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

Diagnosis: Atypical Chest Pain

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient is a male that presented to the hospital complaining of lower extremity swelling, shortness of breath and chest pain. He had been released from another hospital three days prior to presentation. Past medical history was significant for immunocompromised status, chronic obstructive pulmonary disease, cardiomyopathy with a left ventricular ejection fraction of 41%, chronic chest pain and drug abuse. Upon presentation, the patient had stable vital signs. Physical examination revealed clear lung fields lower extremity swelling. Chest x ray revealed no pulmonary edema or infiltrate. Urine toxicology was positive for cocaine, opiates and cannabinoids. Electrocardiogram revealed no evidence of acute ischemia and serum troponin was not elevated. The patient was admitted to the hospital to rule out acute coronary syndrome.

This patient presented with atypical chest pain and no evidence of active ischemia on ECG.(1) Risk assessment of patients presenting with chest pain and no significant sinus tachycardia changes on electrocardiogram was reviewed by Hedayati et al. (2,3) These studies are based on patients that present with an elevated clinical suspicion of an acute coronary syndrome. Thus, a patient that has a past history consistent with a high risk HEART (History, electrocardiogram, Age, Risk Factors, Initial troponin) score is not truly at risk for subsequent cardiac sequelae. Numerous studies have demonstrated that work up for such patients can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care.(4,5) They found no significant difference in outcome at 30 days between the two groups. Fernando Bellolio et al. noted that patients presenting with chest pain,  that were managed in an observation unit, had similar 30 day myocardial infarction rates as those admitted to the hospital.(5)  

Admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been managed at a lower level of care. 

The health care plan did act reasonably and with sound medical judgment and 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: Atopic Dermatitis.
Treatment: Dupixent Syn 300.

The insurer denied Dupixent Syn 300. The health plan's determination is upheld.

The patient is a female with severe atopic dermatitis associated with lichen simplex chronicus from scratching. The patient has scattered hyperpigmented macules and patches of the upper extremities, back, and hands. The patient has tried and failed topical ammonium lactate, clindamycin, triamcinolone, fluocinolone, mometasone, fluocinonide, hydrocortisone, and betamethasone, as well as oral hydrdoxyzine and the biologic agents Humira and Remicade.

Health plan coverage of Dupixent Syn 300 is under review.

Dupixent Syn 300 is not medically necessary for this patient.

The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors, and/or standard first-line oral medications, such as Methotrexate, Azathioprine, or Mycophenolate Mofetil, that are proven to be effective in the treatment of moderate to severe atopic dermatitis. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, as per current medical literature reviews, the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Musculoskeletal/Orthopedic. 
Treatment: Inpatient. (custodial care)
The insurer denied: custodial care (long term care). 
The denial is partially overturned.

The patient is a female with recent medical history significant for right 3rd and 4th metatarsal diabetic ulcer complicated by osteomyelitis who was admitted to a Rehabilitation Center. Long-term placement became effective. The subject under review is whether custodial care (long term care) was medically necessary for this patient.

The health plan's determination is partially overturned.

Custodial Care (Long Term Care) was medically necessary for this patient in part.
The patient is a female with recent medical history significant for right 3rd and 4th metatarsal diabetic ulcer complicated by osteomyelitis. Review of documentation noted the patient required maximum assist (MAXA) for bed mobility, was dependent with sit to stand transfers, required maximum assistance with hygiene/grooming and lower body dressing. She was also dependent for bathing. This level of assistance supports the need for 24 hour care and, therefore, Custodial Care/Long Term Care was medically necessary and appropriate. This opinion is further supported by the nursing note  which noted that the patient found on the floor of her room. Documentation noted that resident said she had been trying to get back to bed without assistance when her knees buckled, and she fell. Continued Custodial Care/Long Term Care, though, is not supported for all dates. The reason being that the patient was stand by assist (SBA) for bed mobility, contact guard assist (CGA) with transfers and ambulating 50' using wheeled walker (WW) with minimal assistance (MINA). Additionally, the patient was now CGA bathing, set-up for hygiene/grooming and CGA for lower body dressing. She had also progressed from dependent for toileting to CGA. Lastly, therapy noted that patient lived with family and while it did note that the home was a two story house documentation did not state that there were any stairs required to enter the home and the patient was supervision for wheelchair mobility. Therefore Custodial Care/Long Term Care was medically necessary only in part.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Neuromyelitis optica.
Treatment: Enspryng 120mg/ml SC SOSY.
The insurer denied the Enspryng 120mg/ml SC SOSY.
The denial is overturned. 

