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

Diagnosis: Blood disorder. 
Treatment: Inpatient Hospital. 
The insurer denied the inpatient stay. 
The denial is upheld in whole.

The patient is a female with a past medical history significant for uterine fibroids and iron deficiency anemia who presented to the hospital because of persistent vaginal bleeding. Reportedly, she went to see her obstetrician/gynecologist (OB/GYN) and underwent outpatient ultrasound, which was remarkable for a large uterine fibroid. The patient was recommended to follow-up with an OB/GYN surgeon, but was unable to do so and decided to come to the emergency department (ED).

The patient was admitted to the hospital with a diagnosis of symptomatic anemia secondary to vaginal bleeding due to uterine fibroids. The patient underwent transfusion of 2 units of packed red blood cells. The patient was evaluated by OB/GYN service and started on Provera. During the hospital stay, the hemoglobin and hematocrit (H&H) remained stable after transfusion. The patient was also started on ferrous sulfate for iron deficiency anemia. Since the patient remained in satisfactory clinical condition, she was transitioned to outpatient care.

The subject under review is the medical necessity for the inpatient stay. 

The inpatient stay was not medically necessary for this patient.

According to the nationally accepted standards of care, admission at the acute inpatient level of care is required for patients with anemia and hemodynamic instability, active hemolysis, active bleeding that could not be controlled in the emergency department or during the period of observation, also in cases of severe or persistent altered mental status, recurrent syncope or near syncope episodes, cardiac arrhythmias of immediate concern, acute peripheral ischemia, high-risk low platelet count, acute renal failure, clinically significant symptoms such as heart failure, chest pain, myocardial ischemia, dyspnea. Admission at the acute inpatient level of care is also indicated for patients with anemia who require pulmonary artery catheter or other invasive monitoring, patients who need urgent inpatient surgery, or some other clinical conditions that were not relevant to this clinical case.

Even though she continued to have some vaginal bleeding while in the hospital, per OB/GYN service the degree of bleeding was acceptable for discharge, and the patient did not require any interventions requiring admission at the acute inpatient level of care. Overall, she remained in stable clinical condition.

Taking into consideration these facts, the admission for monitoring was the most appropriate, in order to perform transfusion of packed red blood cells, ensure hemodynamic stability, and come up with a treatment plan that would address her vaginal bleeding. However, this could have been accomplished at a lower level of care status.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Allergic Rhinitis
Treatment: Formulary exception for Dymista
The insurer denied the Formulary exception for Dymista.
The denial is upheld. 

The patient is a female with allergic rhinitis and eustachian tube dysfunction. She has previously used Flonase, mometasone, and nasacort. She has used Azelastin spray alone as well. Each product alone did not provide adequate relief.

No, the health plan should not cover the Formulary exception for Dymista.

The health plan's formulary is such that they prefer the use of three alternatives including mometasone, fluticasone, and Flunisolide or Triamcinolone with Azelastine. The patient has used two of these products. The health plan's preferences are consistent with the standard of care, and they are expected to be at least as safe and efficacious as the requested Dymista for the patient's indication.

In the patient's appeal letter, she references having to use more sprays per day with combinations of medications than she would need to use with Dymista. This would be a convenience factor and not a medical indication.  In regard to the medication lasting, at recommended doses, the spray medications in each bottle should last for one month.

Therefore, given the above, the health plan should not cover the Formulary exception for Dymista.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis. 
Treatment: Otezla 30mg TABLET, Pre-service. 

The insurer denied the Otezla 30mg TABLET, Pre-service. 
The denial is overturned. 

The patient is a female with psoriasis of the scalp and extremities (5% BSA [body surface area]) for whom Otezla is requested. She has tried and failed topical steroids and Vitamin D derivatives. She has been using Otezla samples and is doing well. 

Yes, the treatment with Otezla is medically necessary. 
The health plan offers alternatives that are not appropriate for the patient. 

The patient is not a good candidate for conventional systemic medications due to childbearing age. Therefore, a biologic medication or small molecule like Otezla are medically appropriate. Additionally, she has been on Otezla samples with good results. Discontinuation of treatment may result in a flare. 

Otezla, an inhibitor of phosphodiesterase 4 (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.  (Celgene) Otezla is an oral small molecule inhibitor of phosphodiesterase 4 (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA) as well as the treatment of patients with moderate to severe plaque psoriasis. (Celgene) 

The patient has moderate to severe psoriasis, for which therapy with Otezla is appropriate and medically necessary. 

