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

Diagnosis: Hypercholesterolemia
Treatment: Repatha (Evolocumab) SureClick 140 milligrams/milliliter (mg/ml) subcutaneous (SC) solution auto injector (SOAJ)
The insurer denied coverage for Repatha SureClick 140 milligrams/milliliter (mg/ml) subcutaneous (SC) solution auto injector (SOAJ)
The denial is upheld

The patient is a woman with a history of hypercholesterolemia, non- ischemic cardiomyopathy on guideline directed medical therapy with an LVEF (left ventricular ejection fraction) of 45-50% (percent), AV (atrioventricular block) status post permanent pacemaker, asthma and obesity. Cholesterol while on Zetia alone was 263mg/dl (milligrams per deciliter) with an LDL (low density lipoprotein) of 163mg/dl. The patient had muscle pain and cramping while taking rosuvastatin and atorvastatin resulting in discontinuation of statin agents. Exercise perfusion study revealed no significant ischemia.

This is a female patient without hypertension. She had a normal myocardial perfusion study and a preserved LVEF. She has no history of atherosclerotic cardiovascular disease. Her ten-year risk of a cardiovascular event is 3%. Although the patient did not tolerate statin therapy, due to muscle cramping, current American Heart Association and American College of Cardiology guidelines recommend Evolocumab only when LDL cholesterol is 190mg/dl or above. The addition of Evolocumab would be indicated if the patient had evidence of clinical atherosclerotic cardiovascular disease and a 10- year risk of greater than or equal to 7.5%, or if LDL cholesterol were higher. In conclusion, treatment with Repatha/Evolocumab is not medically necessary.

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

The insurer's denial of coverage for the Repatha SureClick 140 milligrams/milliliter (mg/ml) subcutaneous (SC) solution auto injector (SOAJ) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System - Respiratory Distress.
Treatment: Inpatient Admission.
The insurer denied Inpatient Admission.
The denial is overturned. 

The patient is a male with asthma (no prior admissions), who presented with 1-2 hours of dyspnea and wheezing. In the emergency department (ED), his temperature was 98.0, blood pressure (BP) was 135/75, heart rate (HR) was 110, respiratory rate (RR) was 23, and pulse oxygen saturation (spo2) was 100 percent (%) high flow nasal cannula (HFNC) (40 liters (L), 40%). His heart was regular, lungs were decreased, and wheezy with accessory muscle use and respiratory distress.
His white blood cell count (WBC) was 10.5, sodium (Na) was 139, bicarbonate was 26, blood urea nitrogen (BUN) /creatinine (Cr) was 13/1.09, troponin (Tn) was less than (<) 0.012, lactate was 2.1, venous blood gas (VBG) was 7.38/48, coronavirus (COVID) was negative. The chest x-ray (CXR) was clear.
He was given intravenous (IV) steroids, nebulized bronchodilators, IV magnesium, and high flow nasal cannula and despite this, his exacerbation remained severe. He was admitted and diagnosed with an acute asthma exacerbation, and started on IV steroids and nebulizers.
He was discharged on by mouth (PO) prednisone.
At issue is the medical necessity of Inpatient Admission.

The health plan's determination of medical necessity is overturned as a whole.

Yes, the requested health service/treatment of Inpatient Admission was medically necessary for this patient.
The patient presented with dyspnea and was diagnosed with an acute asthma exacerbation. While he was not a high-risk individual with prior admissions or intubations, he was severely ill at presentation with severe dyspnea and acute respiratory failure requiring respiratory support with high flow nasal cannula oxygen. This is not considered supplemental oxygen to correct hypoxemia but active respiratory support for acute respiratory failure and life-threatening dyspnea with respiratory muscle fatigue. Patients with this severity of illness require close and often prolonged monitoring given the high risk of worsening and the possible need for invasive mechanical ventilation and critical care. This cannot be done on an outpatient or observation basis. Given this severity of illness, an inpatient admission was medically necessary.
Therefore, the requested health service/treatment of Inpatient Admission was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: New Onset Diabetes

Treatment: Inpatient Hospital Admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

