Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ears/Nose/Throat. 
Treatment: Surgical Services. 
The insurer denied nose surgery. 
The denial is upheld.

The patient is a male reported to have a history of chronic eustachian tube dysfunction and allergic rhinitis. He has undergone several sets of myringotomies with tubes. Exam revealed no tympanic membrane perforations or middle ear fluid and there was a left myringotomy tube in place that was placed when there was fluid in the right middle ear. He underwent nasopharyngoscopy with balloon dilation of the eustachian tubes two years previously. Repeat nasopharyngoscopy with balloon eustachian tube dilations was recommended and is the service under review.

No, based upon the clinicals provided and the current peer reviewed medical literature, nasopharyngoscopy with balloon eustachian tube dilation is not likely to be more beneficial. According to an expert panel of the American Academy of Otolaryngology Head and Neck Surgery, that further studies are needed to refine patient selection and assess outcomes. According to Micucci et al. in a review of the literature, the authors concluded that eustachian tube balloon dilation is a novel technique for the treatment of chronic eustachian tube dysfunction and its role continues to evolve and develop. Current practice patterns demonstrated wide variability in the assessment of eustachian tube dilation, heterogeneity in the timing of eustachian tube dilation and controversy in preoperative computed tomography (CT) screening. A study by Poe was limited by its small cohort and short term follow up.
Based upon the clinicals provided and the peer reviewed medical literature, nasopharyngoscopy with balloon eustachian tube dilation is not likely to be more beneficial.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental
Treatment: Dental/Orthodontic Procedure

The insurer denied braces.
The denial is overturned.

The patient in question is a female with impacted tooth # (number)11. This tooth is impacted in a mesioangular inclination, and it is in close proximity to the root of tooth 10. She presents with a skeletal Class I malocclusion and crowding. She is treatment planned for orthodontic treatment to address the malocclusion and impacted tooth, but treatment was denied due to lack of medical necessity.

The health plan's determination is overturned.

The treatment of braces is medically necessary. If left untreated the damage that will likely occur to the patient's teeth will be more time consuming and complicated to correct than the patient's existing orthodontic problem. Studies show that impacted canines with a mesioangular inclination have a less than 15% (percent) chance of spontaneous eruption.2 Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisors.3 Given the position of #10 and #11, this reviewer would expect #10 to be damaged if #11 is not addressed. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal
Treatment: DME
The insurer denied vacuum socket for artificial leg.
The denial is overturned.

The patient is a male with history of traumatic transtibial amputation. He has been functioning with a vacuum pump socket with custom socket insert for many years but it is worn, and he has gained weight. The socket requires replacement, but the vacuum pump and custom fit liner has been denied due to lack of medical necessity. The subject under review is the medical necessity for special vacuum socket.

The vacuum pump socket and custom liner are medically necessary for this patient. The denial of the system was based on the decision that the vacuum "is not helpful for people with his condition". The vacuum system improves circulation to the residual limb, thus maintaining skin integrity and reducing volume fluctuation. Less volume fluctuation allows for a better fit and decreases pistoning with ambulation. This results in a better gait pattern, improved proprioception, decreased limb pressures. A custom liner is required as the patient has a unique limb shape and has gained weight causing a change in the residual limb. The custom liner will protect bony prominences from causing skin irritation and breakdown.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory
Treatment: Inpatient Hospital
The insurer denied the inpatient stay. 
The denial is upheld.

The patient is a female who presented to the emergency department with concerns of shortness of breath and cough. Pertinent history included asthma.

