Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Psoriatic 

Treatment: Taltz

The insurer denied Taltz. The denial was reversed.   

This is a female patient with a history of psoriasis and PsA (psoriatic arthritis). She has been on Taltz for over a year with good control of her illness. 

All the formulary meds and Taltz work for both psoriasis and PsA.  There are no clear criteria for preferring one agent over the other, although in the section "Treatment of Psoriatic Arthritis" in www-uptodate.com there is a preference for using anti-TNF therapy (in this case Humira and Enbrel) first because we have used them the longest. They also note that benefit of at least 20% (the ACR20) was seen in was seen in 50-65% of patients within 3 months.   In the "Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics."  J Am Acad Dermatol, April 2019 p. 1029 Alan Menter, MD et al., use of all these medications is supported.

The latter source also notes that there are no clear guidelines on criteria for making switches between biologics, and results are not predictable. 

The patient has been on and tolerated Taltz, which is similar to the other biologics.  There would no reason to predict ahead of time any increased risk of toxicity from a Formulary medication. The concern in making a switch is that, in the face of good benefit from Taltz, the patient would be at risk for new toxicities for no apparent extra benefit.  And there is no guarantee the switch would work as well as noted above regarding anti-TNF agents.

None of the Formulary medications have been tried. However, the patient has been on and had a good response to Taltz.  There is no reason to think a switch would give a better response.  There is a risk that the response will not be as good, and that supports making no changes in the absence of any side effects from Taltz. 

The available information would indicate that the patient has been receiving the medication for over a year through another insurer. 

As the patient has been on Taltz with good results and no toxicity, it should be continued.  There is no guarantee a switch will work as well or better.  She has had no side-effects, and would be at risk if there is a change.  

The carrier's denial of Formulary Exception for Taltz is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Protrusive teeth
Treatment: Braces
The Braces are medically necessary.

The patient has upper front teeth that are severely protrusive. Their position makes it easier for them to be traumatized with the results being some type of fracture or loosening. Also, the patient's upper left second molar is in buccal crossbite. This means it is out of position and every time the patient moves her jaw to the left, this tooth grinds together against the lower tooth excessively. Over time this condition can also lead to breakage and/or loosening of this tooth. Only orthodontic treatment can correct these conditions and allow for a lifetime of proper forces to all her teeth. The orthodontic treatment is to be considered medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Crohn's disease
Treatment: Fecal calprotectin
The health plan should not cover the fecal calprotectin.

The requested health service or procedure is not likely to be more beneficial than any standard treatment(s) for the patient's condition or disease. 

Calprotectin (FC), when measured in feces, has accepted use in the gastrointestinal (GI) community. It is commonly used in clinical practice to differentiate between non-organic and inflammatory intestinal disorders, especially to identify inflammatory bowel disease (IBD) and to monitor patients with IBD under treatment and to predict the risk of recurrence of active disease prior to clinical relapse. (1) 

In Mosli's comparative meta-analysis of 19 studies (n=2499), the diagnostic accuracy of C-reactive protein (CRP), fecal calprotectin (FC), or stool lactoferrin (SL) was examined against endoscopy as a gold standard in patients with symptoms/signs consistent with active IBD. The pooled sensitivity and specificity estimates for CRP, FC, and SL were 0.49 (95% confidence interval (CI) 0.34-0.64) and 0.92 (95% CI 0.72-0.96), 0.88 (95% CI 0.84-0.90) and 0.73 (95% CI 0.66-0.79), and 0.82 (95% CI 0.73-0.88) and 0.79 (95% CI 0.62-0.89), respectively. FC was found to be more sensitive than CRP for the patient's indication. (2)  Similar results were reported by Menees' meta-analysis of 140 relevant citations that cross-referenced CRP, FC, SL, and erythrocyte sedimentation rate (ESR). (3)

Relative to the patient's specific case, Bjarnason opines: "the fecal calprotectin test is a functional quantitative measure of intestinal inflammation, and it is inflammation- and not disease-specific. It is a test that usually supplements endoscopy clinically and, at times, can even replace the procedure. Fecal calprotectin certainly has the potential to serve as a diagnostic screening test (as opposed to merely a diagnostic test). An abnormal test result simply indicates intestinal inflammation of any cause. There are numerous intestinal diseases and drugs (eg, NSAIDs, alcohol) associated with low-grade intestinal inflammation." As such, reliance primarily on fecal calprotectin to determine Crohn's activity is not the standard of care in the GI community.

