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

Diagnosis: Treatment Resistant Depression. 
Treatment: Deep Brain Stimulation (DBS) surgery (codes 61867 x2 and 61886) and the associated inpatient stay. 
The insurer denied coverage for deep brain stimulation (DBS) surgery (codes 61867 x2 and 61886) and the associated inpatient stay. 	
The denial is upheld. 

This case involves a male patient who has been recommended to undergo surgical intervention for implantation of a deep brain stimulator.  The documentation indicated the patient has been diagnosed with medically refractory treatment resistant depression.  He has had a trial and failure of multiple medications as well as 18 electroconvulsive therapy (ECT) sessions.  Due to the severe intractability of the condition the patient has been referred for surgical intervention.  The documentation indicated initially the patient had a score of 24 on the Hamilton depression rating scale and a 25 on the quick inventory of depressive symptomatology corresponding to the severe depression.   His symptoms to include severe anhedonia with despair and chronic suicidal thoughts.  The documentation indicated he has been recommended for deep brain stimulation and an associated inpatient stay.

Recent randomized controlled trials show inconclusive results of deep brain stimulation (DBS) for treatment-resistant depression (TRD). Only one recent meta-analysis supports the use of DBS for TRD, but can only support future studies rather than DBS as a standard treatment of depression.

DBS is not an FDA [Food and Drug Administration]-approved treatment of depression.

In the absence of supportive randomized controlled clinical studies, DBS does not meet the criteria for the current patient. There is no evidence that DBS is superior to other treatments for depression.

There is no evidence of an increase in adverse risks of DBS over standard therapy. DBS is not likely to be more beneficial than any standard treatment/procedure.

The carrier's denial of coverage for deep brain stimulation (DBS) surgery (codes 61867 x2 and 61886) and the associated inpatient stay should be upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Crohn's Disease of the small intestine. 
Treatment: Formulary Exception for Ortikos to treat Crohn's Disease. 

The insurer denied coverage for a Formulary Exception for Ortikos to treat Crohn's Disease. 

The denial is overturned. 

This is a female patient who has Crohn's Disease of the small intestine. A video capsule test was done and a stricture in the terminal ileum was found. Treatment with Budesonide was advised. 

The American College of Gastroenterology has published a clinical guideline: Management of Crohn's Disease in Adults. For mild to moderately severe disease recommendations for medical therapy are given. The guideline states that controlled ileal release budesonide at a dose of 9 milligrams (mg) once daily is effective and should be used for induction of symptomatic remission for patients with mild to moderate ileocecal Crohn's disease. The guideline also states that oral mesalamine has not consistently been demonstrated to be effective compared to placebo for induction of remission and achieving mucosal healing in patients with active Crohn's disease and should not be used to treat patients with Crohn's disease. 

This patient has Crohn's disease with an ileal stricture. Controlled release Budesonide is a recommended treatment of the American College of Gastroenterology. The formulary drugs have been shown to not be as effective as the controlled release Budesonide. Based on the recommendations of the American College of Gastroenterology clinical guideline for the management of Crohn's disease in adults, the requested drug is likely to be more effective. The denial is overturned. 

The insurer's denial of coverage for a Formulary Exception for Ortikos to treat Crohn's Disease is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders-psoriasis
Treatment: Pharmacy/Prescription Drugs-Cosentyx
The health plan denied Cosentyx as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

The patient has psoriasis. The patient has reportedly been on Tremfya injections, which did not help. The patient was on Cosentyx which helped at that time. The patient has also failed ultraviolet B (UVB) phototherapy. Correspondence from the plan notes that Tremfya was approved for coverage but not Cosentyx, and that sample use of Cosentyx is not honored under the plan. Otezla, Stelara, Skyrizi, and Taltz were recommended as alternative treatment options for this patient instead of Cosentyx.