Initial vital signs revealed a temperature of 100.2 Fahrenheit (F), heart rate (HR) 134, blood pressure (BP) 134/89, respiratory rate (RR) 22, peripheral capillary oxygen saturation (SpO2) 98% on room air. Electrocardiogram (EKG) revealed sinus tachycardia without acute ischemic changes. Initial laboratory testing revealed a white blood cell (WBC) count 25.4, hemoglobin (Hgb) 12.8, platelets (Plt) 384, blood urea nitrogen (BUN) 8, creatinine (Cr) 0.8, glucose (Glu) 98, sodium (Na) 141, potassium (K) 4.3, carbon dioxide (CO2) 27, Troponin negative, Lactate 2.28 -> 2.0 -> 2.4, Procalcitonin 0.8, creatine kinase (CK) 468, D-dimer unremarkable. Urinalysis was relatively unremarkable. Chest radiograph was without active pulmonary disease. Computed tomography angiography (CTA) of the chest was essentially unremarkable. The patient was admitted with an impression of sepsis and likely asthma exacerbation. Treatment plan included cultures, bronchodilators, corticosteroids, an echocardiogram, and withholding antibiotics as the patient was not toxic appearing. The next day, hemodynamics were stable. Echocardiogram was relatively unremarkable. Infectious disease consultation was obtained and had an impression of acute exacerbation of asthma. Recommendations were to discharge on oral antibiotics for possible bronchitis. Pulmonary consultation was obtained who had an impression of an exacerbation of asthma and elevated lactate. Recommendations were to continue steroids and bronchodilators, add azithromycin, ambulate, continue observation, and anticipate early discharge with office follow-up. The patient was discharged thereafter. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission.

The patient had a history of asthma and presented with shortness of breath and chest pressure. Initial evaluation revealed a leukocytosis, tachycardia, tachypnea, and an elevated lactic acid. A chest radiograph and computed tomography (CT) angiogram of the chest were essentially unremarkable. Initial treatment plan by the admitting physician included nebulizers and corticosteroids. Pulmonary consulted who had an impression of an asthma exacerbation and recommended early discharge with outpatient follow-up. Following one night of observation, the patient was deemed medically stable for discharge. To note, the lactate level was not normalized at time of discharge suggesting the abnormal value was of low clinical significance. Moreover, clinical indications for admission to inpatient care were not met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems- Missing Tooth/Teeth. 
Treatment: Dental/Orthodontic Procedure. 

The health plan denied the Implant Placement as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

This patient presents for a dental exam with his Dental Provider. The medical History is unremarkable. The patient's chief complaint is difficulty chewing, and pain worsens when chewing. Initial visit notes state that the patient has difficulty with partials to speak and the partials cause nausea, due to a sensitive gag reflex. The treating dentist is recommending Implant placement on #4, 6, 7, 8, 9, 10, 11. 

There is not sufficient evidence that there is a medical necessity of placing implants on teeth #4, 6, 7, 8, 9, 10, and 11, upon reviewing the medical records and x-rays submitted for review. The treating dentist states in the chart that the patient is unable to use dentures due to a sensitive gag reflex, and difficulty with speaking. The patient uses partials to go out but not to eat. The panoramic X-ray reveals missing teeth #8, 9, and 4, and failing root canal treatments in teeth #7, 10, and 11, and missing restorations, most likely from a failing fixed bridge on teeth #6, 7, 10, and 11. The patient most probably had an existing, failing fixed bridge from teeth #6, 7, 8, 9, 10, and 11. There is no evidence of this patient currently using removable partials to support that they are causing dysphasia and nausea. Upon reviewing the medical records and X-rays, there is not sufficient evidence that supports medical necessity of placing implants on teeth #4, 6, 7, 8, 9, 10, and 11.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: Spinal Surgery (codes 22633, 22853, 63047, 20936, 20930, 22840, 20939)
The insurer denied the Spinal Surgery (codes 22633, 22853, 63047, 20936, 20930, 22840, 20939)
The denial is overturned.

The patient is a male with chronic low back pain and left posterior thigh pain for several years. He has had physical therapy, injections, chiropractic, yoga and medications. The patient has a history of bipolar disorder and ankylosing spondylitis. MRI (magnetic resonance imaging) and CT (computed tomography) scan show fragmentation of the superior aspect of S1 (first sacral vertebra) superior articular process with some foraminal narrowing. X-rays show anterolisthesis on forward flexion which reduces upon extension. His provider recommends L5-S1 (fifth lumbar spine vertebra-first sacral vertebra) fusion.

Yes, the spinal surgery is medically necessary.
This patient has failed maximum conservative care and has persistent back and leg pain. He has spinal instability due to a fragmented S1 (first sacral vertebra) superior articular facet with documented spondylolisthesis and more than 3mm (millimeters) of motion on flexion/extension views. Lumbar fusion would be appropriate.

