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

Diagnosis: Neck abscess
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned. 

This case involves a man with a history of intravenous (IV) drug use who was admitted to the hospital due to a right posterior neck abscess that had been present for about nine days. It started as a pimple, which he unsuccessfully drained at home. Four days before this presentation, the patient was evaluated in the emergency department with recommendations for admission and IV vancomycin but left Against Medical Advice (AMA). 

Based on the provided documentation, the inpatient hospital admission is medically necessary. The patient has a neck abscess requiring incision and drainage and poorly controlled diabetes. Therefore, as he is an IV drug user, he is at risk for multidrug-resistant organisms in the abscess, such as methicillin-resistant staphylococcus aureus (MRSA), which turned out to be the case. Standard of care treatment for abscesses, in particular around the neck area, which contains a lot of sensitive structures, where deep-seated infections can occur, leading to catastrophic consequences, are typically treated with empiric broad-spectrum antibiotics, in an inpatient setting, until cultures and sensitivities are available. Incision and drainage require frequent packing in the posterior neck, which is difficult for anybody to perform independently, especially in the initial stages. It requires monitoring for the development of deeper infection, such as spinal osteomyelitis, extension of abscess into the neck compartments, and airway compromise. The poorly controlled diabetes, with elevated Hemoglobin (HGB) A1c, is another reason for admitting to inpatient care, to up titrate the insulin treatment without producing hypoglycemic episodes. The complexity of this presentation requires an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

Asked to review the case of an adult male with no significant past medical history that presented  to the hospital with chest pain radiating to the left shoulder.  Pain was intermittent in nature. While being evaluated in the cardiologist's office he was noted to have an abnormal electrocardiogram (ECG) and was sent to the Emergency Department (ED).  On arrival at the hospital, vital signs were stable (Blood Pressure 155/107, Pulse 63).  Physical examination revealed no major abnormality.  12 lead ECG revealed sinus rhythm with left ventricular hypertrophy and no evidence of ischemic ST or T wave abnormalities. Serum troponin levels were not elevated (< (les then) 6).  The patient was admitted to the hospital for additional testing and treatment. Echocardiogram demonstrated a normal left ventricular ejection fraction (LVEF) with no evidence of wall motion abnormalities or valvular abnormalities. A perfusion study demonstrated a fixed defect in the inferior wall with inferior wall hypokinesis and a preserved LV (left ventricular) ejection fraction (57% (percent)). Cardiac catheterization was performed via a right radial artery approach and demonstrated no evidence of obstructive coronary disease. The patient was treated with antihypertensive medication and discharged with cardiology follow up.

This patient presented with chest pain and no past medical history. His pretest probability of coronary artery disease was low.(Reference 1)  Utilizing the HEART (History, Electrocardiogram (EKG), Age, Risk Factors, and Troponin) score he was considered low risk.(Reference 2)  Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days .  (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  Recent American College of Cardiology expert consensus statement for treatment of acute onset chest pain places this patient in a low-risk group and eligible for outpatient workup.  (Reference 4) In conclusion, admission to the hospital to treat an acute cardiac event 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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 Braces

The insurer denied coverage for D8080 Braces.

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 impacted maxillary anterior teeth among other findings.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index choosing the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated on the HLD index. 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 by internal reviewers attaining a score of 22 points. Devika Sharma is appealing the decision on behalf of 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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, 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 completes the HLD index, choosing the impacted permanent anteriors criterion to justify orthodontic care.  The clinical circumstance as documented meets this criterion for approval of 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.  

Based on the above, the insurer's denial must be reversed. 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 D8080 Braces is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who presented to the emergency department (ED) with the complaint of abdominal pain of 1-day's duration. Her past medical history included no chronic health conditions. She was evaluated with a surgical consultation that identified right lower abdominal tenderness. Her vital signs identified a normal heart rate and blood pressure at the time of presentation.  A computed tomography (CT) scan was completed showing findings of acute appendicitis without perforation. The patient was admitted to the hospital and started on intravenous (IV) antibiotics. The surgical service proposed nonoperative treatment with antibiotics (Cipro and Flagyl) for the condition of acute appendicitis.
Her vital signs were consistently normal during the period of monitoring. Her diet was advanced. She was discharged from the hospital.

