supplemental oxygen; severe acute asthma exacerbations (AAE) despite 1-2 hours of continuous nebulization salbutamol (potential ICU admission); continued moderate AAE for more than 4-6 hours after corticosteroid administration; continued deterioration on conventional treatments; social environment limiting the delivery of care; and risk factors for fatal asthma with a child living at a major geographic distance from appropriate care." As is seen in this case, social environment and risk factors for fatal asthma necessitated a hospital admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sudden onset of loss of left arm and leg motor function
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is a woman. She presented with sudden onset of loss of left arm and leg motor function.

The patient was noted to be tachycardic, stiff in her upper extremities and having clonus in the lower extremity. She was given Valium 15 mg (milligrams) with minor improvement. Due to her psychiatric history and taking serotonin related medications, she was admitted for possible serotonin syndrome.

Coverage for the inpatient hospitalization was denied by the health plan as not medically necessary. This denial is being appealed.

Yes, the inpatient hospital admission was medically necessary.

The patient was admitted due to concern for serotonin syndrome, and this required inpatient consultation with psychiatry. Given that serotonin syndrome can lead to significant mortality and morbidity, the risk of managing this in an outpatient setting would be unacceptable. Milliman Care Guidelines (MCG) for drug overdose/ingestion states that inpatient hospital admission is warranted when there is psychiatric risk that is not acceptable for outpatient management.

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

Serotonin syndrome is a potentially serious condition that can lead to mortality and morbidity if not adequately monitored or treated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis Vulgaris
Treatment: Taltz
The insurer denied Taltz.  
The denial is upheld. 

The proposed treatment with Taltz is not medically necessary.
The patient is a male diagnosed with moderate to severe psoriasis and eczema. The patient has a history of colon cancer and hypertension. He has tried and failed topical steroids, Dupixent and Skyrizi, and has been prescribed Taltz. The request for Taltz was denied by the health plan; the treating provider is appealing the denial.
The treating provider has indicated that due to the patient's past medical history and previous medications tried and failed, the patient is not a candidate for Tremfya and tumor necrosis factor (TNF) alpha inhibitors. The provider has stated that Taltz is in a different class of biologics and is requesting approval.
There are other treatment alternatives for this patient's disease including Cosentyx which is in the same class as the requested Taltz. 
The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The provider has indicated that the other preferred alternatives are either contraindicated or not likely to work due to failure of similar medications; however, the patient has not had a trial of Cosentyx which is in the same class as the requested Taltz. There is insufficient documentation of contraindications to Cosentyx and there is no indication why the patient would not have a positive response to this medication.
Frieder J, et al (2018) writes "Cosentyx (secukinumab) is an efficacious anti-interleukin (IL)-17A biologic agent for the treatment of moderate to severe plaque psoriasis. It has demonstrated superiority to placebo in a number of phase II and III clinical trials, as well as superiority to etanercept and ustekinumab. Specifically, secukinumab is associated with a rapid rate of clinical response, with Psoriasis Area and Severity Index (PASI) 50/75 responses observed by 4 weeks, and maintained or improved responses documented through week 52.38,48. Furthermore, a greater proportion of patients on secukinumab achieve higher clinical responses of PASI 90 and 100 compared with other biologics."
Yang, EJ et al (2018) writes "Secukinumab has also demonstrated efficacy for psoriasis located in difficult-to-treat areas, including the scalp, palms and soles, and the nails. In a randomized, double-blind, placebo-controlled Phase III trial of patients with scalp psoriasis, treatment with 300 mg secukinumab for 12 weeks improved scalp disease severity as compared to placebo with respect to 90% (percent) reduction in Psoriasis Scalp Severity Index (52.9% vs 2.0%) and scalp only IGA 0/1 (56.9% vs 5.9%). In the randomized, double-blind, placebo-controlled GESTURE study of patients with non-pustular palmoplantar psoriasis, treatment with 300 mg secukinumab for 16 weeks resulted in significant improvements in palmoplantar psoriasis disease severity, as measured by Palmoplantar Investigator's Global Assessment 0/1 (33.2% vs 1.5%)."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.
 
The child presented to the Emergency Department (ED) with complaints of shortness of breath (SOB) and a nonproductive cough. As indicated, it is well known that peak symptoms of bronchiolitis is the 3rd or 4th day. There was no documentation that the patient required continuous positive airway pressure (CPAP) or high flow nasal canula (HFNC). The patient had only mild respiratory distress. The ED doctor also mentioned "no distress" appearance. The respiratory rate decreased by 36 breaths per minute by the time the admission History and Physical was done. There was no significant acidosis nor respiratory acidosis in the initial labs. In fact, the pH (potential of hydrogen) was 7.41. 

There was no significant lactic acidosis. There was also no need for multiple boluses for severe dehydration nor shock. The patient did not have underlying chronic lung disease nor congenital heart disease nor any neuromuscular deficits. The hospital course was representative of an "as expected" clinical course, as the trajectory showed improving respiratory status. Chest Xray (CXR) did not show pneumonia. 

Also, there was no evidence of the patient needing continuous nebulizers, epinephrine injection nor terbutaline drip. Intravenous (IV) fluids and nebulizers could be administered in observation status. The Pediatric Early Warning Score (PEWS) was desirable. Due to the above facts, the patient could have been managed as observational status.

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

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

Diagnosis: Diabetes

Treatment: Inpatient hospital admission 

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

This is a patient with past medical history significant for diabetes who presented to the emergency room with complaints of a chronic diabetic ulcer on the right foot. The patient had been receiving intravenous vancomycin via PICC (peripherally inserted central catheter) line at a nursing home. 

Vitals on presentation included: T (temperature) 97.8 F (Fahrenheit), BP (blood pressure) 144/95, P (pulse) 92, RR (respiratory rate) 17, O2 sat (oxygen saturation) was 97% (percent) on RA (room air). Laboratory results included the following: WBC (white blood cell) count 4.0, HGB (hemoglobin) 12.9, HCT (hematocrit) 39.3, creatinine 0.6, glucose 198.

The patient was started empirically on intravenous (IV) antibiotics (vancomycin) for a right foot diabetic ulcer. An X-ray of the foot showed soft tissue infiltration, likely edema, no ankle joint effusion. Podiatry performed an incision and drainage procedure. The patient remained afebrile and hemodynamically stable. He was discharged to continue oral antibiotics (Augmentin and doxycycline for 2 weeks) as an outpatient.    

According to documentation, the patient was electively admitted for a routine, follow-up incision and debridement (I&D) of a chronic diabetic foot ulcer. The patient had been receiving IV antibiotics for the past month at a nursing home. Otherwise, the patient was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC. The patient denied any fever or pain. Based on above findings, the patient met criteria for same day, elective I&D procedure. He did not fulfill criteria for acute inpatient hospital admission.  

Prior determination of denial of coverage for inpatient hospital is upheld.

The health plan acted reasonably, with sound medical judgment, and 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.