Persius/hicric huggingface dataset:
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 female with extensive abdominal surgical history that presented to the emergency department with abdominal pain. The patient was found to have elevated leukocytosis, normal liver function tests (LFTs), slightly elevated amylase, and elevated creatinine. Imaging showed no fluid or thickening on ultrasound. There was also no fluid or thickening on computed tomography, and the patient had a normal hepatobiliary iminodiacetic acid (HIDA) scan. 

No, the proposed inpatient admission was not medically necessary. 

The patient did not have evidence for acute cholecystitis on imaging. She had no fevers and no imaging evidence that the gallbladder was inflamed. Her leukocytosis and elevated creatinine are likely due to dehydration, not from a severe inflammatory response. It is also documented in the appeal letter that the patient was hypotensive on admission; however, her blood pressure was 108/75 millimeters of mercury (mmHg) which is a normal blood pressure. This case does not meet criteria also the per the Milliman Care Guidelines (MCG) for acute cholecystitis due to the lack of fever on admission, and lack of documentation of change in abdominal exam or progress notes that demonstrate need for inpatient admission. 

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

There is insufficient documentation to support the use of a inpatient admission for this case. Although the patient's clinical lab values show a leukocytosis and elevated creatinine, she did not have any change or persistent pain that necessitated her to remain in the hospital at an inpatient level of care. The patient also did not meet the diagnosis of acute cholecystitis based on the Tokyo Guidelines which are a guideline for treating acute cholecystitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic thrombocytopenia purpura
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld
 
This patient presented with a history of rash and was found to have thrombocytopenia. She was noted to have bruising, petechiae and nose and mouth bleeding. Her hemoglobin was 12.7 and white blood cell count was normal. She had platelets count of 9000 and was diagnosed with idiopathic thrombocytopenia purpura (ITP) and was admitted to the hospital. She received a dose of intravenous immunoglobulin (IVIG) and was discharged home.

The hospital admission is not considered medically necessary for this patient. The member had petechiae and bruising with a low platelet count. All other cell lines were normal. The patient was diagnosed with ITP and treated with IVIG. There was no evidence of severe bleeding, fever or other comorbidities that required acute care hospitalization. The patient could have been safely managed at a lower level of care where IVIG could be safely given followed by outpatient care with a pediatric hematologist.

"Treatment should always be tailored to the patient because many factors contribute to treatment decisions. Impacting management decisions are the extent of bleeding, age, comorbidities predisposing to bleeding, complications of specific therapies, activity and lifestyle, fatigue, tolerance of side effects, need for interventions with a bleeding risk, accessibility of care, patient expectations, patient worry or anxiety, and patient need for non-ITP medications that may create a bleeding risk. Patient preference must be considered when discussing treatment options." (Provan et al., 2019)

"Management of children with newly diagnosed immune thrombocytopenia (ITP) consists of careful observation or immunomodulatory treatment. Observational studies suggest a lower risk for chronic ITP in children after IVIG treatment." (Heitink-Polle et al., 2018)

"Conclusion: The total platelet count rises higher in early and late phases with IVIG than Anti-D, but in long term it is higher with methylprednisolone. Additionally, IVIG causes less adverse effects than Anti-D and corticosteroids." (Acero-Garces et al., 2020)

"Conclusions and relevance: We demonstrated a significant practice change in the management of newly diagnosed ITP at a pediatric care tertiary care hospital in the United States surrounding revision of the American Society of Hematology (ASH) management guidelines for childhood ITP. Our experience supports adoption of observation alone for a proportion of patients with newly diagnosed childhood ITP. This form of management did not lead to an increase in later treatment or an increase in delayed bleeding symptoms." (Schultz et al., 2016)                                                       