The patient is male with past medical history of hypertension (HTN), asthma, hepatitis C virus (HCV), and chronic low back pain (LBP). The patient presented to the emergency department (ED) with complaints of fatigue, polyurea, polydipsia, and vomiting that started the morning before presentation. The patient was previously informed by his primary care provider that he was pre-diabetic. The patient's fasting blood sugar (FBS) was taken by his cousin, which showed blood glucose over 500 mg/dl (milligrams per deciliter). In the ED, the patient's vital signs were stable (VSS). Point of care glucose more than 500 mg/dl times two. Laboratory significant for glucose 708 mg/dl, sodium 126, anion gap 17, CO2 (carbon dioxide) 19, lipase 84, VBG (Venous Blood Gas): PO2 (pressure of oxygen) 61, glucose 687, sodium 140. UA (urinalysis): Glucose greater than or equal to 1000 and trace blood. LFTs (Liver Function Tests): alkaline phosphatase 168, ALT (Alanine Transaminase) 80, AST (Aspartate Transaminase) 54. Intervention: Regular insulin IV (intravenous) 10 units x (times) 1 and 12 units x1, normal saline (NS) intravenously bolus, twice. The patient was transferred to another facility for further management of new onset diabetes.

"Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management is key to the successful resolution of DKA and HHS. Critical components of the hyperglycemic crises management include coordinating fluid resuscitation, insulin therapy, and electrolyte replacement along with the continuous patient monitoring using available laboratory tools to predict the resolution of the hyperglycemic crisis. Understanding and prompt awareness of potential of special situations such as DKA or HHS presentation in comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA, and risk of brain edema during the therapy are important to reduce the risks of complications without affecting recovery from hyperglycemic crisis. Identification of factors that precipitated DKA or HHS during the index hospitalization should help prevent subsequent episode of hyperglycemic crisis." (Gosmanov, et al, 2018)

The inpatient admission is not considered medically necessary for this patient.

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

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

Diagnosis:  Urosepsis.
Treatment:  Inpatient admission.

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

This is an adult female with past medical history of diabetes, pancreatitis, and hypertension. This patient presented to emergency department with complaints of a 3 day history of abdominal pain, nausea and vomiting. The patient's urinary analysis was suggestive of a urinary tract infection (UTI). Her temperature was 102.6 degrees Fahrenheit. The x-ray of her foot revealed a moderate inferior calcaneal spur. The patient was admitted with urosepsis and was given intravenous (IV) Vancomycin and Cefepime. The patient left against medical advice (AMA) before the care plan could be completed. The insurer has denied coverage for the inpatient admission as not medically necessary. They stated there was no sign that the patient had a serious health issue requiring an inpatient admission. The appeal on behalf of the hospital is noted and read in detail. Per MCG Health (25th) Urinary Tract Infection, patient fails to meet clinical indications for admission to inpatient care. These include hemodynamic instability, altered mental status, urethral obstruction, or worsening of clinical finding despite observational care treatment, etc. 

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: iron deficiency anemia

Treatment is the drug (Infed) (procedure code J1580)

The insurer denied coverage for the drug (Infed) (procedure code J1580)
 
The denial is overturned

The patient is an adult female who was pregnant with a diagnosis of iron deficiency anemia. The patient has poor iron absorption due to celiac disease necessitating intravenous iron. The patient had a prior reaction to iron sucrose. The patient was given Infed. Oral and intravenous iron are both effective for replenishing iron stores. However, because of celiac disease this patient has poor iron absorption, therefore the need for intravenous (IV) iron.

All intravenous iron products appear to have equivalent safety and efficacy, as illustrated by various studies, including single-agent studies and direct comparisons between different products in pregnant and nonpregnant populations. Thus, the choice of products is based on the costs and burdens of administration. One exception is formulations that contain benzyl alcohol as a preservative (the ferric gluconate preparation Ferrlecit). In addition, iron sucrose requires four to five separate infusions, in contrast to other formulations for which a single replacement dose can be administered in a single visit with a single infusion.

Ferric carboxymaltose (FCM), low molecular weight iron dextran (LMWID), ferumoxytol, ferric derisomaltose (iron isomaltoside) are all safe options for a pregnant woman. In summary, this patient was pregnant and had iron deficiency anemia necessitating IV infusion. 

