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

Diagnosis: Back pain

Treatment: outpatient minimally invasive lumbar decompression (MILD) procedure (back surgery) (code 0275T)

The insurer denied coverage for outpatient minimally invasive lumbar decompression (MILD) procedure (back surgery) (code 0275T)

The denial is upheld

This case involves an adult patient under review for the minimally invasive lumbar decompression (MILD) procedure. Magnetic Resonance Imaging (MRI) of the lumbar spine reported grade 1 anterolisthesis at Lumbar (L)4-5 with severe bilateral facet hypertrophy, moderate ligamentum flavum hypertrophy, minimal posterior disc bulge, mild to moderate left neuroforaminal stenosis, mild right neuroforaminal stenosis, moderate lateral recess stenosis, and moderate to severe central canal stenosis. At L5-Sacral (S)1 there was mild to moderate bilateral facet hypertrophy, disc bulge impressing on the descending left S1 nerve root and contacting descending right S1 nerve root. Clinical note reported the patient had intermittent neurogenic claudication due to lumbar spinal stenosis causing low back and left lower extremity pain. Previous treatment included interlaminar epidural straight injection, medication management, activity modification, and home exercises. Physical examination reported pain with rising from a seated position along with extension, and side bending. There was normal motor strength. Treatment plan was for surgical intervention at the L4-5 level.

MILD describes a percutaneous procedure for decompression of the central spinal canal in patients with lumbar spinal stenosis. In contrast to surgical decompression, the MILD procedure is a percutaneous decompressive procedure performed solely under fluoroscopic guidance. However, there is no indication that this minimally invasive surgery is superior to open surgical techniques. There is a lack of studies to support that minimally invasive surgery has clinically significant advantage in terms of short or long-term measures of pain or function. As such, the denial of outpatient the MILD procedure (back surgery) (code 0275T) is upheld.

In summary, the denial of outpatient MILD procedure (back surgery) (code 0275T) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polysubstance Use
Treatment: Inpatient Rehabilitation Treatment
The insurer denied: Inpatient Rehabilitation Treatment
The denial is Upheld.

The patient is an adult male with history of polysubstance abuse who was admitted to the inpatient rehabilitation level of care. The comprehensive evaluation note states the patient admitted to drinking 1-2 pints of rum daily and smoking $100 to $200 worth of crack cocaine daily. He also admitted to marijuana use 3 to 6 times per week. He had been admitted for detox multiple times previously and had most recently left rehab against medical advice 5 months ago. He reported a history of depression and post-traumatic stress disorder, which were diagnosed 4 years ago but stated that he only took medications while in rehab. He denied suicidal ideation, homicidal ideation, and hallucinations. He denied depressed mood and anxiety symptoms, and the psychiatric evaluation note states that no psychiatric intervention was warranted. The patient denied current withdrawal symptoms. He denied any comorbid medical conditions. He noted that he was homeless at the time of admission. The against medical advice nursing note indicates the patient requested discharge and stated he planned to travel to Florida. At issue is the inpatient rehabilitation level of care. Coverage was denied by the health plan as not medically necessary because the patient did not have any medical or mental health concerns that required 24 hour per day nursing support, nor did the patient meet Level of Care for Alcohol and Drug Treatment Referral 3.0 (LOCADTR 
3) for substance use inpatient rehabilitation treatment. It notes the patient's care could be safely addressed in a less restrictive level of care such as stabilization services in a residential 
setting. The decision was appealed by the treating facility, who state that the patient met criteria for the inpatient rehab level of care. 

The proposed treatment was not medically necessary.