While fecal calprotectin may be attractive to some clinicians for monitoring patients with IBD in lieu of direct imaging of the gut, in answer to the query posed for this review, the service in question is less specific and sensitive to gold standard imaging modalities and as such is not likely to be more beneficial than any standard approach for the patient's disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Crohn's disease
Treatment: Fecal calprotectin
The health plan should cover the fecal calprotectin.

The requested health service or procedure is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.

The new American College of Gastroenterology (ACG) Guidelines for the Management of Crohn's Disease published in 04/2018 state that fecal calprotectin has a role in noninvasively monitoring disease activity in Crohn's disease. Studies have shown that both fecal lactoferrin and fecal calprotectin are sensitive markers of disease activity and correlate with a number of the endoscopic activity indices such as the colonic Simple Endoscopic Score for Crohn's Disease (SES-CD). There have been several studies that suggest that levels of fecal calprotectin can be used to monitor patients for postoperative recurrence after ileocolic resection for Crohn's disease. Levels of greater than (>) 100 g/g indicate endoscopic recurrence with a sensitivity in the range of 89%. In patients with an infliximab-induced remission, fecal calprotectin of >160 g/g has a sensitivity of 91.7% and a specificity of 82.9% to predict relapse. 

Therefore, as the latest recommendation by the American College of Gastroenterology is to strongly recommend fecal calprotectin in diagnosing and managing inflammatory bowel disease (IBD), fecal calprotectin testing is no longer considered investigational in the diagnosis and management of intestinal conditions, including the diagnosis and management of IBD. It is likely to be more beneficial for the patient than standard treatment such as repeating a colonoscopy or performing a small bowel series, capsule endoscopy or CT or MR enterography, and the health plan should cover it.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: severe Obstructive Sleep Apnea (OSA)

Treatment: CPAP titration sleep study in a sleep center

The insurer denied coverage for CPAP titration sleep study in a sleep center. The denial was reversed.

This patient is a male diagnosed with snoring, somnolence, sleep apnea, unspecified, and a history of hypertension, asthma, and gastroesophageal reflux disease.  The patient's Epworth Sleepiness Scale was 8 out of a possible 24.  The patient was recommended for a home sleep study, which was performed and revealed that the patient had a respiratory event index (REI) of 40.9, consistent with obstructive sleep apnea.  The patient had repetitive respiratory events and oxygen desaturations to 79%.  The recommendation was for the patient to undergo formal sleep evaluation and in laboratory pressure titration. The follow-up office visit indicated the patient was interested in pursuing continuous positive airway pressure (CPAP) therapy for management of his sleep-related symptoms.  The patient continued to complain of snoring, fragmented sleep and daytime somnolence.  The provider noted that given the patient's diagnosis of severe obstructive sleep apnea, the patient warranted a CPAP titration study.

The insurer denied the medical necessity for the sleep study in a sleep center as CPAP titration studies in sleep centers are done for certain types of problems and the patient did not have 1 of these types of sleep problems.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The CPAP titration sleep study in a sleep center, for service is considered medically necessary for this patient.

The patient was found to have severe Obstructive Sleep Apnea (OSA) (AHI over 40/hr) with minimum oxygen desaturation to 79 percent and fragmented sleep.  The patient additionally has the diagnosis of hypertension, which means that his originally diagnosed obstructed sleep apnea with home sleep study could be mixed apnea once the patient would receive an Auto-PAP.  Auto-PAP would not be able to adequately address potential central sleep apneas, and in cases of severe OSA, some patients need bilevel positive airway pressure (BiPAP) or Adaptive Servo Ventilation (ASV) if they have cardiac risk factors which hypertension (HTN) is considered to be a risk factor.  Home sleep studies are usually only indicated for mild to moderate sleep apnea, but it in this case patient has severe OSA with a cardiac risk factor of HTN which would warrant an in-lab titration study.

The carrier's denial of coverage for the CPAP titration sleep study in a sleep center is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
 
Treatment: CPT code 43775- Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy) and associated inpatient admission

The insurer denied CPT code 43775- Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy) and associated inpatient admission. The denial was reversed.

This female was recommended for a laparoscopic sleeve gastrectomy.  She has a history of asthma, benign intracranial hypertension, sleep apnea, and obesity.  Documentation indicated she is 5 feet 3 inches tall and initially weighed 206 pounds, with a body mass index of 36.5.  She has participated in a multidisciplinary weight loss program.  The patient continued to be overweight and has undergone multiple visits including a psychiatric evaluation.  She has participated in treatment such as behavioral modification and diet.  The most recent chart note states the patient weighed 213 pounds with a body mass index of 37.7.