INFeD (Iron Dextran Injection USP) is safe in pregnancy and is medically necessary for this patient.

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 drug (Infed) (procedure code J1580) is overturned. 

Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: disc herniation

Treatment is an inpatient admission 

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

This is an adult male who presented to the emergency department complaining of severe lumbosacral pain radiating to the right leg for 6 days. He took Tylenol extra strength and oxycodone IR (instant release) without relief of symptoms. He was scheduled for surgery the following week. However, surgery was rescheduled for the following day after his physician noted a large L (lumbar) 2-L3 central disc herniation with inferior migration. The patient was admitted for pain control and preoperative work-up prior to the L2-L3 laminectomy/discectomy. His pain control could have been rendered on an outpatient basis or under observational care. The surgery could have been completed on an outpatient basis as there were no complications following the procedure. An appeal letter was submitted stating that in addition to the L2 laminectomy, the patient required removal of an extra mass and an L3 revision with partial L4 laminectomy, excision of a migrated herniated disc behind the L3 vertebral body, and posterior lateral fusion with local autograft at L2-L3. Based on the risk for complication that could potentially affect neurological function, the patient required a higher level of monitoring and care. This review pertains to the denial of coverage for inpatient admission.

The Milliman Care Guidelines state that patients with low back pain typically will require hospitalization when they have severe pain that cannot be managed in the emergency department, have a suspected spinal infection, or have a suspected cause that requires inpatient treatment such as aortic dissection or spinal cord impingement. The guidelines state that in terms of lumbar fusion, the goal length of stay is 2 days postoperative.

Based upon the provided information, the prior determination is partially overturned to allow for partial coverage for the inpatient admission.

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 inpatient admission is modified. Medical necessity is substantiated for 2 days. Medical necessity is not substantiated for 1 day. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: disc herniation

Treatment is an inpatient admission 

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

This is an adult male who presented to the emergency department complaining of severe lumbosacral pain radiating to the right leg for 6 days. He took Tylenol extra strength and oxycodone IR (instant release) without relief of symptoms. He was scheduled for surgery the following week. However, surgery was rescheduled for the following day after his physician noted a large L (lumbar) 2-L3 central disc herniation with inferior migration. The patient was admitted for pain control and preoperative work-up prior to the L2-L3 laminectomy/discectomy. His pain control could have been rendered on an outpatient basis or under observational care. The surgery could have been completed on an outpatient basis as there were no complications following the procedure. An appeal letter was submitted stating that in addition to the L2 laminectomy, the patient required removal of an extra mass and an L3 revision with partial L4 laminectomy, excision of a migrated herniated disc behind the L3 vertebral body, and posterior lateral fusion with local autograft at L2-L3. Based on the risk for complication that could potentially affect neurological function, the patient required a higher level of monitoring and care. This review pertains to the denial of coverage for inpatient admission.

The Milliman Care Guidelines state that patients with low back pain typically will require hospitalization when they have severe pain that cannot be managed in the emergency department, have a suspected spinal infection, or have a suspected cause that requires inpatient treatment such as aortic dissection or spinal cord impingement. The guidelines state that in terms of lumbar fusion, the goal length of stay is 2 days postoperative.

Based upon the provided information, the prior determination is partially overturned to allow for partial coverage for the inpatient admission.

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 inpatient admission is modified. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atherosclerotic Cardiovascular Disease (ASCVD).
Treatment: Repatha.
The insurer denied Repatha. 
The health plan's determination is overturned. 

The patient is a male with hypercholesterolemia. Repatha is medically necessary for this patient.

This patient has marked hyperlipidemia with a baseline low density lipoprotein (LDL) cholesterol level of 220-248. Based on this level, he meets criteria for a diagnosis of phenotypic heterozygous familial hypercholesterolemia. Published studies have indicated that the long-term atherosclerotic cardiovascular disease risks for US (United States) adults with a baseline LDL greater than or equal to 190 are increased approximately 5-fold compared to those with average levels of LDL, even after adjustment for other cardiovascular risk factors. Current guidelines, including the 2017 National Lipid Association Update on the Use of PCSK9 (Proprotein convertase subtilisin/kexin type 9) Inhibitors in Adults and the 2017 Focused Update of the 2016 American College of Cardiology (ACC) Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk, endorse the use of PCSK9 inhibitors (such as Repatha) in this situation.