Per New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0, the patient does not meet criteria for the inpatient rehabilitation level of care. There is no 
documentation of serious psychiatric or medical symptoms that need to be managed in an inpatient rehab setting for substance use disorder treatment to be effective. There is no documentation that the patient abuses substances in hazardous situations, in amounts or frequencies likely to imminently cause severe physical or emotional harm to self or others. There is no documentation of strong cravings or urges to use that are unmanageable or behavioral or emotional instability. As such, criteria for the inpatient rehabilitation level of care are not met. The definition of medical necessity generally includes that a treatment must be considered effective for the patient's condition and not primarily for the convenience of the patient or provider. Since the inpatient rehabilitation level of care does not fit this definition in this case, it is not medically necessary for the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Alopecia Areata
Treatment: Xeljanz 10 mg (milligrams) tablet
The insurer denied: Xeljanz 10 mg tablet
The denial is: Upheld

The patient is a male with history of alopecia areata who had previously failed therapy with intramuscular corticosteroid injections. The patient initiated off-label therapy with Xeljanz with resultant improvement of his disease at a dose of 10 milligrams (mg) twice daily. The request is for Xeljanz 10mg tablets for continuation of therapy. The subject under review is whether Xeljanz is likely to be more beneficial for this patient than any standard therapy.

The proposed treatment Xeljanz is not likely to be more beneficial than any standard treatment or treatments for the insured's condition.

The prescriber is requesting for coverage of Xeljanz for the treatment of this patient's alopecia areata. Xeljanz is an oral Janus Kinase (JAK) inhibitor that is Food and Drug Administration (FDA)-approved for several rheumatologic and inflammatory conditions. While its use for alopecia areata has been reported in the published medical literature, it is not FDA-approved for the treatment of alopecia areata. The standard of care for moderate to severe alopecia areata is Olumiant, which is also an oral JAK inhibitor. There is no documentation that this patient has previously tried Olumiant, nor has a clinical contraindication to Olumiant. As an oral JAK inhibitor, it is likely to be as effective and beneficial as Xeljanz in the treatment of alopecia areata. Due to the availability of Olumiant as an on-label treatment for this patient's disease, the use of Xeljanz is not considered appropriate or the standard of care for this patient's disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Alopecia Universalis
Treatment: Xeljanz 10 mg (milligrams) tablet
The insurer denied: Xeljanz 10 mg tablet
The denial is: Upheld

The patient is a male with alopecia universalis. He has had alopecia for 15 years. He has tried and failed psoralen-ultraviolet A (PUVA). He has also failed systemic steroids. The subject under review is whether the treatment with Xeljanz is likely to be more beneficial than any standard treatment for this patient's condition.

The proposed health service or treatment Xeljanz is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

There are no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Xeljanz for this patient's condition as an accepted standard of practice in the U.S. (United States) prior to the conventional alternatives. There is no documentation the patient has exhausted all topical options, and that it would therefore be appropriate to start systemic treatment with Xeljanz, which would carry a higher side effect profile. It is noted that the patient has tried and failed topical steroids.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite. 
Treatment: D8080 Braces, D8670 Monthly Visit x12. 

The insurer denied D8080 Braces, D8670 Monthly Visit x12.  The denial has been overturned. 

The proposed treatment is medically necessary. 

The patient is a pediatric female requesting orthodontic benefits with monthly visits. The patient has a Class I skeletal malocclusion with Class II canines. There is moderate upper and lower crowding.  The prior denial was due to a handicapping index score of seven. 

The patient has an anterior crossbite (reverse bite) between teeth #10, #22 and #23 with gingival attachment loss. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this and the monthly visits are to follow up and make sure the treatment is progressing properly. The case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient presented with right lower quadrant (RLQ) abdominal pain. He was afebrile and the vital signs were stable. The surgical consult notes reports that there were no peritoneal signs. There was no leukocytosis. A computed tomography (CT) scan showed the presence of acute appendicitis. An open appendectomy was performed. He tolerated the procedure well and no complications were reported. 

Medical necessity was determined using Milliman Care Guidelines (MCG) guideline MG-GAS for Gastroenterology. A suspected acute intra-abdominal process is an indication if it is associated with hemodynamic instability or peritoneal signs such as a rigid abdomen and rebound tenderness. Nonoperative management of acute appendicitis is also an indication for admission if there is a hemoperitoneum. In this case, the patient did not have peritoneal signs on the surgeon's examination or a hemoperitoneum. 

This patient had acute appendicitis without a fluid collection or perforation. The appendectomy could have been performed as an ambulatory procedure. After the surgery the patient did well, and no complications were reported. He did not meet MCG criteria for admission under the MCG guideline for Gastroenterology. 

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 Inpatient Admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Prolonged pre-C-section monitoring.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is modified.