In view of the above, and since the patient has initiated therapy with Otezla, is doing well, and has not reported any adverse events, it is medically appropriate and necessary to continue the treatment. 

Since the patient has initiated therapy with Otezla, is doing well, and has not reported any adverse events, it is medically appropriate and necessary to continue the treatment. For the patient, this is a continuation of therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cortical age related cataract of the right eye.
Treatment: CPT 65572-RT/59 (corneal relaxing incision for correction of surgically induced astigmatism).

The insurer is denied coverage for CPT 65772 (corneal relaxing incision for correction of surgically induced astigmatism).  The denial is upheld. 

This male patient with a history of anxiety, hyperlipidemia, obstructive sleep apnea (OSA), a cardiac murmur, and astigmatism of the right eye. The patient had a right eye phacoemulsification with intraocular lens implant trifocal femtosecond laser procedure to treat a cortical age related cataract of the right eye.

CPT 65572-RT/59 (corneal relaxing incision for correction of surgically induced astigmatism) was denied.

The operative note indicates a pre-operative diagnosis of "visually significant cataract and corneal astigmatism, right eye." The post-operative diagnosis is the same. The procedure performed was "Femtosecond laser assisted cataract extraction by phacoemulsification with posterior chamber PanOptix trifocal intraocular lens implant and astigmatic incisions, right eye." Review of the report indicates no mention of surgically induced astigmatism. 

CPT 65572-RT/59 is not considered medically necessary, given that the intent of this procedure to reduce the need for reading glasses or contact lenses after surgery.

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 CPT 65572-RT/59 is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dysfunctional uterine bleeding and endometriosis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a history of dysfunctional uterine bleeding and endometriosis, as well as multiple sclerosis (MS), status post (s/p) previous ovarian cystectomies, as well as rectosigmoid resection and ileostomy.  The patient underwent a robotic-assisted total hysterectomy, lysis of adhesions and right salpingectomy, as well as bladder cystectomy. She underwent the surgery and was discharged.

No, the proposed inpatient admission was not medically necessary.

The proposed treatment is not medically necessary since there are no data that outcomes after robotic assisted hysterectomy including lysis of adhesions are better if patients are admitted after the procedure. This is deemed to be an ambulatory procedure and the patient did not have any conditions that would render inpatient level of care after it to be medically necessary. Specifically, the patient did not require conversion to laparotomy, the patient did not have any underlying medical conditions that would require inpatient level of care after the procedure, the surgery was not complicated, and the patient was able to ambulate, void, and take oral medications, and an oral diet. Thus, the patient did not have any conditions that required inpatient level of care. Inpatient level of care in this case is not supported by peer-reviewed literature, it is not standard of care and is not supported by professional organizations.

The patient did not have any conditions that required inpatient level of care. Inpatient level of care in this case is not supported by peer-reviewed literature, it is not standard of care and is not supported by professional organizations.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (severe crowding, overjet, overbite and impacted canines). 
Treatment: Braces.

The insurer denied coverage for braces.  The denial is overturned. 

This is a female child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to severe crowding, overjet, overbite and impacted canines. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements. 

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, an HLD Index is utilized. 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 claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Braces are considered medically necessary for this patient. 

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

The medical necessity for braces is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Irritable Bowel Syndrome (IBS). 
Treatment: Xifaxan 550mg, Pre-service. 

The insurer denied the Xifaxan 550mg, Pre-service. 
The denial is overturned. 

The patient is a male with IBS-D (Irritable Bowel Syndrome with Diarrhea). He has failed Imodium, dicyclomine, hyoscyamine and tricyclic antidepressants. His provider is requesting treatment with Xifaxan. 

Yes, the treatment with Xifaxan is medically necessary. 

Xifaxan is FDA (Food and Drug Administration)-approved, safe and effective, clinically appropriate and accepted standard of medical care for the treatment of IBS-D (Irritable Bowel Syndrome with Diarrhea). As this patient has failed treatment with anti-diarrheals, anti-spasmodics and tricyclic antidepressants, the requested Xifaxan is medically necessary. 

The patient has IBS-D (Irritable Bowel Syndrome with Diarrhea) and has failed all other treatment for IBS-D (Irritable Bowel Syndrome with Diarrhea). As Xifaxan is supported by medical literature for use in IBS-D (Irritable Bowel Syndrome with Diarrhea), the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intestinal obstruction. 
Treatment: Inpatient admission. 