Per the medical record and the case notes, the patient also has a diagnosis of atherosclerotic cardiovascular disease (ASCVD). The above mentioned guidelines also consider this an indication for treatment with PCSK9 inhibitors in statin intolerant patients whose LDL cholesterol level is 70 or greater.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: Personal Care Aide (40 hours per week, 6 hours x 5 days, 5 hours x 2 days)
The insurer denied the Personal Care Aide (40 hours per week, 6 hours x 5 days, 5 hours x 2 days. 
The denial is upheld. 

The patient is a male with medical history notable for back and arm pain secondary to arthritis. The plan approved 24.5 hours per week of level 2 personal care assistance (3.5 hours per day for 7 days a week). The patient and his care team requested an increase to 40 hours per week (6 hours a day, 5 days a week and 5 hours per day, 2 days per week). The plan increased hours to 28 hours per week (4 hours per day, 7 days per week) but denied the complete request for 40 hours per week. This denial is the subject under review. 

The health plan's determination is upheld.

The requested service of Personal Care Aide (40 hours per week, 6 hours x 5 days, 5 hours x 2 days) has not been demonstrated to be medically necessary for this patient. 
The patient has several functional limitations related to pain which impact his ability to complete activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). These limitations are outlined in the UAS (Uniform Assessment System). The tasking tool associated with the UAS recommends 23.8 hours for personal care activities. He was approved for 28 hours, a 17% increase over the recommended minimum hours. There is no documentation of unmet personal care needs that would justify medical necessity for increased hours.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 braces and D8670 monthly visit
The insurer denied coverage for D8080 braces and D8670 monthly visit.
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified anterior crossbite in addition to asymmetric mandible, and maxillary and mandibular spacing. The orthodontist has completed the HLD (Handicapping Labiolingual Deviation) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic index; the HLD New York State Medicaid program modeled after HLD 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 crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 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. Regarding the validity of the HLD, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies referenced. Each of these 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 appropriate approach for assessing orthodontic need. 

Based on the above, the insurer's denial must be overturned. 

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

The medical necessity for D8080 braces and D8670 monthly visit services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is overturned.

This is a young male child with a history of asthma. He was noted to have a cough and nasal congestion for 2 days. He was taken to the emergency room (ER) for difficulty breathing and he was treated with three doses of DuoNebs and prednisone. He was discharged home to continue to take the albuterol and prednisone. The next day he continued to cough and have difficulty breathing and the parents indicated that he was breathing worse than the day before so that brought him back to the ER for additional treatment. In the ER, he was noted to be in respiratory distress with suprasternal and subcostal retractions and tachypnea. He was noted to be fatigued with a lack of energy. On physical examination he was noted to be wheezing and had evidence of inspiratory crackles. He was treated with another 3 doses of DuoNebs nebulizer treatments, prednisone, and magnesium sulfate. He was also treated with 2 boluses of normal saline. Following this treatment, he was also administered 2 additional inhalation treatments with albuterol. Following treatment in the ER, the decision was made to admit the child to the hospital with a diagnosis of status asthmaticus for continued treatment with albuterol every 2 hours.

The patient was treated appropriately in the ER for an acute episode of wheezing, and difficulty breathing. The child was seen in the ER the day prior to the admission and was treated for an acute episode of asthma and sent home on continued treatment for asthma. When the child failed to improve with treatment in the home and he continued to have persistent retractions in the ER following aggressive therapy for asthma, it was appropriate and consistent with the standard of care to admit the child to the hospital with a diagnosis of status asthmaticus for ongoing albuterol every two hours. He had failed to improve with home treatment for asthma following the ER visit on the day prior to the admission and he was not stable enough to be safely discharged. 

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 inpatient hospital is overturned. Medical Necessity is substantiated.