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

Diagnosis: Puberty
Treatment: Lupron Depot-PED 30 milligrams (mg) (Pre-service)
The insurer denied the Lupron Depot-PED 30 milligrams (mg) (Pre-service)
The denial is upheld. 

This patient is a female diagnosed with central precocious puberty (CPP). This request is for Lupron depot. 

As reported, the patient states that she does not feel that there likely was both pubic hair and breast development that occurred prior to her eighth birthday. It was a very small amount and over time, it has been progressively increasing the last year. Her bone age, is 1.5 years advanced compared with her chronological age (CA). 

The patient's estradiol was ten; follicle stimulating hormone (FSH) was 3.04 (0.72-5.33); and luteinizing hormone (LH) was one.

No, the proposed treatment is not medically necessary.
The definition of precocious puberty is children who have the onset of secondary sexual characteristics younger than age eight in girls and younger than age 9.5 in boys [1-3]. Central precocious puberty (CPP) is diagnosed using a basal luteinizing hormone (LH) of greater than (>) 0.3 or  stimulation testing with a gonadotropin-releasing hormone (GnRH) analog such as leuprolide showing a pubertal response defined as an luteinizing (LH) greater than (>) five and estradiol greater than 40 [4]. Central precocious puberty (CPP) is treated with gonadotropin-releasing hormone (GnRH) agonists [5-10] such as Lupron [11] and supprelin [12]. 

The Food and Drug Administration (FDA) indication for gonadotropin-releasing hormone (GnRH) agonists is for use in central precocious puberty (CPP). In addition when used for central precocious puberty (CPP) the Food and Drug Administration (FDA) recommends discontinuation of gonadotropin-releasing hormone (GnRH) agonists before age 11 for females and before age 12 for males [11]. This is consistent with accepted recommendations for discontinuation of gonadotropin-releasing hormone (GnRH) agonist therapy at a bone age of 12 in girls and 13 years in boys [2, 4-7]. 

The patient has puberty based on the luteinizing hormone being greater than 0.3; however, it is not precocious.  The onset of puberty was not before age eight. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary. The health plan acted reasonably, with sound medical judgment, as the request is not medically necessary as described above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient presented to the emergency department (ED) with a 1 day history of right upper quadrant pain and epigastric pain associated with nausea and vomiting, and unable to tolerate anything by mouth (including water).

Acute cholecystitis is a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year, and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 3, 4] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. [4] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [5]

Per clinical documentation, this patient presented with a one-day history of right upper quadrant and epigastric abdominal pain. There was associated nausea with vomiting. Vital signs in the ED were within normal limits. An ultrasound with acute on chronic cholecystitis. Liver function tests were normal. White blood cell count was 9.85. The patient was taken to the operating room for a laparoscopic cholecystectomy. There were no reported complications. There is no clinical evidence of inadequate pain control or oral intolerance postoperatively. The patient was discharged. According to clinical documentation, inpatient admission was not medically necessary. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. Inpatient admission is not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission upheld. Medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia

Treatment: peroral endoscopic myotomy [POEM] (procedure helps permanently relax tight esophageal muscles and open up areas of the esophagus that have narrowed).

The insurer denied coverage for POEM (procedure helps permanently relax tight esophageal muscles and open up areas of the esophagus that have narrowed).

The denial is overturned

This is the case of an adult male patient with a past medical history of gastroesophageal reflux disease (GERD) who has been diagnosed with achalasia. The patient had a Telehealth visit with gastroenterologist. According to the visit notes, a detailed discussion with the patient regarding achalasia and various treatment options. The patient wished to proceed with peroral endoscopic myotomy (POEM).

Per Werner YB. et al., "POEM has a low rate of serious adverse events (SAEs); minor adverse events (AEs) are more frequent but lack a consistent definition. Therefore, based on our experience and literature analysis, we suggest a classification of AEs for POEM." 

Per Ngamruengphong S, Inoue H, Ujiki MB, et al., "POEM is safe and effective for patients with achalasia who were not treated successfully by prior Heller's myotomy (HM). Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups." 