The inpatient stay was not medically necessary. The examination, lab data, and computed tomography (CT) scan supported the diagnosis of acute appendicitis. The diagnosis was established. She was treated with a nonsurgical treatment of antibiotics with improvement. She was clinically stable, with a normal WBC count and was started on a diet. 
She was clinically stable at the time of presentation and remained so during the course of care. A lower level of care would have provided for presurgical assessment, surgical consultation, and antibiotics. This lower level of care would have also allowed for overnight monitoring.
In this case, the patient tolerated oral hydration, diet and medication and pain was well controlled. A lower level of care would have appropriately provided for surgical assessment, provision of antibiotics and pain medications. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.
The patient remained clinically stable and responded appropriately to the prescribed therapy. There were no complications or other clinical issues that mandated inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Colitis.
Treatment: Anser VDZ testing.
The insurer denied Anser VDZ testing.
The determination is upheld.

The patient is a female with Ulcerative Colitis. She was on Entyvio 300 milligrams (mg) every 8 weeks. She presented on Entyvio; she was feeling great, without rectal bleeding, and was having a soft, formed bowel movement. She presented again on Entyvio; she felt excellent on it and was tolerating her infusions well. She presented with a lack of gastrointestinal symptoms. Anser VDZ (vedolizumab) showed an Entyvio level of 13.0 micrograms per milliliter (ug/mL) and a lack of anti-Entyvio antibodies. At issue is the medical necessity of Anser VDZ testing. 

This is not medically necessary as active Ulcerative Colitis is not documented. There is a lack of sufficient medical evidence to support the effectiveness of testing for Entyvio level and anti-Entyvio antibodies compared with conventional courses of action in the management of Ulcerative Colitis. The published studies including the use of anti-Entyvio antibodies and serum levels are small, retrospective, and/or observational rather than controlled (in regards to the study of using Entyvio levels and anti-Entyvio antibody levels) in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment response and the presence of anti-Entyvio antibodies, which do not allow firm conclusions regarding cause and effect. Additionally, the antibodies can be transient. A meta-analysis of Ulcerative Colitis patients on Entyvio noted that the cause-effect relationship between Entyvio levels and remission remains unclear and that prospective studies on reactive and proactive therapeutic drug monitoring of Entyvio are warranted. A study demonstrated no relationship between Entyvio trough levels and mucosal healing, and another concluded that larger, independent studies are needed. Recent guidelines for the treatment of Ulcerative Colitis do not recommend testing for Entyvio level or anti-Entyvio antibody level. Controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with Ulcerative Colitis compared with conventional management. Finally, there was a lack of active Ulcerative Colitis in this case, so testing for Entyvio level and anti-Entyvio antibodies would not have been useful.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Myeloma

Treatment: procedure code 8479

The insurer denied coverage for procedure code 8479

The denial is upheld 

The patient has relapsed myeloma. The patient is on therapy with scarlisa plus (+) venetoclax + kyprolis. The attending provider (AP) has performed clonoSEQ testing.

The test was denied by the insurer, noting they cannot approve the test because the notes did not show that this test is being used to monitor the patient's multiple myeloma after a transplant. 

An appeal letter notes the patient has been diagnosed with multiple myeloma (MM) and clonoSEQ is a next-generation sequencing (NGS)-based assay for the assessment of minimal residual disease (MRD) in patients diagnosed with specific lymphoid malignancies.

The procedure code 8479 is not considered medically necessary for this patient. There is no role for the use of MRD assessment of multiple myeloma in the multi relapsed setting on palliative therapy with scarlisa plus (+) venetoclax + kyprolis. While MRD assessment is supported following Stem Cell Transplant (SCT) and at completion of maintenance therapy, there is no evidence or role for this testing in a multi relapsed setting. There is no evidence that MRD assessment is of clinical relevance in this setting.

"Numerous studies have evaluated the prognostic value of minimal residual disease (MRD) in patients with multiple myeloma (MM). Most studies were small and varied in terms of patient population, treatment, and MRD assessment methods" (Munshi et al., 2017). 