The patient was admitted at 27 weeks and 3 days of gestation for prolonged monitoring before her cesarian (C) section. She has a history of a fetal anomaly of sacrococcygeal teratoma (SCT). 

She underwent a C-section delivery.  Her postpartum course was uneventful, and she was discharged home.

Sacrococcygeal tumors range in size and severity. Most of them feed on blood. This makes the tumor grow fast and the heart to work harder. It also may increase amniotic fluid, causing it to build up in other areas of the body. When this occurs, the fetus can develop hydrops. This is a condition that can lead to heart failure and endanger the lives of both the mother and baby. 

Prenatal diagnosis and close monitoring have improved outcomes for fetal sacrococcygeal teratoma (SCT), but overall perinatal mortality remains high. Estimates of perinatal mortality for prenatally diagnosed SCT range from 25 to 50 percent when cases of pregnancy termination, intrauterine death, and neonatal death are included. Potential perinatal complications include preterm labor, spontaneous tumor hemorrhage or rupture, and maternal Mirror syndrome (maternal edema and hypertension mirroring fetal hydrops).

In selected high-risk sacrococcygeal teratoma (SCT) fetuses, early delivery and ex utero surgery are an option. They suggest Cesarean delivery, using an ex utero intrapartum therapy (EXIT) procedure when possible, for high-risk sacrococcygeal teratoma (SCT) after 27 to 28 weeks is recommended. 

It is obvious from the above that this is a very specific case, and admission with very close monitoring with immediate intervention was medically necessary and standard of care.

Admission on was medically necessary. However, after the c-section, the patient was stable and could have been discharged on day 5. There was no medical reason for continuous admission, and the continuous admission day 6 and day 7 was not medically necessary.

Based on the above, the insurer's denial must be modified. 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 the inpatient stay from day 1 to day 5 is substantiated. However, continuous admission for day 6 and day 7 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other - Shortness of Breath
Treatment: Inpatient Admission
The health plan denied: Inpatient admission
The determination is: Overturned

The patient is a female who was admitted to the hospital for new onset diabetes and asthma exacerbation. She has a history of asthma and obesity. On presentation, the patient had dyspnea that woke her up from sleep. She has no history of hospital stays from asthma. She was having new onset polyuria and polydipsia. She was started on bronchodilators. The patient did not require oxygen. Labs noted a potassium of 5.7, a sodium of 131, a creatinine of 1.24, and a glucose of 708 on admission. These significantly improved on the day of discharge. The patient was started on insulin, and her blood sugar improved. The patient's condition improved and was stable at discharge.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient hospital admission was medically necessary for this patient. The patient does meet medical necessity for the acute inpatient level of care per current literature and standard of care. According to the National Asthma Education and Prevention Program (2007), the Global Initiative for Asthma (GINA), and the British Guideline on the Management of Asthma, the patient did appear to have an asthma exacerbation, but more concerning, the patient had severely elevated blood sugar and potassium level where she was at risk of abnormal heart rhythm and decompensation. The patient would not have been appropriate for an alternate level of care for the duration of the admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Headaches
Treatment: Emgality Pen 120 milligrams per milliliter (mg/ml) Pen Injector
The insurer denied: Emgality Pen 120 milligrams per milliliter (mg/ml) Pen Injector
The denial is overturned.

The patient is a teenaged female with migraines who has previously tried amitriptyline, fluoxetine, magnesium, escitalopram, ibuprofen, Cambia, almotriptan, and lasmotidan. She is currently on Emgality with sustained improvement in her migraines. The provider wishes to continue Emgality. The request was previously denied as the patient is not over the age of 18.

The proposed treatment is medically necessary.

This medication should be covered as the patient has migraines and it is recommended by Szperka and colleagues that anti-calcitonin gene-related peptide (CGRP) (which Emgality is) be used in adolescents after trial of other migraine medications, which is the case here. Additionally, the patient has had improvement on Emgality and discontinuing it would make her migraines significantly worse. Lastly, there is data that shows that insurance-driven medication changes negatively affect patient outcomes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy, vaginal bleeding. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

In this case, the patient is a pregnant female who presented at 32-2/7 weeks gestational age with no prenatal care and prior history of placental abruption with history of D&C (Dilation and curettage) on two occasions. She was a user of marijuana and tobacco (smoking). She also had history of chlamydia and fibroids. At presentation, the patient reported painless vaginal bleeding. She denied leaking of fluid and reported positive fetal movement. 