The POEM procedure is a medically necessary option in order to relieve the patient's swallowing difficulties related to achalasia. The POEM procedure for the treatment of achalasia is a minimally invasive procedure performed endoscopically. The surgical procedure is not experimental/investigational, based on recent and relevant peer literature. It is an endoscopic method for performing a myotomy of the lower esophageal sphincter (LES) and is being studied for the treatment of achalasia. POEM is a form of natural orifice transluminal endoscopic surgery. POEM uses available laparoscopic instrumentation and, as a surgical procedure, is not subject to regulation by the U.S. [United States] Food and Drug Administration (FDA). The POEM technique has been successfully used to treat spastic esophageal disorders (eg, spastic achalasia, distal esophageal spasm, jackhammer esophagus, or nutcracker esophagus) and severe gastroparesis refractory to medical therapy. Therefore, the POEM surgical procedure can be considered medically necessary for this patient, based on recent and relevant peer literature.

The requested service is likely to be more beneficial than any of the standard treatments/ procedures for this patient. 

The insurer's denial of coverage for peroral endoscopic myotomy (POEM) (procedure helps permanently relax tight esophageal muscles and open up areas of the esophagus that have narrowed) is overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia

Treatment: peroral endoscopic myotomy [POEM] (procedure helps permanently relax tight esophageal muscles and open up areas of the esophagus that have narrowed).

The insurer denied coverage for POEM (procedure helps permanently relax tight esophageal muscles and open up areas of the esophagus that have narrowed).

The denial is overturned

This case involves an adult male with a diagnosis of achalasia. Past diagnostic work-up included an endoscopy that revealed dilated and tortuous esophagus with functional narrowing at the gastroesophageal junction suggestive of achalasia. The patient had also undergone an esophagram that revealed standing column of contrast up to the level of the thoracic inlet suggestive of achalasia. In addition, an esophageal manometry revealed elevated integrated relaxation pressure measuring 19 millimeters of mercury (mmHg) with pan esophageal pressurization suggestive of type II achalasia. The patient had been referred for peroral endoscopic myotomy (POEM). Subjective complaints included regurgitation of food and liquid, occasional wheezing, and esophageal reflux disease. Treatment included omeprazole and diet modification. The patient was recommended for surgical intervention.

According to the current peer-reviewed medical literature and the American Gastroenterology Association, if the expertise is available, POEM should be considered as primary therapy in patients with achalasia. In addition, if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. POEM does not require approval from regulatory bodies. However, this patient is a good candidate for POEM as it is the best available treatment for this patient at this time. The adverse risks are not increased over standard treatment/services. 

The requested service is likely to be more beneficial than any of the standard treatments/ procedures for this patient. 

The insurer's denial of coverage for peroral endoscopic myotomy (POEM) (procedure helps permanently relax tight esophageal muscles and open up areas of the esophagus that have narrowed) is overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia

Treatment: peroral endoscopic myotomy [POEM] (procedure helps permanently relax tight esophageal muscles and open up areas of the esophagus that have narrowed).

The insurer denied coverage for POEM (procedure helps permanently relax tight esophageal muscles and open up areas of the esophagus that have narrowed).

The denial is overturned

The patient has a diagnosis of achalasia. Esophageal manometry revealed type 2 achalasia. The patient desires a minimally invasive procedure and POEM has been recommended.

UpToDate has an article titled "Peroral endoscopic myotomy (POEM)". The article states that POEM is highly effective for achalasia.

A Summary of 14 studies showed clinical success in 82 to 100 percent of patients. In studies comparing POEM with a surgical myotomy, both procedures were equally successful in controlling symptoms. The POEM procedure also had a lower rate of severe adverse events, although more esophageal reflux was present.

This patient has achalasia, and the POEM procedure has been shown to improve health outcomes. The Food and Drug Administration (FDA) has approved the devices that are used for POEM. The patient is a good candidate for the procedure as his manometry showed that he has achalasia. There are several treatment options for achalasia both surgical and non-surgical. POEM has been shown in multiple clinical studies to be beneficial in achalasia. It is less invasive than a surgical myotomy and is associated with fewer severe adverse events. The denial is reversed.