The patient is a female with antibody positive neuromyelitis optica (NMO), myasthenia gravis (MG) and spastic hemiplegia. She has been treated with rituximab in the past.

The health plan should cover the proposed treatment.
The patient has antibody positive NMO (neuromyelitis optica) on the documentation provided for review.  The patient has antibody testing that was positive confirming the diagnosis. This medication is FDA approved for the treatment of persons with antibody positive NMO based on data derived from clinical trials (Levy et al., Yamamura et al.).  Therefore, this would be considered a standard of care treatment for this member's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine.
Treatment: Ajovy.
The insurer denied Ajovy. The health plan's determination is upheld. 

The patient is a woman with chronic migraine headaches. Treatment with Ajovy is the subject of this review. The patient was on topiramate for migraine prevention but developed kidney stones. The drug was stopped. She is also treated with lamotrigine.

Ajovy 225 MG/1.5 Auto Injector is not medically necessary.
The formulary alternatives include a CGRP (calcitonin gene-related peptide) inhibitor. The provider notes that this medication is non-preferred due to side effects and inefficacy. Both Ajovy and Aimovig are CGRP antagonists. Both Ajovy and Aimovig have similar side effect profile, which is local injection site reactions. Aimovig may cause constipation. However, there are no studies to show that Ajovy is superior to Aimovig for migraine prevention. Data are lacking for this comparison. As such, Ajovy cannot be medically necessary over Aimovig. Both are Food and Drug Administration (FDA) approved and literature supported for treatment of chronic migraine. The patient does not have an absolute contraindication to Aimovig. The requested drug is not superior to Aimovig.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pregnancy. 
Treatment: Prenatal Testing (CPT 81420) Fetal Chromosomal Aneuploidy. 

The insurer denied the Prenatal Testing (CPT 81420) Fetal Chromosomal Aneuploidy. 
The denial is overturned. 

The patient is a female who is pregnant with a singleton gestation and underwent cell-free deoxyribonucleic acid (DNA) testing. No other clinical information is submitted for review. 

Yes, the proposed treatment is medically necessary. 

Prenatal screening for trisomy 21 (Down syndrome), trisomy 18, trisomy 13, and common sex chromosome aneuploidies can be performed using cell-free DNA (cfDNA) in the maternal circulation. It is the most sensitive screening option (highest detection rate [DR]) for trisomy 21, 18, and 13 and the most specific. Performance varies by trisomy. Based on multiple meta-analyses, the consensus highest detection rate (DRs) and false-positive rates (FPRs) in successful tests are as follows: 

Trisomy 21  DR (highest detection rate) 99.5 percent, FPR (false-positive rates) 0.05 percent, 

Trisomy 18  DR (highest detection rate) 97.7 percent, FPR (false-positive rates) 0.04 percent, 

Trisomy 13  DR (highest detection rate) 96.1 percent, FPR (false-positive rates) 0.06 percent. 

As per ACOG (American College of Obstetricians and Gynecologists), "Prenatal genetic screening (serum screening with or without nuchal translucency [NT] ultrasound or cell-free DNA screening) and diagnostic testing (chorionic villus sampling [CVS] or amniocentesis) options should be discussed and offered to all pregnant women regardless of maternal age or risk of chromosomal abnormality. After review and discussion, every patient has the right to pursue or decline prenatal genetic screening and diagnostic testing". 
Based on the above, the proposed treatment is medically necessary. 

Cell-free DNA testing is routine standard of care and recommended by obstetrical societies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain. 
Treatment: Outpatient Procedure (0275T) - Minimally Invasive Lumbar Decompression (Mild; Vertos Medical Inc.). 

The insurer denied coverage for the Outpatient Procedure (0275T) - Minimally Invasive Lumbar Decompression (Mild; Vertos Medical Inc.). 

The denial is upheld. 

This is a female patient with chronic low back pain, intervertebral disc protrusions causing central stenosis at multiple levels in the lumbar region, left lumbar radiculopathy, long term current use of opiate analgesic, lumbar spondylosis, and hypertrophy of the ligamentum Flavum. She has failed conservative measures including physical therapy, non-steroidal anti-inflammatory medications and epidural steroid injections.  Her pain physician has recommended the Minimally Invasive Lumbar Decompression (MILD) procedure. She has not had any procedures on her protruding discs or laminectomy. 
   