From published medical literature, adult candidates for a bariatric surgical procedure with a BMI between 35.0 to 39.9 kg/m2 should have at least one serious co-morbidity, including but not limited to: Type 2 diabetes; obstructive sleep apnea (OSA); hypertension; hyperlipidemia; obesity-hypoventilation syndrome; Pickwickian syndrome; non-alcoholic fatty liver disease; non-alcoholic steatohepatitis; pseudo tumor cerebri; gastroesophageal reflux disease; asthma; venous stasis disease; severe urinary incontinence; debilitating arthritis; impaired quality of life; and/or disqualification from other surgeries as a result of obesity. This patient is considered obese with a body mass index of 37.7.  She has had numerous previous treatment failures and has comorbidities such as moderate obstructive sleep apnea.  The patient has been under the care of multiple physicians and multiple specialties.  Therefore, the CPT code 43775- Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy) and associated inpatient admission is considered medically necessary.  

Regarding the inpatient stay, the procedure would require a 1 day inpatient stay. Inpatient status is needed to ensure the patient is hemodynamic stability, there is no evidence of postoperative or surgical site infection, a clear liquid diet tolerated, pain is absent or managed, and discharge plans and education is understood. The patient needs adequate monitoring post-operatively to ensure the staple line does not leak or other complications are present to include peritonitis, thromboembolic disease, wound infection, suture line bleeding, pneumonia, respiratory failure, portomesenteric thrombosis, and splenic injury.

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

Based on the above, the medical necessity for CPT code 43775- Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy) and associated inpatient admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Numbness and left sided weakness
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient is a female. She presented with the complaint of left-sided numbness and weakness. At presentation, her vital signs were stable and computed tomography (CT) of the brain was negative. 

The patient had six hours of paresthesia and normal neuro-imaging. Her presentation was not consistent with stroke or TIA (transient ischemic attack). The patient could have safely and effectively completed the diagnostic studies, monitoring and treatment at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain
Treatment: Inpatient admission

The proposed treatment, inpatient admission, was medically necessary.  

The patient is a G2P001 at 17 weeks' gestation who presented with nausea and periumbilical migrating to right lower quadrant pain for three days, worsening in nature and was eight out of ten (8/10) at presentation.  On exam there was tenderness at McBurney's point and positive obturator sign.  White blood cell (WBC) count was 10.7.  Ultrasound could not identify the appendix.  Magnetic resonance image (MRI) did revealed mildly thickened appendix.  The clinical diagnosis of appendicitis was made and surgical management was recommended.  However, the patient declined surgery and was given intravenous antibiotics.  

Repeat MRI demonstrated mildly thickened appendix with trace luminal fluid and surrounding edema.  The patient continued to refuse surgery and was discharged home.  

Appendicitis in pregnancy is associated with considerably greater morbidity and mortality compared to appendicitis in the non-pregnant state.  Peritonitis develops in 30% more women and there is a two fold increase in sepsis, septic shock, transfusion, pneumonia, bowel obstruction, postoperative infection, and increased length of stay.  Conservative management is associated with increased risk of shock, peritonitis, and venous thromboembolism compared to surgical management.  Particularly in the case of this patient who refused surgery, close monitoring is imperative due to the very high rate of complications.  In all cases, admission and immediate operation constitute the standard of care. Therefore the admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Vertigo 
Treatment:  Inpatient stay

The patient is a female who presented to the emergency department by ambulate after a near-syncopal episode, which occurred while taking a class at her gym.  The patient had not eaten that morning and had sudden onset of dizziness along with a spinning sensation and several episodes of vomiting.  She denied loss of consciousness.

The patient presented with unremitting vertigo refractory to intravenous fluids and medications.  Evaluation in the emergency room demonstrated overt risk factors for stroke, such as prior lacunar stroke and small vessel disease on brain imaging.  The patient required frequent neuro checks and observation for evolving signs of stroke.  Therefore, the decision for acute inpatient admission was justified, and this service was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness, headache
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient's elevated blood pressure was not accompanied by evidence of end organ damage such as hypertensive encephalopathy, acute cerebrovascular accident, acute heart failure or acute kidney injury.  The minimally elevated troponin was documented to be due to demand ischemia and not acute myocardial infarction.  Troponin levels remained flat and the electrocardiogram showed no acute ischemic changes.  Intravenous antihypertensive agents were not required after admission; the blood pressure improved with only oral antihypertensive agents.  The evaluation for acute cerebrovascular accident was negative.  There was no evidence of seizure activity.  There was no evidence of active bleeding during the hospital stay and the hemoglobin rose appropriately in response to transfusion of packed red blood cells.  The patient remained afebrile.  