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

This is a female patient with a history of a gastric lap-band and a coagulation disorder. She presented to the Emergency Room (ER) with one day of vomiting and abdominal pain; she had a diagnostic laparoscopy with removal of a lap-band 3 weeks earlier. The patient was afebrile, and her vital signs were stable. There was no abdominal rebound or guarding. The patient's computed tomography (CT) scan was read as being suspicious for early/ low grade obstruction. The patient did not need a nasogastric tube. The patient was given intravenous (IV) hydration. The patient did not need any surgical intervention. The patient was able to tolerate an oral diet. 

Clinical indications for admission for intestinal obstruction, according to Milliman Care Guidelines (MCG) include signs of bowel obstruction that are severe. These signs include feculent vomiting, hypotension, electrolyte abnormalities, bowel ischemia or suspected perforation. In this case, the patient did not have these conditions. The patient also did not have the continued need for nasogastric suction and intravenous hydration support. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. This patient had a possible low-grade obstruction which resolved without any acute interventions. The patient did not meet the MCG criteria for admission for intestinal obstruction. The patient could have been managed with observation status. 

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

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

Diagnosis: Possible seizure activity. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for the Inpatient Hospital Admission. 
The denial is upheld. 

This is a male patient with a history of substance abuse who was admitted for worsening weakness and possible seizure activity. The patient has a history of vomiting and low oral intake. In the Emergency Department (ED) he was noted to be tachycardic, with mucous membranes dry. The patient was noted to be ambulatory in the ED. The patient had been treated aggressively with intravenous (IV) fluids. The patient's electroencephalogram (EEG), computed tomography (CT) scan of the head and chest X-ray were all unremarkable. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scores were 0-2. The patient was discharged in stable condition on Keppra. 

Based on the review of the medical record, inpatient hospital admission was not medically necessary for this patient. The patient was hemodynamically stable, with normal oxygenation and negative cultures. The patient did not have significant electrolytes disturbance, did not have cardiac arrhythmias, did not have altered mental status or persistent nausea and vomiting with dehydration, and did not have any documentation of refractory pain. The patient was able to tolerate oral diet and did not need total parenteral nutrition (TPN). It was noted he had acute kidney injury (AKI) which was likely prerenal azotemia and no evidence of acute tubular necrosis and creatinine almost normalized within 48 hours with IV fluids and did not require renal replacement therapy. The patient's condition responded to IV fluids within 48-hours. This patient's condition could have been treated safely under a lower level of care. 

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

The carrier's denial of coverage for the Inpatient Hospital Admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Pharmacy/prescription drugs

Diagnosis: Duchenne muscular dystrophy 
Treatment: Emflaza
The insurer denied Emflaza. The health plan's determination is overturned. 

The patient is a male who has been diagnosed with Duchenne muscular dystrophy (DMD) due to a mutation at exon 59. The patient was noted to have features of autism spectrum disorder before he was 2 years old. A physical therapist observed motor delay and weakness, and he was diagnosed with DMD at around 4 years of age. His younger brother also has the condition.

He was started on deflazacort (Emflaza) when he was 4, initially at a dose of 0.4mg/kg/day (milligrams/kilograms/day). The dose was increased to 0.9 mg/kg/day when he was 9 years old. At present, he is on a higher pulsed dose on weekend days (noted to be 150 mg in a report by his neurologist, with 3 mg daily Monday-Friday. He started a trial of Ataluren at age 9, and had a good response to the medication, which he continued as open-label. He also takes vitamin D, calcium and enalapril.

Emflaza is medically necessary for this patient.

The medical literature supports Emflaza (deflazacort) as being more effective than prednisone in the treatment of DMD, with the likelihood of fewer side effects.