"Measurable (minimal) residual disease (MRD) is an independent prognostic factor for survival outcomes in patients with lymphoid and plasma cell malignancies and has been incorporated into consensus criteria regarding treatment response, strategy, and clinical trial endpoints. clonoSEQ (a next-generation sequencing [NGS]-MRD assay) uses multiplex polymerase chain reaction and NGS to identify clonotypic rearrangements at the immunoglobulin (Ig) H, IgK, IgL, T-cell receptor (TCR)-, and TCR- loci, as well as translocated B-cell lymphoma 1/IgH and 2/IgH sequences for MRD assessment. Additionally, it can be used to confirm diagnoses of cutaneous T-cell lymphoma (CTCL)" (Hussaini et al., 2022).

"The measurement of minimal residual disease (MRD) with clonoSEQ can be used in the assessment of B-cell lymphoid tumor burden throughout treatment with accuracy, sensitivity and standardization when compared to traditional cytomorphology. With the approval of novel treatments, standardized MRD assessment with improved performance is increasingly important" (Walzer et al., 2021).                                                         

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 procedure code 8479 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crohn's Disease
Treatment: Stelara 90mg every 4 weeks
The insurer denied Stelara 90mg every 4 weeks
The determination is overturned.

This is a male patient with severe Crohn's colitis. He has previously tried and failed steroids, and an anti-tumor necrosis factor (TNF) agent (adalimumab). He was started on Stelara but did not achieve mucosal healing. He had flares of his Crohn's disease leading to hospitalization. He has elevated inflammatory markers (fecal calprotectin). Therapeutic drug monitoring revealed low ustekinumab levels. Therefore, the attending provider is requesting the use of Stelara at the escalated dose of 90 milligrams (mg) subcutaneous (SC) every 4 weeks to treat this patient's severe Crohn's disease. This is under review for medical necessity.
The requested health service/treatment of Stelara 90 mg every 4 weeks is medically necessary for this patient.
Since this patient was not responding to standard dosing of Stelara, it is reasonable to increase the dose of Stelara to 90 mg every 4 weeks. Dose escalation in biologic therapy used in inflammatory bowel disease can be done either based on clinical symptoms or laboratory markers or endoscopic or radiological features with or without therapeutic drug monitoring. Dose escalation is done either by increasing the dose of the medication or shortening the interval between doses or sometimes a combination of both. There are only a finite number of biological agents used to treat inflammatory bowel disease and the standard of care is to optimize dose of the biological agent before switching to another agent. Therefore, it is medically necessary to use Stelara 90mg SC every 4 weeks to treat this patient's severe Crohn's disease (CD).
Crohn's disease results from a pathological immune response to luminal antigens in genetically predisposed individuals. Since the causes of Crohn's disease are complex and only partially understood, treatment is based on the empiric use of anti-inflammatory drugs. Although multiple therapies for Crohn's disease currently exist, a substantial proportion of patients are unresponsive to conventional agents. Approximately a third of patients fail treatment with tumor necrosis factor (TNF) antagonists, and up to 40 percent (%) of patients who initially benefit subsequently lose response. Ustekinumab, a fully human immunoglobulin (Ig)G1-kappa monoclonal antibody to the p40 subunit shared by interleukin (IL)-12 and IL-23, has emerged as a promising new treatment for both psoriasis and Crohn's disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ear infection. 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is an infant who presented with an ear infection. He was noted to have right ear drainage, pain, and decreased oral intake. The examination revealed an elevated white blood cell count (WBC) and fevers necessitating admission due to hemodynamic instability. Antibiotics and oral feedings were initiated, and the patient was discharged after three days. 

The patient was noted to have fevers, ear discharge, and an elevated white blood cell (WBC) count. Antibiotics and fluids were needed in order for the infant to improve. Hemodynamic instability was the criteria used for admission which is appropriate. Per " Milliman Care Guidelines (MCG) Health General Recovery Care 27th Edition Medical Admission Case Management Head and Neck Disease (GRG), hospital admission is needed for appropriate care of the patient because of 1 or more of the following: Otitis media requiring treatment beyond scope of observation care, as indicated by 1 or more of the following: Hemodynamic instability, Mastoiditis, Suspected CNS infection, Bacteremia, Surgical drainage needed that cannot be performed in observation care". 