Alternative, effective, and appropriate treatment options exist for this patient with similar and equivalent degrees of efficacy, safety, tolerability, and favorable short-term and long-term outcomes as the requested Cosentyx. The use of Cosentyx samples in and of itself for psoriasis is not a practice or treatment course that supports the conclusion of medical necessity of Cosentyx for this patient's treatment. Convenience and/or preference by the provider and/or patient is not the same as medical necessity. The patient has no documented treatment failure with, or true medical contraindication to, either Otezla, Stelara, Skyrizi, or Taltz. Of note is that Taltz is a preferred treatment that is of similar efficacy with, and a similar mechanism of action to, the requested Cosentyx (both are Interleukin-17 inhibitors). Current medical literature [1-4] supports use of any of the preferred medications as much as the requested Cosentyx. Accordingly, as per standards of care, Cosentyx is not medically necessary for this patient, when alternative and appropriate options exist for this patient at this immediate time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancytopenia.
Treatment: Inpatient Hospital Admission.
The insurer denied coverage for inpatient hospital admission
The denial is upheld

The patient had a history of cirrhosis, alcohol withdrawal, and an intracranial hemorrhage.  He reported exertional shortness of breath (SOB).  His physician found a hemoglobin of 5.2.  He was afebrile and the vital signs were stable.  The hemoglobin was 4.9.  He had pancytopenia.  The stool was hemoculture negative.  Transfusions were given.  A sonogram showed a possible gallbladder mass.  It did not require any acute interventions during this hospitalization.

Clinical Indications for Admission for Iron Deficient Anemia (M-35) include hemodynamic instability, active bleeding, altered mental status, recurrent syncope, serious cardiac arrhythmias, a platelet count under 20,000 with active bleeding, and acute renal failure.  The patient did not have these conditions.

This patient had pancytopenia with worsening anemia.  He required blood transfusions.  However, he was stable to have been transfused with Observation status.  The gallbladder mass did not require any acute interventions at this time.  He did not meet MCG criteria for admission for iron deficient anemia.  He was not actively bleeding and his cardiac status was stable for transfusions under observation care.  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 hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient who presented to the hospital complaining of chest pain.  The pain was described as intermittent lasting for 5-10-minute periods and was exacerbated by deep inspiration.  Past medical history was significant for coronary artery disease and stents placed in the left anterior descending, left circumflex and right coronary arteries in the past.  In addition to coronary artery disease (CAD) the patient had a history of diabetes mellitus (DM) and hypertension (HTN).  Upon arrival physical examination was unremarkable, vital signs were stable.  Electrocardiogram (EKG) demonstrated normal sinus rhythm.  Serum blood testing revealed no abnormality and troponin was not elevated.  The patient was admitted to telemetry for further testing.  Pharmacologic perfusion testing revealed a preserved left ventricular ejection fraction (LVEF) 55% and no evidence of ischemia or infarction.  Echocardiography revealed a preserved LVEF with no wall motion abnormalities. The patient was diagnosed with non-cardiac chest pain and released the same day. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with atypical chest pain.  Despite his history of coronary disease, the atypical nature of the pain with no EKG abnormalities makes pretest probability of an acute coronary event very low. (1)  Utilizing the HEART [history, EKG, age, risk factors, and initial troponin] score he was considered low risk (3 points).(2)  Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1).(3) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al.(3)  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would also have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, inpatient hospital admission was not medically necessary and this patient could have been treated at a lower level of care.

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

Diagnosis: Chronic pain
Treatment: Formulary exception for Levorphanol, Pre-service
The insurer denied the Formulary exception for Levorphanol, Pre-service
The denial is overturned.

The patient is a male with chronic pain. He has been prescribed Levorphanol.  The patient has had chronic pain for a number of years, with subsequent surgery following a trauma. The requested medication was denied by the health plan, as the patient has not met formulary requirements.

Yes, the health plan should cover the Formulary exception for Levorphanol.
The patient is male with chronic pain. He has been prescribed Levorphanol.  The patient has had chronic pain for a number of years, with subsequent surgery following a trauma. He is followed by a chronic pain management provider.  There are no red flags. The requested medication was denied by the health plan, as the patient has not met formulary requirements.