The inpatient hospital stay was not medically necessary. 
In this case, the patient was noted to have a singleton gestation at 32-2/7 weeks gestation with threatened preterm labor. There was a cervical exam on admission to document the cervix as closed and long by the physician. However, given preterm contractions with vaginal bleeding reported, a plan was made for magnesium for neuroprotection and steroids (course of betamethasone). The fetal monitoring was reported as normal and reassuring with a singleton gestation that was normally grown by ultrasound. The patient completed magnesium sulfate without complications until she desired discharge to home against medical advice. There was completion of one dose of betamethasone for fetal lung maturity (she was requested to come back for the second dose as she was leaving against medical advice). The patient had a trial of tocolysis that was successful and without complications with the magnesium sulfate. In this case, the care rendered would have been appropriate at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The health plan's determination is overturned in part. A 2 day stay was appropriate. 

The patient is a male with past medical history (PMH) of seizure disorder and non-compliance with AEDs (anti-epileptic drugs), hypertension (HTN), and traumatic brain injury (TBI) who was admitted with complaints of (c/o) suffering from a seizure. Vital signs were unremarkable. Physical exam was notable for no apparent distress (NAD). Lab work was notable for white blood cell count (WBC) 12.6, and a negative urine culture. A chest x-ray (CXR) showed no acute pathology, computed tomography (CT) head showed right parietal encephalomalacia, and magnetic resonance imaging (MRI) brain showed no acute changes. 

The inpatient hospital admission was medically necessary for 2 days. This patient presented with altered mental status and confusion after repeated seizures due to non-compliance with anti-seizure medications. The patient was at risk of subsequent seizures and was clearly documented to be altered on admission, which did not immediately resolve.

However, day 2, the reviewed documentation states that the patient was alert and oriented to person, place and time, that the neurological examinations were within normal limits, and there was no acute worsening during the hospital stay. There were no new focal neurologic deficits. Imaging was negative for acute injury or disease, and the patient was not comatose or in severe alteration in mental status. There was no severe dehydration, acute psychiatric illness or problem, disruptive behavior, other acute coexisting illnesses, or otherwise clinical instability. This patient was treated with AEDs and clinical observation and was monitored for repeat seizures, both of which could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Class I occlusion
treatment: braces
The insurer denied braces. The health plan's determination is upheld. 

The patient in question is a male with a Class I occlusion with 3 millimeter (mm) overbite and 2mm overjet. He has minor maxillary and mandibular crowing. He is treatment planned for braces to correct his malocclusion. 

There is no medical reason to correct his malocclusion with braces. While the patient is crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with skeletal Class I occlusion. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Braces are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Bilateral lower extremity pain.
Treatment:  Inpatient admission.
The insurer denied coverage for inpatient admission.  
The denial is upheld.

This is the case of a patient with a history of hypertension, who presented to the emergency department (ED) with complaints of bilateral lower extremity pain. The patient's magnetic resonance imaging (MRI) revealed L4-L5 (lumbar) disc desiccation, large central disc herniation, and severe thecal desiccation. 

Diagnostic labs were significant for creatinine kinase (CK) 1147. The patient was admitted and underwent a laminectomy with discectomy with intraoperative monitoring (IOM). 

The medical record shows the patient had recurrence of his back and leg pain. He was ambulatory in ED. His physical examination failed to show objective neurologic deficit. His imaging study showed a herniation but no evidence of root/cord compression. His surgical procedure was non-complicated and of limited duration. His post-surgical course was satisfactory. His vital signs were stable. He did not have evidence of bleeding. There were no neurologic findings. He did not require additional imaging nor subspecialty consultation. The post-surgical plan included "discharge planning when cleared" on each visit.

These findings do not substantiate necessity for the inpatient admission and continuance. The services could have been provided at a lower level of care. The Milliman Clinical Guidelines (MCG) Criteria for Inpatient Services were not met.

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 hospital admission is not substantiated.