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

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

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


The patient has Crohn's disease and failed high-dose Remicade, Humira, and Entyvio. He started Stelara with a rapid increase to the dose of Stelara 90 milligrams (mg) every 4 weeks. He is also on ciprofloxacin, metronidazole, and sulfasalazine. He has had persistent fistula drainage. He was noted to have a feeling of developing an abscess, ongoing intermittent disease flares characterized by diarrhea, urgency, bleeding, and increased fistula drainage, and had a seton exchange. At issue is the medical necessity of continued Stelara 90 mg every 4 weeks for the treatment of fistulizing Crohn's disease.
The requested Stelara 90 mg every 4 weeks is medically necessary in this case per the current medical literature. Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease [1-3]. Guidelines for the treatment of Crohn's disease recommend the use of Stelara [4]. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response [5-7]. One study showed that dose escalation was required and approximately half of patients, and successful in 61.1% of dose escalation attempts [5]. Another study showed the efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted [7]. Additionally, the American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy" [4]. In this case, the patient has been maintained on Stelara 90 mg every 4 weeks, but has had intermittent disease flares (characterized by diarrhea, urgency, bleeding, and increased fistula drainage) and has ongoing fistula drainage on this dose. A decrease of dosing to 90 mg every 8 weeks, or discontinuation of Stelara (even if an alternative therapy is attempted immediately) is likely to result in complications such as further fistula disease, abscess, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications of Crohn's disease. For all of these reasons, the request to continue Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of Crohn's disease in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission 
The denial is upheld

The patient had a history of CNS (central nervous system) lymphoma and presented with nausea, vomiting, and diarrhea. In the emergency room (ER) she had a temperature of 101 .8 and a tachycardia. There was no abdominal rebound or guarding. There was no leukocytosis. A head CT (computed tomography) scan was negative for acute disease. She was diagnosed with a gastroenteritis. An abdominal CT scan showed a mild infiltration of the mesenteric root. It was felt that the gastroenteritis was most likely viral, but antibiotics were given. She was treated with a PPI (proton pump inhibitor) and antiemetics and the diarrhea, nausea, and vomiting resolved. No interventions were required at this time for the mesenteric root infiltration. 

Clinical indications for admission for Gastroenteritis (MCG M-170) include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had a gastroenteritis. Intravenous (IV) hydration, antiemetics, and PPI therapy could have been given in the ER with observation status. If antibiotics were felt to be necessary, she could have been given a course of an oral antibiotic. She responded to the treatment and her symptoms improved. She did not meet MCG (Milliman Care Guidelines) criteria for admission for Gastroenteritis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld.

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular/Chronic Pain Syndrome
Treatment: Skilled Nursing Facility
The health plan denied the continued skilled nursing facility stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with diabetes, hypertension, CVA (cerebrovascular accident) and a right knee ACL (anterior cruciate ligament) rupture.
At issue is the medical necessity of the requested health service/treatment of a Skilled Nursing Facility Admission.

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

The requested health service/treatment of Skilled Nursing Facility Admission is not medically necessary for this patient. The patient is a male with diabetes, hypertension, CVA (cerebrovascular accident) and right knee ACL (anterior cruciate ligament) rupture. The occupational therapy note stated that he required minimal assistance for toileting, contact guard assistance for dressing upper body, moderate assistance for dressing lower body, and minimal assistance for bathing. The physical therapy note stated that he was performing bed mobility with set up, transfers with supervision, ambulating 100 feet with supervision with rolling walker, and walking up stairs with contact guard. Later, his left lower extremity strength was 4/5. He had no focal neurologic deficits. On a later date, the occupational therapy note stated that he required minimal assistance for toileting, contact guard assistance for dressing upper body, minimum assistance for dressing lower body, and minimal assistance for bathing. The physical therapy note stated that he was performing bed mobility with set up, transfers with set up, and ambulating 200 feet with supervision with rolling walker. The patient could participate in a home program to include strengthening, range of motion exercises, and functional exercises. Skilled Nursing Facility Admission is not medically necessary, as there was no documentation of significant improvement in bathing, dressing, transfers, toileting, or ambulation during the later time frame. The peer-reviewed medical literature in the United States at this time would not include the continued Skilled Nursing Facility Admission. Further, the medical standard of care does not support the continued Skilled Nursing Facility Admission. Additionally, the continued Skilled Nursing Facility Admission does not meet InterQual Criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 1 Diabetes Mellitus.
Treatment: Ozempic.
The insurer denied Ozempic.
The determination is upheld.