The patient has been on this medication for several years, and thus this is a continuation of therapy. The patient has failed numerous alternatives, and is currently on one of the alternatives. The patient has failed Morphine extended release, oxycodone extended release, hydromorphone extended release, and hydrocodone.  The literature documents Levorphanol as a medication with experience in treating chronic pain. It is especially useful in situations with neuropathic pain.  Alternatives are limited.  Changing the patient's medication is unlikely to be of benefit, given the numerous options that have failed. Therefore, an atypical opioid, i.e., Levorphanol, is medically necessary in this setting and should be covered.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma/Injuries-Brain Injury-intracranial hemorrhage
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has overturned in whole the health plan's determination.

The patient has a history of alcohol abuse and homelessness and was admitted to the hospital. He presented with an intracranial hemorrhage after falling onto his forehead on the prior evening in the setting of alcohol consumption. There was no vomiting, and it was unclear whether there was loss of consciousness. Computed tomography (CT) imaging at an outside hospital demonstrated a left frontal hemorrhage. The patient was complaining of a headache, but denied fevers, chills, nausea, and vomiting. Vital signs showed blood pressure 144/85, respiratory rate 18, and oxygen saturation 97%. Chest x-ray demonstrated a right-sided infiltrate and there was concern for possible pneumonia. A CT scan of the chest showed a small right upper lobe consolidation representing possible pulmonary contusion versus infectious or inflammatory etiology. Labs showed a white blood cell count (WBC) of 10.79, hemoglobin 13.8, platelets 96, sodium 141, potassium 3.8, and creatinine 0.69. The patient was admitted for a traumatic intraparenchymal frontal hemorrhage after a fall. This plan of care included tetanus vaccination, repeat head CT, neurosurgery (neuro) consult, cervical collar, CT imaging of the spine, and monitor for withdrawal. Neurosurgery saw the patient and recommended starting Keppra for seven days. Repeat CT head showed the hemorrhage was stable, and Neurosurgery cleared the patient for discharge. The lung opacity was thought to represent aspiration rather than an infectious pneumonia. 

The patient had a moderately complex presentation with intraparenchymal hemorrhage, concern for alcohol withdrawal, and a lung nodule opacity that was concerning for contusion versus infection. The complexity of his presentation would not have been appropriate for a lower level of care due to the need for close monitoring for complications related to the intraparenchymal hemorrhage and the risk of alcohol withdrawal, which together increase the overall risk for altered mental status and encephalopathy. The lung finding also increased the patient's complexity. 

The risk of complications from intraparenchymal hemorrhage included seizure, stroke, and worsening bleeding, along with the risk of alcohol withdrawal. While neurosurgery's assessment was that the hemorrhage was small and that the patient could be medically managed with Keppra, he required additional head imaging and neuro checks/close monitoring. Inpatient hospital stay was therefore medically necessary, due to the patient's complexity at the time of presentation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: D8080 Braces, And D8670 Monthly Visit x 12, Pre-service
The insurer denied the D8080 Braces, And D8670 Monthly Visit x 12, Pre-service
The denial is overturned.

The patient is a female. The request is for orthodontic benefits.

Yes, the braces and monthly visits are medically necessary.
The patient has tooth #27 (lower right canine) in crossbite.  When there is an anterior tooth in crossbite with gingival attachment loss, this is an "automatic qualifier," according to the handicapping index scale. This case has medical necessity because of this problem.

Therefore, the braces and monthly visits are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.  

This case involves a male with a history of schizoaffective disorder who presented to the hospital with abdominal pain and vomiting complaints. He complained of epigastric pain, which started on the morning of the presentation, described as constant, aching, and non-radiating. He experienced 3-4 episodes of yellow vomitus with food particles. There was no report of hematemesis or rectal bleeding. The patient abuses marijuana but denied using any recently. Vital signs on admission included a blood pressure of 148/87, pulse rate of 41, respirations of 20, and temperature of 97.3. Twelve-lead electrocardiogram (EKG) showed sinus bradycardia, with a heart rate of 41, with no ST-segment changes.