The provider is requesting a posterior lumbar interbody fusion 22633 with cage 22853. The laminectomy code (63047) would be bundled with the 22633 code and not separately reimbursable.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
This patient has been suffering for years and has spinal instability.  There is not evidenced to be any other option for this patient. He has been through conservative treatment, including physical therapy. Lumbar fusion is the standard of care for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower Extremity Cellulitis

Treatment: inpatient level of care

The insurer denied coverage for inpatient level of care

The denial is upheld.

The patient with a past medical history significant for morbid obesity and asthma presented to the emergency department for worsening bilateral lower extremity pain and swelling. Vitals on presentation were stable. The patient was started empirically on intravenous antibiotics (vancomycin and Zosyn) for lower extremity cellulitis. Lower extremity venous Doppler was negative for deep vein thrombosis (DVT). All cultures were negative. The patient improved clinically, remained afebrile and hemodynamically stable. She was discharged to continue oral antibiotics as an outpatient. 
   
According to documentation, the patient presented with lower extremity cellulitis, and was otherwise afebrile and hemodynamically stable. Laboratory results were unremarkable including a normal white blood count (WBC). The patient had a localized infection, and no surgical intervention was required. Based on above findings, patient did not meet criteria for acute inpatient admission. 

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

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

Diagnosis: Systolic Heart Failure

Treatment wearable cardiac defibrillator (K0606)

The insurer denied coverage for wearable cardiac defibrillator (K0606)

The denial is upheld

The patient was diagnosed with systolic heart failure and prescribed an external lifevest defibrillator.  The patient presented to the hospital complaining of worsening shortness of breath.  Past medical history was relevant for a prior work up for systolic congestive heart failure including cardiac catheterization and treatment with guideline directed medical therapy and psychiatric disease treated with Seroquel and Buproprion.  Upon arrival to the hospital, vital signs were stable. Serum blood testing revealed an elevated troponin level (0.22ng/ml [nanogram per milliliter]) and (BNP) B type natriuretic peptide was over 2000 pg/ml [picogram per milliliter]. Echocardiogram revealed a severely depressed left ventricular ejection fraction (LVEF) 15-20% (percent) with an apical thrombus and moderate mitral regurgitation.  Electrocardiogram (ECG) revealed sinus tachycardia with no ectopy.  The patient noted that he was non-compliant with medications.  He was restarted on guideline directed medical therapy and discharged home with an external lifevest defibrillator.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.  The proposed treatment is not likely to be more beneficial than any available standard therapy.  The SCD HFT [sudden cardiac death in heart failure] trial demonstrated a survival benefit in patients with NYHA [New York Heart Association] functional class II symptoms of CHF [congestive heart failure] and an LVEF less than or equal to 35% (1). Current guidelines do not recommend primary prevention of sudden cardiac death prior to treatment with anti-congestive therapies (2).  The patient presented with a reduced ejection fraction and new onset heart failure.  His clinical presentation and hospitalization did not suggest high risk features for sustained ventricular arrhythmia. Based on current available guidelines and clinical trial data the proposed treatment was not medically necessary and was unlikely to be beneficial for the patient (2).  

In conclusion, evidence-based indications do not support the routine use of external lifevest defibrillators in patients with heart failure without high risk features for arrhythmia (3).  This patient presented with new onset heart failure and without significant arrhythmia during hospitalization. External lifevest defibrillator was not medically necessary in this case.

Based on the above, the medical necessity for the wearable cardiac defibrillator (K0606) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical left upper arm pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a who presented with atypical, left upper arm pain. He denied palpitation, dyspnea, or nausea. He has a history of automatic implantable cardioverter defibrillator (AICD), coronary artery disease (CAD), myocardial infarct (MI), chronic obstructive pulmonary disease (COPD), hypertension, chronic kidney disease, and substance abuse.  Intravenous access was started.  The patient's drug screen was positive for cocaine. Other than mild hypertension, the patient's exam was normal. 

The patient was admitted to telemetry.  His echocardiograms showed reduced ejection fraction (chronic). Troponin trivially elevated and likely was due to cocaine, congestive heart failure (CHF), and renal failure. The patient had an uneventful stay with no further chest pain, or arrhythmias, and he was discharged. 

No, the proposed inpatient admission was not medically necessary. 

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam (blood pressure normalized) and cardiac findings were normal. He had a  minimally elevated troponin secondary to chronic renal failure (CRF), congestive heart failure (CHF), and cocaine.  Echocardiogram showed reduced ejection fraction but not changed from the previous.  Past nuclear scan was negative for coronary artery disease (CAD). The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for acute coronary syndrome such as intravenous heparin, dual antiplatelet inhibitors, high dose beta blockers or intravenous nitroglycerin (NTG). 