Messiah et al. (1) reviewed the evidence supporting the MILD procedure and concluded: "there is not enough high-quality evidence to make a recommendation regarding the use of MILD versus interspinous spacers for neurogenic claudication. There remains a need for high-quality evidence regarding the efficacy of different conservative treatments, interventional procedures, and surgical outcomes in patients with neurogenic claudication in LSS [lumbar spinal stenosis]." 

Jain et al. (2) reviewed the literature and noted two ongoing studies: one is the Motion study which is a multicenter randomized controlled trial (RCT) comparing the MILD procedure together with conventional medical management to conventional medical management alone in the treatment of LSS in a cohort of 150 patients [52]. Another ongoing study is the MILD Percutaneous Image-Guided Lumbar Decompression: A Medicare Claims Study [53]. This is a prospective longitudinal study comparing outcomes of Medicare beneficiaries treated with MILD versus those treated with interspinous process decompression at the 24-month follow-up. Primary outcome measures will include the rate of surgery or minimally invasive intervention in the patient post index procedure and the rate of participants with harms associated with the index procedure. 

In summary, this is a promising therapy, but it is still the subject of on-going clinical trials and its place in the therapy of lumbar spinal stenosis is still uncertain. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the Outpatient Procedure (0275T) - Minimally Invasive Lumbar Decompression (Mild; Vertos Medical Inc.) is upheld. Medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Innopran XL Capsules. 
The denial is upheld in whole.

The patient is a female with a past medical history significant for palpitations, premature ventricular contractions, and possible atrial fibrillation. Records show that her treating physician initially treated the patient with metoprolol succinate 25 milligrams (mg) daily. However, the patient failed this medication and continued to remain symptomatic. Therefore, the patient was switched to the non-formulary alternative beta-blocker, propranolol sustained release (SR), which has been effective at controlling the patient's symptoms. A prescription benefit exception request has been submitted for coverage of propranolol SR but has been denied because it did not meet prescription benefit exception criteria. The subject under review is whether the formulary drug will be ineffective for this patient.

The health plan's determination is upheld.

Based on the patient medical history provided, there are other alternative formulary medications not previously prescribed to this patient, such as propranolol extended release (ER), which will likely be as effective as well as medically appropriate compared to the non-formulary drug, propranolol SR. In addition, there is no documentation that patient has tried and failed alternative beta-blocker therapy, other than metoprolol succinate, which is required according to prescription benefit exception criteria.
Finally, based on the American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) guideline for the management of patients with atrial fibrillation, the listed formulary beta-blockers can be used and would be appropriate for medical management in this case (1).
There are alternative medications that would be likely to be effective and would be medically appropriate in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperlipidemia. 
Treatment: Repatha. 

The insurer denied Repatha. The health plan's determination is upheld. 

The patient is a man with hyperlipidemia. He has a family history of premature coronary artery disease (CAD) and per the appeal letter, he was unable to take statins due to elevated liver function tests (LFT) and increased risk for myalgia. Also, he was on chronic colchicine for recurrent pericarditis, and there was concern for possible interaction with colchicine and statins. Per the notes, he had tried ezetimibe, but it was stopped due to elevated LFTs. His low-density lipoprotein (LDL) was 244. 

Repatha, is not medically necessary for this patient. 

The patient does have hyperlipidemia, with LDL reported to be 244. However, there is no documentation of clinical atherosclerotic cardiovascular disease or documentation of familial hypercholesterolemia based on Dutch Lipid Network Criteria or Simon Broome criteria. 

Per the current American College of Cardiology (ACC) guidelines, PCSK9 (Proprotein convertase subtilisin/kexin type 9) inhibitors (Praluent or Repatha) are indicated for very high risk atherosclerotic cardiovascular disease (ASCVD) patients only after maximal statin and ezetimibe have been tried. In this case, very high risk ASCVD has not been established, and statin trials not documented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Back Pain.
Treatment: Fusion Sacroiliac Joint Through the Skin or Minimally Invasive Using Guidance (CPT-27279), Pre-service.
The insurer denied the Fusion Sacroiliac Joint Through the Skin or Minimally Invasive Using Guidance (CPT-27279), Pre-service.
The denial is overturned.

The patient is a female with history of neck and low back pain. The patient had a previous microdiscectomy and fusion in the past. The patient takes non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, and robaxin for pain. The first sacroiliac (SI) joint injection provided 50% improvement for several weeks and second injection was not documented. Exam reveals positive (+) distraction, compression, and thigh thrust. X-ray showed mild hip degeneration and sacroiliitis versus degenerative changes. The patient was recommended for right sacroiliac (SI) joint fusion.