The patient was admitted to the hospital with a principal diagnosis of asymptomatic bradycardia. The patient had negative orthostatic vital signs; the medical team ordered thyroid function tests. They suspected gastritis versus cannabis hyperemesis syndrome as the cause of nausea. 
Cardiology assessed the patient and reported he denied dizziness, chest pain, or shortness of breath. He was not on any beta-blockers or calcium channel blockers that would cause bradycardia. Cardiac enzymes were negative, and they recommended repeating the EKG and an echocardiogram as a precaution. The following morning, the patient demanded to leave the hospital. Psychiatry was called; however, the patient eloped. Contacting him was unsuccessful. The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld in whole.

The requested health service/treatment of inpatient stay are not medically necessary for this patient. The patient came into the hospital for nausea and abdominal discomfort. He was incidentally found to have asymptomatic bradycardia. There was no evidence of acute coronary syndrome. There is no evidence of hemodynamic instability. The patient was not on any nodal blocking agents, which could be contributing to the bradycardia. There was no documentation of bradycardia causing syncope. The bradycardia was not affecting the patient in any meaningful way. This is a relatively healthy male with a psychiatric history. There is no prior documentation of cardiac arrhythmias, premature coronary disease. There is no evidence of pulmonary embolism that could be causing the patient's bradycardia. It was reasonable to admit the patient under a lower level of care status and obtain an echocardiogram. There were no clear clinical indications for pacemaker placement. The patient was mildly dehydrated from nausea and vomiting, possibly having vagal symptoms as a result. QT intervals were within the normal range on the EKG. The documentation fails to demonstrate any red flags that the patient had a life-threatening condition, causing the asymptomatic bradycardia. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Consumer Directed Personal Assistant Program (CDPAP) 24 Hours (live-in x 7 Days Per week) (The health plan approved 23 hours/week)
The insurer denied the Consumer Directed Personal Assistant Program (CDPAP) 24 Hours (live-in x 7 Days Per week) (The health plan approved 23 hours/week)
The denial is upheld.

The patient is a male with seizure disorder, mood disorder and cognitive impairment. He has had multiple injuries from seizure activity. The provider has indicated that he requires constant monitoring due to seizures fatigue and cognitive impairment. His current seizure medication include Oxtellar and gabapentin.

No, the requested Consumer Directed Personal Assistant Program (CDPAP) 24 Hours (live-in x 7 Days Per week) is not medically necessary.
There are no standard-of-care guidelines to support the use of 24-hour care for persons with seizure to monitor for seizures. Similarly, there is no indication to provide 24-hour care for a person for fatigue or forgetfulness. There is no indication that the patient cannot complete his ADLs (activities of daily living) or that appropriate medication support cannot be provided within the guidelines.

The standard of care for individuals that are so severely impaired as to not be able to live independently is nursing home placement.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pyoderma gangrenosum.
Treatment: Ilaris.
The insurer denied coverage for Ilaris. 
The denial is overturned. 

This is a male patient whose past medical history includes pyoderma gangrenosum (PG), osteoarthritis, diabetes, and venous stasis dermatitis. The patient had a Televisit for rheumatologic evaluation and reestablishment of care. Per the consult notes, the impression was worsening pyoderma gangrenosum skin lesions. The patient has severe disease, especially of the legs, and is wheelchair bound. The notes state that in addition to infliximab and intravenous immunoglobulin (IVIG) infusions, the patient has tried various immunosuppressive therapies, including prednisone and CellCept, and has either had no response or had intolerance to these therapies. There is a long discussion of treatment options in the office visit. 

This patient has severe PG refractory to multiple therapies. There are no Food and Drug Administration (FDA)-approved treatments but the patient has been on multiple medications used for PG. See www.uptodate.com chapter "Pyoderma Gangrenosum: Treatment and Prognosis." PG is rare and this degree of treatment-resistant disease is even rarer, making study opportunities limited.

Of the preferred treatments recommended in "Effectiveness of systemic treatments for pyoderma gangrenosum; a systematic review of observational studies and clinical trials" (Partridge et al.), the only one the patient hasn't gotten is Ilaris. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer does not feel they took the particular problems of this case into account. Use of Ilaris off-label at this stage of this patient's treatment is appropriate. 
				
The insurer's denial of coverage for Ilaris is overturned. Medical necessity is substantiated.