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of acute coronary artery disease.   While there is always a potential for an adverse event, one did not happen and no actual treatment was added. 

Milliman criteria requirements were not fulfilled as there was never any evidence of acute coronary syndrome present. 

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary. 

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypogonadism
Treatment: Humatrope, Pre-service
The insurer denied the Humatrope, Pre-service.
The denial is upheld.

The patient is a male with type II diabetes, hypogonadism with abnormal growth hormone stimulation test with glucagon with peak growth hormone level of 0.4.  His insulin-like growth factor one (IGF-1) was 110 (52-328). The request for Humatrope is under review.

The prior request for Humatrope was denied by the health plan, as the documentation does not support that the patient has at least two provocative growth hormone tests with highest level less than five nanograms per milliliter (ng/mL) or abnormal stimulation with Macrilen. The attending physician is appealing this determination, as the patient is symptomatic, with persistently low insulin-like growth factor one (IGF-1) levels and abnormal glucagon stimulation test.

No, the requested Humatrope is not medically necessary.
Idiopathic growth hormone deficiency in adults is very rare, and this patient does not have a documented condition, such as pituitary tumor, that would cause growth hormone deficiency. Because in the absence of suggestive clinical circumstances there is a significant false-positive error rate in the response to a single growth hormone stimulation test, the Endocrine Society guidelines recommend the use of two abnormal growth hormone stimulation tests before making the diagnosis of growth hormone deficiency. This patient does not have two abnormal documented growth hormone stimulation tests, he only has one. Humatrope has risks including headaches and joint pain. Therefore, no, the requested Humatrope is not medically necessary.

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

Diagnosis: Central Nervous System/Neuromuscular
Treatment: Pharmacy/Prescription Drugs
The insurer denied Botox.
The denial is upheld.

The patient is a female with a history of chronic migraine headaches. She has a history of headaches since childhood. The patient was said to have been receiving Botox injections for the preceding 8 years with a positive response to therapy. Other preventative therapies used by the patient in the past had also included topiramate, gabapentin, verapamil, Namenda and Emgality. A request has been made of her health plan for coverage of Botox.

The health plan's determination is upheld.

It cannot be concluded on the basis of current medical literature that the use of a beta blocker would be more effective, ineffective, or less effective than the requested non-formulary drug (Botox). There have not been any direct comparison studies completed to date between Botox and propranolol which would permit a conclusion that Botox results in superior outcomes when compared to the formulary alternative(s).

Both drugs are known/recognized as being superior to placebo in migraine prevention. It otherwise cannot be conclusively inferred that the use of Botox is otherwise expected to result in a greater decrease in migraine frequency versus the formulary drug on the basis of these placebo-controlled studies alone.

Consequently, it cannot be stated at this time that there would be a medical basis for a waiver of the health plan's formulary requirements.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Onychomycosis
Treatment: Jublia
The insurer denied Jublia.
The health plan's determination is upheld.

The patient is a female who has been treated for onychomycosis. Records indicate treatment for patient's onychomycosis includes clarus 1% (percent) antifungal tolnaftate solution. She has continued this topical medication for a few years. Records indicate that "[p]atient finished course of Lamisil." A nail culture was taken and sent for PAS (periodic acid Schiff) stain and Jublia was subsequently prescribed.

A formulary exception is not indicated.

Records do not indicate a clinical reason such as expected adverse reaction or contraindication that prevents the patient from trying all formulary alternatives: itraconazole, terbinafine tablet. Records indicate that patient has completed a course of oral terbinafine (Lamisil) and used clarus 1% antifungal tolnaftate solution for more than one year. She continues to have signs and symptoms of onychomycosis. Although the patient has tried two different treatments, one oral and one topical, she has not tried all formulary alternatives, which also includes itraconazole. Records do not indicate an intolerance or contraindication to a course of itraconazole.

Therefore, the formulary drugs (itraconazole, terbinafine tablet) have not both been shown to be ineffective as itraconazole has not been used. They may be as effective as the non-formulary drug (Jublia), as not all formulary drugs have been used, and they would not have anticipated adverse effects according to the records.