"Acute otitis media (AOM) is the most common infectious disease encountered by children under the age of two years and the most common cause of antibiotic use in children in the United States. AOM causes irritability, sleeplessness, decreased appetite, imbalance, and dizziness in patients, especially young children. This assessment was conducted to measure the effectiveness of surgical interventions in treating AOM. We reviewed the present findings regarding the etiology, clinical presentations, diagnosis, treatment, and surgical treatment of complications of AOM. Pain associated with AOM (otalgia) can be severe enough to cause parents to seek treatment for their infants or children. Various suggested measures have been used to treat AOM; antibiotic treatment with amoxicillin is still the treatment of choice for AOM, yet other antibiotics may be used in cases of allergy to penicillin or recent use of amoxicillin. Surgical intervention has been introduced and studied as a diagnostic, therapeutic, and preventive measure for AOM; nevertheless, a few studies have shown that surgical interventions are beneficial in treating and preventing AOM compared to the common practice of using antibiotics. Overdiagnosis of AOM is widespread, leading to injudicious antibiotic use, which contributes to antibiotic resistance."(Jamal A., et al 2022). 

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 inpatient hospital stay is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis

Treatment: Inpatient admission

The insurer denied coverage for Inpatient admission

The denial is overturned
 

This is an adult male diagnosed with Diabetic ketoacidosis. The request is for coverage of admission. The patient has a history of Type I diabetes. He presented to the emergency room (ER) with nausea and vomiting, fatigue, and weakness since Wednesday. The patient has been unable to hold any food down since the day before morning.

Vitals: Blood Pressure 142/95, Pulse 105. Labs: Glucose 403, Sodium 127, Calcium 10.7, Bicarbonate low 18, anion gap 21, potential of hydrogen (PH) 7.31, Beta hydroxybutyrate greater than 4, Blood urea nitrogen (BUN) 26, creatinine 1.52, Potassium 5.1, Chloride 88, carbon dioxide (CO2) 18, lactic acid 2.9. The patient was diagnosed with diabetic ketoacidosis (DKA) and acute kidney injury due to DKA.

Hospitalization for DKA is universally medically necessary. Patients with diabetes and diabetic ketoacidosis (DKA) initially generally require intensive care unit (ICU) level care until they are converted to subcutaneous insulin and have closed their anion gaps and have no other conditions requiring ICU level care.  Most hospitals admit patients with DKA to the ICU due to rules regarding level of service with every (q) 1 hour blood draws and nursing rules. 

The patient was admitted for diabetic ketoacidosis, Acute kidney injury and hyperglycemia.  

The patient met the criteria for the diagnosis of DKA based on a pH of 7.31 with an anion gap of 21 and a high beta hydroxybutyrate and a low bicarbonate. The patient had acute kidney injury with a creatinine of 1.52. 

The admission is consistent with generally accepted standards of medical practice and is therefore medically necessary.

Based on the above, the insurer's denial must be reversed. 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 inpatient hospital admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Vertebrogenic Low Back Pain. 
Treatment: Intracept Procedure (64628, 64629). 
The insurer denied: Intracept Procedure (64628, 64629). 
The denial is upheld. 

The patient is an adult male. The appeals letter states the patient has a history of chronic low back pain due to degenerative disc disease that resulted in development of vertebrogenic pain identified by degenerative endplate changes on magnetic resonance imaging (MRI). The patient has pain and has failed treatment for greater than six months. Prior treatments include medication, injections, and physical therapy. 

The health plan should not cover the proposed treatment. 

Based on the documentation provided, the requested procedure is not recommended at this time. Though the patient has a history of chronic pain, there was lack of documentation on magnetic resonance imaging (MRI) that supports the requested procedure. There was no documentation of any Modic type changes noted. As such, this procedure is not recommended in this case.