In 2016, the American Academy of Neurology issued a practice guideline update summary regarding corticosteroid treatment of DMD. The authors concluded that "Prednisone 0.75 mg/kg/day has significant benefit in Duchenne muscular dystrophy (DMD) management and should be considered the optimal prednisone dose. Prednisone 10 mg/kg/weekend is equally effective over a 12-month period, although long-term outcomes of this alternate regimen remain to be seen." Prednisone is not specifically Food and Drug Administration (FDA) -approved for the treatment of DMD. Continued treatment with deflazacort is medically necessary for this patient. Suddenly stopping the medication and replacing it with an equivalent dose of prednisone puts him at risk for the development of acute myocarditis, which is life-threatening. In addition, deflazacort has shown significant decrease in functional decline compared with prednisone and is associated with a lower risk of scoliosis, greater percentage lean body mass, and lower weight.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic /Musculoskeletal/Joint Problem/Pain
Treatment: Pain Management

Diagnosis: Orthopedic /Musculoskeletal/Joint Problem/Pain.
Treatment: Pain Management.
The health plan denied the requested sacroiliac Joint injection. The health plan's determination is overturned.

The patient is a male with right sided sacroiliac joint pain. Treatments tried include physical therapy for >6 weeks, medications for >3 months, daily exercise, and reduction in activities for >6 weeks. A right sacroiliac joint (SIJ) injection performed performed about 12 months of meaningful pain relief.
Physical examination is significant for pain with provocative SIJ maneuvers (FABERS, distraction, thigh thrust, compression and Gaenslen's). A repeat SIJ injection to be performed under image guidance is proposed.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, based on the submitted clinical material and relevant eviCore clinical guideline for medical necessity, the proposed SIJ injection is medically necessary.
The initial request was denied because ongoing, active participation in rehabilitative / therapeutic exercise program was not identified and the use of image-guidance was not identified. The patient's progress notes  state the patient is performing daily home exercises when not in physical therapy and image guidance (including fluoroscopy) will be utilized when performing the SIJ injection.
The relevant eviCore clinical guideline for medical necessity states SIJ injections "should be performed using fluoroscopy....a total of four therapeutic sacroiliac injections for the treatment of sacroiliac pain may be performed per joint during a 12-month period of time, with a minimum of two months duration between each injection, for the recurrence of pain" [1]. The eviCore clinical guideline medical necessity criteria are met.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Zenker's diverticula.
Treatment: Inpatient admission.
The insurer is denied coverage for inpatient admission
The denial is overturned. 

This male patient has a history of hyperlipidemia (HLD), asthma, pernicious anemia, and benign prostatic hypertrophy (BPH). He presented to the hospital with complaints of pharyngeal reflux. The patient had a transcervical cricopharyngeal myotomy and diverticulectomy with endo GIA (Endovascular gastrointestinal anastomosis) stapler, and placement of Coude catheter. The procedure was performed without complications. He was admitted with Zenker's diverticula. He was brought to the post anesthesia care unit (PACU) after surgery for monitoring. He was later transferred to the inpatient floor for hydration and pain management. Vital signs were monitored and wound sites were assessed. Vital signs remained stable. The patient was restarted on home Finasteride and Alfuzosin before removing the Foley catheter. The Foley catheter was removed and the patient passed a trial of void. Pain was well controlled and the patient was tolerating oral (PO) intake. He was ambulating. The patient was discharged home in hemodynamically stable condition. He was instructed to follow up with urology on an outpatient basis.  

The inpatient admission was medically necessary. This is a patient who presented with a recurrent Zenker's diverticulum after endoscopic excision in. The patient underwent repeat open Zenker's diverticulectomy, cricopharyngeal myotomy, and sternocleidomastoid flap. The patient has a history of BPH, and a Foley catheter was inserted for the surgical procedure. The patient was evaluated by urology, who recommends re-starting Alfuzosin and Finasteride prior to a void trial. The patient was to be discharged with outpatient follow-up with urology for a void trial. The foley catheter did not contribute to the patient's longer hospital stay. Zenker's diverticulectomy is generally an ambulatory procedure. However, inpatient admission is warranted if an open approach is needed instead of the usual endoscopic approach. (1) Studies have shown a superior outcome in patients who are treated with an open approach with less incidence of recurrence. (2) Similar length of stay has been demonstrated in the open and endoscopic approach. Patient's who are undergoing a repeat diverticulectomy, often have a larger diverticulum during the recurrent surgery. Regardless of the repair type, patients undergo a barium esophagram prior to being started on a clear liquid diet. (3) 

This patient had an esophagram that did not demonstrate a leak. The patient was then started on a clear liquid diet, and discharged home. As this patient underwent an open procedure due to a recurrent Zenker's diverticulum, inpatient admission was warranted and medically necessary. 

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 inpatient hospital admission is overturned.  The medical necessity is substantiated.