The patient was diagnosed with Type 1 diabetes mellitus (T1DM) and overweight. This request is for Ozempic. As reported; she has been on Ozempic for several years to assist with weight loss as well as glycemic control and she is doing well on it.

Ozempic is a glucagon-like peptide-1 receptor (GLP1R) agonist[1] that is FDA approved in the treatment of type II diabetes [2-4]. There are no studies showing safety or efficacy of Ozempic in patients with type 1 diabetes. The patient has type 1 diabetes. The FDA label specifically prohibits use of Ozempic and type 1 diabetes. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite.
Treatment: For D8080 braces and D8670 monthly visit.
The insurer denied coverage for D8080 braces and D8670 monthly visit.
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radio graph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to impacted permanent anterior among other findings. The orthodontist has completed the HLD (Handicapping Labia-Lingual Deviation) index as required and has chosen the automatically qualifying condition of impacted permanent anterior where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 15 points on review by internal reviewer.  

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care; New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labia-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care, additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of impacted permanent anterior where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care. This reviewer concurs with the findings of the insurer attaining 15 points on the HLD index (3 points overjet, 4 points overbite, 5 points anterior crowding, 3 points labiolingual spread).

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  

Each of the peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an approach for assessing orthodontic need.

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

The insurer's denial of coverage for the D8080 braces and D8670 monthly visit is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lightheadedness and chest pain

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission

The denial is overturned

The patient presented to the hospital complaining of palpitations, chest discomfort, and lightheadedness for one week. Three weeks earlier, he presented with SVT (Supraventricular tachycardia) that terminated with adenosine therapy. Upon arrival to the hospital vital signs were stable: Blood pressure 132/83 mmHg (millimeters of mercury), pulse 69 bpm (beats per minute). No abnormal findings were noted on physical examination. A 12 lead ECG (electrocardiogram), while patient was having symptoms, revealed an idioventricular rhythm. He was treated with IV (intravenous) Magnesium and admitted to the hospital for evaluation.  A repeat 12 lead ECG demonstrated normal sinus rhythm without significant ST (interval on a ECG) or T (interval on a ECG) wave changes. Serum blood testing revealed no elevation in troponin (<0.01ng (nanograms)/ml (milliliter) and electrolyte levels were within normal limits. Telemetry monitoring revealed repeated runs of idioventricular rhythm, and an electrophysiologist was consulted. An echocardiogram revealed normal LV (left ventricular) ejection fraction without evidence of valvular heart disease. Options including electrophysiologic study and antiarrhythmic drug therapy were reviewed and ultimately the patient was treated with dronedarone.

This patient presented with recurrent lightheadedness and periods of AIVR (Accelerated Idioventricular Rhythm). The differential diagnosis of AIVR includes acute myocardial infarction. Although most patients with palpitations can be evaluated in the outpatient setting, this patient had symptoms of lightheadedness and recurrent AIVR on telemetry that was concerning. (Reference 1-2). Given repeated symptoms of lightheadedness over the course of a week this patient was at risk for syncope and required inpatient hospital admission for evaluation and treatment. (3) In conclusion, an inpatient hospital admission was medically necessary in this case. 

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

The insurer's denial of coverage is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dehydration

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission

The denial is overturned

The patient was admitted for diarrhea and poor oral intake. BUN (blood urea nitrogen) / Cr (creatinine) on admission was: 80/3.5 (Cr baseline: 2). The patient was managed with IVF (intravenous fluids) and PO (oral) hydration as nausea and vomiting resolved on day 2 of admission. The patient's renal function improved to baseline with BUN/Cr of 20/1.5. A CXR (chest x-ray) and abdominal x ray showed no acute process. 