The requested procedure is likely to be more beneficial than any other standard health service.

The insurer's denial of coverage for peroral endoscopic myotomy (POEM) (procedure helps permanently relax tight esophageal muscles and open up areas of the esophagus that have narrowed) is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache and Numbness of the Right Face and Right Sided Weakness.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who presented to the emergency ward with the complaint of vertigo, headache and right hemi-body paresthesia. Computed tomography (CT) of the brain and neurological examination were normal at presentation. She was admitted for possible stroke. After admission, magnetic resonance image (MRI) of the brain was negative for acute stroke.

No, the proposed treatment was not medically necessary.
The patient had a normal neurological examination at presentation. Current transient ischemic attack (TIA) risk stratification guidelines do not support acute inpatient level of care based on the clinical presenting symptoms and examination findings (Mendelson and Prabhakaran). There were no concerning features in regards to her headache complaints to warrant acute inpatient level of care. The diagnostic studies, monitoring, neurological evaluation and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

The female pediatric patient was presented by ambulance transfer from another facility with a one day history of abdominal pain, nausea, and fever. The patient was originally seen at another facility. White blood cell count at the outside hospital was 15,100 with left shift (85% neutrophils). Computed tomography (CT) scan at the transferring facility diagnosed the patient with appendicitis without evidence of perforation. The patient received intravenous antibiotics at prior to transfer. 

The patient was admitted to acute inpatient level of care. The patient underwent laparoscopic appendectomy later that day in the early afternoon. The operative report describes a straightforward appendectomy for acute non-perforated appendicitis. The procedure skin-to-skin was 71 minutes in duration. Postoperative orders included clear liquid diet to be advanced as tolerated. The patient was discharged within hours of completion of the procedure.  The acute inpatient level of care was denied as not medically necessary. 

The hospital, through its nurse agent, has appealed the denial of the acute inpatient level of care. The agent states the patient required preoperative optimization, continuous intravenous hydration, surgical intervention and pain management. The agent states that the treatment could not have been rendered at a lower level of care or in an outpatient setting. The agent cites Milliman Care Guidelines of Pediatric Admission Criteria requiring emergency surgery and Ambulatory Surgery Exceptions that the patient required an emergent procedure and the preoperative situation, condition or finding that warrants inpatient stay.

No, the inpatient level of care was not medically necessary. The care rendered did not require acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet, overbite, and anterior crowding

Treatment: Comprehensive orthodontics (braces)

The insurer denied coverage for comprehensive orthodontics (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 notes as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, and anterior crowding. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index, attaining 26 total points. 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, scoring only 11 points on the HLD index.

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, the use of an orthodontic index, the Report HLD modeled after the Handicapping Labio-Lingual 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 completed the second portion of the index arriving at 26 points to justify orthodontic care. The reviewer concurs with the index completed by the orthodontist attaining a total of 26 points on the HLD index (7 overjet, 5 overbite, 1 anterior crowding, 4 labiolingual spread) which meets and attains the threshold of 26 points to support orthodontic care.

Regarding the validity of the Handicapping Labio-Lingual Index, it has been shown through scientific scrutiny in peer-reviewed journals that this methodology for assessing orthodontic need is a valid approach. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

Based on the review of the submitted records, there was sufficient evidence to support that comprehensive orthodontics (braces) are considered medically necessary treatment. 

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

The insurer's denial of coverage comprehensive orthodontics (braces) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Hip Severe Osteoarthritis.

Treatment: Emergent inpatient admission.

The insurer denied coverage for emergent inpatient admission.

The denial is upheld.

This is the case of an adult male with a medical history of right hip severe osteoarthritis. The patient underwent a right total hip replacement (THR) with robotic assistance. He was admitted and received postoperative intravenous (IV) antibiotics and physical therapy (PT). The patient was discharged home with home care services.