Yes, the proposed treatment is medically necessary.
To be a candidate for sacroiliac (SI) joint fusion, according to the major spine societies, patients must meet several criteria which include documentation of positive clinical findings suggestive of sacroiliac joint pathology including positive FABER (flexion abduction external rotation) test, compression test, and Gaenslen's test, and Patrick's test. Next, the imaging studies must not demonstrate any other cause for the patient's pain. The patient must have an adequate trial of conservative therapy, and finally, the patient must have two separate sacroiliac joint injections which provide 75 to 80% relief with each injection.

This patient has met the criteria including having attempted two injections which have demonstrated significant improvement.  Therefore, the surgery is medically necessary.

The patient meets the most common accepted standards for the proposed surgery. Specifically, the patient did have an adequate response to two separate sacroiliac (SI) injections.  Therefore there is sufficient evidence that the patient has a pain generator in the sacroiliac (SI) joint. For this reason, the health plan did not act with sound judgement to deny the service.  The proposed surgery is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male without medical history. He presented with one day history of abdominal pain.

The patient's ultrasound demonstrated cholelithiasis and cholecystitis.  The WBC (white blood count) was 11.56.  He was started on Ancef and Flagyl, and he was admitted to the hospital.  He underwent laparoscopic cholecystectomy with umbilical hernia repair the next day.

On the following day, the patient was discharged home without complications.

No, the Inpatient admission was not medically necessary.
The patient did not have significant complications postoperatively after laparoscopic cholecystectomy. Therefore, he did not have an indication for inpatient admission.  Preoperatively, he did not have complicating factors requiring inpatient admission.  Therefore, the inpatient admission was not medically necessary.

The health plan denied coverage for inpatient admission because inpatient criteria were not met. The patient did not have significant sepsis, elevated liver function tests, or vital sign changes. Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypertensive urgency
	
Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This female patient has a history of gastroesophageal reflux disease (GERD) who presented to the Emergency Department (ED) for hypertension (HTN). The patient reported that she had her blood pressure (BP) checked at her doctor's office the day prior to presentation and her systolic BP was 200. The patient reported that she was not started on medication by her doctor and was instead advised to go to the ED. In the ED, the patient's vital signs were: BP 201/92, pulse 66, temperature 98.7, respiratory rate 18, and oxygen saturation 99%. The patient also endorsed headache and shoulder pain. She was started on amlodipine 10 milligrams (mg). She was admitted to Telemetry for hypertensive urgency. During the hospital course, the patient's BP was monitored and her systolic BP remained below 180. An echocardiogram was done and was normal. Chest X-ray revealed no acute findings. Electrocardiogram revealed sinus bradycardia with heart rate in the 50s; the patient was reportedly asymptomatic and this was noted as her baseline. The patient was discharged home with instructions for primary care provider follow-up.  

There is no evidence that this patient required an acute inpatient level of care to treat her elevated blood pressure. This should have been initiated in the ED or at an observation level of care, followed by outpatient monitoring and management. Denial of coverage for the inpatient admission is upheld because there is no evidence that this patient was at increased risk for short term adverse cardiovascular events requiring inpatient monitoring and management, based on her clinical presentation and results of testing performed in the ED.

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

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

Diagnosis: Dental Problems-Brace.
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and adjustments for braces for medical necessity. 
The denial was upheld in whole.

The patient is a male with a Class I occlusion with a 4-millimeter (mm) overbite and 6 mm overjet. He has moderate maxillary and mandibular crowding. The provider states he has blocked out mandibular second molars. He has treatment planned for 24 to 30 months of orthodontics with extraction of first premolars to correct his malocclusion.
At issue is the medical necessity of braces and adjustments for braces.

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

The requested health service/treatment of Braces and adjustments for braces, is not medically necessary for this patient.
There is no medical reason to correct the patient's malocclusion with braces. While the patient has moderate crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. His overbite is slightly high but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs that there is any soft tissue damage on this patient.
The patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. If his teeth were aligned, it would provide an aesthetic improvement, but it would not create a medically significant improvement to the patient's health. The provider states that the patient's mandibular second molars are blocked out, but they have a path of eruption according to the provided panoramic radiograph.
Therefore, the requested health service/treatment of Braces and adjustments for braces, is not medically necessary for this patient.