In summary, inpatient admission on was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Decay and missing teeth
Treatment: D2752 - White glass with gold crown, Tooth #29
D3320 - Nerve treatment on bicuspid tooth, Tooth #29

Summary:
The patient is a female requesting benefits for a crown and root canal procedure on tooth #29.

While the patient definitely needs to hold onto this tooth to help chew properly, x-rays submitted do not show much tooth structure missing on tooth #29. An amalgam or composite restoration will be adequate to restore this tooth. There was no periapical x-ray submitted of tooth #29 showing the apex. If there was an infection in the tooth, a periapical x-ray, of the whole length of the tooth, would show this. Since this x-ray was not taken (or submitted), there is no infection seen, and therefore no need for the root canal procedure. A photo showing the full extent of the missing tooth structure might help in diagnosing the need for a crown, but none was submitted.
Appeal type: Medical necessity
Decision: Upheld

This patient admitted for acute inpatient hospitalization  for the indication of elevated blood pressure in the ambulatory setting. This patient  who presented at 30 weeks gestation with known gestational diabetes from  the  primary doctor's office with a blood pressure that was elevated to 165/105.Uphold (in whole) the health plan's determination of medical necessity in this case.
No, the requested inpatient hospital stay was not medically necessary.
The patient was admitted to the hospital for evaluation and management with diabetic teaching and for hypertension. The patient  was also noted to have hypertension with no severe features. The patient was also seen by dietary who set up a plan of meal and insulin management for this patient. Fetal testing was reassuring during hospitalization without any concern for non-reassuring fetal well-being.
Based upon a review of the American College of Obstetricians and Gynecologists (ACOG) guidelines for management of diabetes in pregnancy, there is a recommendation for frequent monitoring of blood glucose and institution of insulin for control.  There is also a recommendation for dietary advice and counseling.  These items can be completed in the hospital at a lower level of care and would not require inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: GI Bleed; Polysubstance abuse

Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services. The denial upheld.

This patient is a female patient with a past medical history of polysubstance abuse who presented with vomiting of coffee ground emesis. She was afebrile and the vital signs were stable. The abdominal exam was benign. The hemoglobin was 8.5. The platelets were 396,000. The patient was treated with Pantoprazole. Intravenous (IV) hydration was given for an elevated CPK level. An endoscopy revealed gastritis and esophagitis. There was no active bleeding seen. The CPK improved with intravenous (IV) hydration.

Clinical indications for admission for upper gastrointestinal (GI) bleeding include ongoing bleeding and high risk endoscopic features. The patient did not have these conditions. Severe liver disease is an indication, but in this case the patient did not have evidence of cirrhosis. The patient also did not have syncope, hemodynamic instability, anemia with evidence of myocardial ischemia, or thrombocytopenia.

This patient had polysubstance abuse and vomited coffee grounds. She required proton pump inhibitor (PPI) therapy and an endoscopy. However, she was stable to have had the endoscopy performed on an outpatient basis. There was no evidence of ongoing bleeding. She did not meet MCG criteria for admission for upper gastrointestinal bleeding. She could have been managed with observation status. She was stable to have had the gastritis and esophagitis treated with a Proton inhibitor (PPI) as an outpatient. The healthcare plan acted reasonably and with sound medical judgment. An inpatient medical admission was not medically necessary. The denial was appropriate.  

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

Diagnosis: Gastroenteritis

Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was upheld.   

This is a female patient with a history of hypertension and hyperlipidemia who presented to the Emergency Department (ED) with complaints of nausea, vomiting, and diarrhea with associated abdominal pain. A computed tomography (CT) scan of the pelvis was performed revealing liquid stool in the colon. The patient's stool was tested for clostridium difficile toxin which was negative. Gastroenterology consulted on the patient. She received intravenous (IV) antibiotics and potassium chloride supplementation. The patient was deemed medically stable and was discharged home with outpatient follow up instructions.

Based on the clinical guidelines, clinical indications for admission for gastroenteritis (M-170) include having a suspected severe infection such as bloody diarrhea, severe abdominal tenderness, hemodynamic instability, severe vomiting, and severe dehydration.  The patient did not have these conditions.

This patient had gastroenteritis.  She required intravenous (IV) hydration and stool testing.  This could have been done with observation status.  If antibiotics were felt to be necessary, they could have been given orally as an outpatient.  She did not meet MCG criteria for admission for gastroenteritis.

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 is upheld.  The medical necessity is not substantiated.