The gold standard for the distinction between prerenal disease secondary to volume depletion and post-ischemic and nephrotoxic ATN (Acute Tubular Necrosis) is the response to fluid repletion per KDIGO (Kidney Disease Improving Global Outcomes) and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of prerenal disease, whereas persistent acute kidney injury (AKI) is considered to represent ATN, this patient's kidney function did not return back to baseline after adequate fluid challenge which is consistent with ATN.

ATN has higher risk for mortality which requires close monitoring of kidney function, electrolytes abnormalities and possible need for renal replacement therapy.

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

The insurer's denial of coverage for the full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis and Psoriatic Arthritis
Treatment: Otezla and Skyrizi, Pre-service
The insurer denied the Otezla and Skyrizi, pre-service.
The denial is upheld.

This patient is a male with history of psoriatic arthritis and psoriasis. The patient has previously tried and failed biologic disease modifying anti-rheumatic drugs (DMARDs) Tremfya, Taltz, Stelara, Ilumya, and Humira. The patient was started on Skyrizi and has good control of his psoriasis but does not have good control of his psoriatic arthritis. The reason Otezla was initially denied was due to policy not allowing coverage of the requested medication if it will be combined with a biologic or targeted synthetic DMARD. The reason the provider is appealing the determination is because the patient has difficult to control disease and the provider feels that combination therapy will improve both psoriatic arthritis and psoriasis.

The proposed treatment is not medically necessary.

The patient has difficult to treat psoriatic arthritis and psoriasis. The patient has previously tried and failed many medications. The patient is currently on biologic DMARD Skyrzi and this is helping the patient's psoriasis, but he is still having problems with psoriatic arthritis. While there are many clinical studies showing that Otezla can be safely combined with biologic DMARDs with improved efficacy and no concern for safety, I do not see any documentation that the patient has already tried and failed other conventional DMARDs such as methotrexate and leflunomide (Arava) first as these are more often first line combination therapy as opposed to Otezla. Therefore, at this time the proposed treatment is not medically necessary.

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

There is no documentation that the patient has first tried and failed conventional DMARDs in combination with biologic DMARD Skyrizi such as methotrexate and leflunomide (Arava). These are more well studied and standard of care first before adding Otezla.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Burns to left hand

Treatment: Inpatient admission 

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

The health plan did not act reasonably. An inpatient admission was medically necessary. This patient had a partial thickness burn that required wound care, pain medication and instruction on range of motion and outpatient wound care. According to the MCG (Milliman Care Guidelines), 26th Edition, admission to a burn unit is required for any of the following indications:

	1) Hemodynamic instability
	2) Full-thickness (third-degree) burn
	3) Partial thickness (second-degree) burn greater than 10% of total body surface area[A]
	4) Partial thickness (second-degree) burn of face, hand, foot, genitals, or perineum
	5) Partial thickness (second-degree) burn that crosses major joint or is circumferential
	6) Inhalation injury 
	7) Burn accompanied by other significant medical problems or injuries (e.g., altered mental status, arrhythmia, inability to maintain oral hydration, significant wound, or fracture)
	8) Serious chemical burn 
	9) High-voltage (e.g., 1000 volts or more) electrical burn 
	10) Pain management requiring inpatient care (e.g., IV (intravenous) narcotics)

In this case, the patient had a second degree burn of the hand. The presence of blisters indicates a second-degree burn. Per the MCG guidelines, admission is medically necessary for hand burns due to the high risk of secondary problems including finger contractures and chronic joint stiffness. The admission was medically necessary to treat this high risk burn to the hand.
The insurer's denial of coverage for inpatient hospital admission is overturned. Medical Necessity is substantiated.