The medical records show the patient's procedure and post surgical course were not complicated. He underwent a right total hip replacement without problem. The procedure was over an one hour with exit to recovery room (RR). His blood loss was expected. His vital signs were stable. There was no evidence of fever nor infection. He was able to tolerate oral pain medications. There were no problems with his wound. He was able to proceed with physical therapy (PT) and demonstrated independence. He was also status post THR on left. 

He did not require treatment for underlying medical conditions. The record noted "DC [discharge] planning and home". 

These findings do not substantiate necessity of admission and level of service provided. There was no reason a lower level of care could not have been given. 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 emergent inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid Obesity.

Treatment: Full hospital admission.

The insurer denied coverage for full hospital admission.

The denial is overturned.

The patient is a female with a past medical history of morbid obesity and anemia who presented to the Hospital for Bariatric Surgery. The patient underwent a laparoscopic gastric band which she tolerated well. Postoperatively, the patient experienced chest pain. She was changed from observation to inpatient with a chief complaint of chest pain. Cardiology and Pulmonary were consulted. The D-dimer was elevated. A Computed tomography pulmonary angiography (CTPA) was obtained and revealed no evidence of pulmonary embolism. She received intravenous (IV) pain medication. The patient's chest pain and shortness of breath resolved, and she was discharged.

The health plan did not act reasonably and with sound medical judgement and in the best interest of the patient.  The full hospital admission is considered medically necessary for this patient.

This patient is a morbidly obese patient who underwent abdominal surgery for over 3 hours. She is at high risk for pulmonary and cardiac complications.  She developed chest pain for which the differential diagnosis was deep vein thrombosis (DVT), or myocardial infarction (MI). She also required IV pain medication. Therefore, inpatient admission was indicated to evaluate for postoperative complications as well as for pain control.

Chang, S. H., et al. assesses the major complications associated with bariatric procedures, including anastomotic leak, myocardial infarction and pulmonary embolism. "Among all patients, mortality rate following anastomotic leak, myocardial infarction and pulmonary embolism was 0.12% [percent], 0.37% and 0.18%, respectively." 
  
The insurer's denial of coverage for the full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension

Treatment: Bystolic 10MG OR TABS

The insurer is denied coverage for Bystolic 10MG OR TABS

The denial is overturned. 

This male patient has a history of hypertension, coronary artery disease, and hyperlipidemia.

Bystolic is a beta-adrenergic blocking agent indicated for the treatment of hypertension, to lower blood pressure. The patient had been on Bystolic since 2018 with adequate results. He had previously tried and failed carvedilol, atenolol, Norvasc, and metoprolol. Given the duration of use and results as well as the list of previously ineffective medications, continuation of Bystolic 10 mg would be considered medically necessary treatment for the patient's condition.

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

The carrier's denial of coverage for the Bystolic 10MG OR TABS is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fibroids. 
Treatment: Inpatient admission. 

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

According to the medical records, the patient is an adult female who underwent surgery. The procedure was an abdominal myomectomy that was done under general anesthesia and via an open abdomen (Pfannenstiel incision). Two intramural fibroids were found and removed. Estimated blood loss was 300 cubic centimeters (cc). The patient was obese, weighing 300 pounds. She recovered without complications and was discharged from the hospital. 

"Conclusion(s): Operative time (ORT) was predictive of complications for both minimally invasive and abdominal myomectomies. Despite longer ORTs, minimally invasive procedures generally had superior 30-day outcomes up to 270 minutes. Careful patient counseling and preparation to increase surgical efficiency should be prioritized for either approach." (Vargas, M. V. et al.) 

A myomectomy can sometimes be done on an outpatient basis, but that would be via laparoscopy, not via an open abdominal incision (laparotomy) as in this case. An abdominal myomectomy requires general anesthesia as an inpatient, with a normal recovery time of three to five days. (This patient was actually discharged on postop day three.) This patient would not be an ideal candidate for laparoscopic hysterectomy because of her obesity (300 pounds). Therefore, the inpatient admission is considered medically necessary for this patient. 

There is no question that this procedure could not have been done on an outpatient basis. The surgery involved an abdominal laparotomy (not laparoscopy) which is incompatible with an outpatient procedure. 

The health care plan did not 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 overturned. Medical necessity is substantiated.