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


Diagnosis: fever
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a female with a past medical history significant for hypertension and hyperlipidemia who presented to the emergency department because of high fever and elevated heart rate. The patient denied losing her taste or smell, cough, sore throat, dizziness, chest pain, shortness of breath, cough, abdominal pain, or dysuria. Reportedly, the patient recently finished a course of Nitrofurantoin that she took because of a urinary tract infection. The patient denied any recent travel or sick contacts.
Upon initial evaluation in the emergency department, the patient underwent a chest x-ray as well as a urinalysis. Both studies were negative. When seen by the admitting physician, the patient's temperature was 99.3F, heart rate 99 beats per minute (bpm), respiratory rate 18 breaths/min, blood pressure 129/64, and oxygen saturation 98% on room air.

The acute inpatient admission was not medically necessary.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care.
Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.

The review of the medical records demonstrated the patient came to the hospital with complaints of fever that resolved very quickly, as well as tachycardia that was likely the result of the fever. The acute kidney injury that was mentioned in the medical records was minimal and resolved very quickly. There was no evidence that the patient had a urinary tract infection since the urinalysis was normal.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia

Treatment: D6010 implant placement of tooth #2, #3, #4, #8, #9, #10, #12, #13, #14, #15, #18, #19, #20, #30 and #31

The insurer denied coverage for D6010 implant placement of tooth #2, #3, #4, #8, #9, #10, #12, #13, #14, #15, #18, #19, #20, #30 and #31.

The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in areas enumerated above. The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. The insurer has denied the aforementioned services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants.  The insurer states that the medical records received do not demonstrate such a condition and therefore the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available.

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in both the maxilla and mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. Further the documentation provided does not support, justify, or substantiate the requested treatment.  Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

The health plan acted reasonably with sound medical judgment, as an appropriate alternative standard of care treatment would be conventional removable dentures and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable partial dentures. Therefore, as other acceptable alternative treatments are appropriate, and the documentation provided does not support the recommended treatment this renders the endosteal implants and associated services not medically necessary.

Based on the above, the medical necessity for the D6010 implant placement of tooth #2, #3, #4, #8, #9, #10, #12, #13, #14, #15, #18, #19, #20, #30 and #31 is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis

Treatment: hyaluronan injections (procedure code J7326)

The insurer denied coverage for hyaluronan injections (procedure code J7326)

The denial is upheld.

This is a patient with a history of synovitis of the left knee, and osteoarthritis. She presented to the Orthopedic Surgeon's for an evaluation. Magnetic resonance imaging (MRI) revealed evidence of osteoarthritis with moderate to severe cartilage abnormality along the patellofemoral region with partial medial meniscectomy, medial meniscal extrusion, and tear of the anterior horn with sprain with left knee joint effusion and popliteal cyst. The physician recommended arthroscopic joint debridement of the left knee followed by a series of three gel injections to the left knee.  

The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis if all other courses failed prior to surgery. The recommendations for use of Viscosupplementation have changed. A review of the Clinical Practice Guideline (CPG) by American Academy of Orthodedic Surgeons 

(AAOS [American Academy of Orthopaedic Surgeons]) cites:

The OA [osteoarthritis] knee treatment CPG contains one significant recommendation change from the CPG, and this is with regard to the issue of viscosupplementation. The  OA knee CPG included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG.

The second edition CPG recommendation reads "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "Strong" rating, based on supporting evidence from 3 high-quality and 11 moderate-quality research studies that met the inclusion criteria.

The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the CPG's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight HA preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). 

The Orthopedic group reports "strongly do not recommend use"

There has been no change to this Guideline. 

Additional references and expert opinion do not support benefit. 
A meta-analysis was completed of multiple references. This is a high-level evidence-based criteria which does not support use. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Hyaluronan injections (procedure code J7326) considered is not medically necessary for this patient.

The insurer's denial of coverage for hyaluronan injections (procedure code J7326) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia.

Treatment: D6010 implant placement, tooth 2, 18, 19, and 20.

The insurer denied coverage for D6010 implant placement, tooth 2, 18, 19, and 20.

The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in areas as enumerated above.  The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. The insurer has denied the aforementioned services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants.  The insurer states that the medical records received do not demonstrate such a condition and therefore the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available.  

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits a heavily restored dentition and oligodontia in the mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. Further the documentation provided does no support, justify, or substantiate the requested treatment.  Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary. 

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient. D6010 implant placement tooth #2, #18, #19, and #20 is not considered medically necessary for this patient.

Uphold denial of coverage for dental implants as not medically necessary, as an appropriate alternative standard of care treatment would be conventional removable dentures and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable partial dentures. Therefore, as other acceptable alternative treatments are appropriate, and the documentation provide does not support the recommended treatment this renders the endosteal implants and associated services not medically necessary.

The insurer's denial is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders
Treatment: Inpatient Hospital Stay

Diagnosis: Skin Disorders-abscess
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient stay as not medically necessary. The reviewer has upheld in whole the health plan's determination.

This is a healthy patient who presented to the emergency department (ED)  with a 3-day history of cellulitis and abscess at a port-site incision status/post (s/p) laparoscopic ovarian cystectomy 2 years earlier. This was the second infection that she experienced at this site. On physical examination, her vital signs were normal. She was afebrile, and not tachycardic. She had a 3 centimeter (cm) indurated area with fluctuance that was tender to palpation. Her white blood cell (WBC) count was normal at 10. Ultrasound showed a 2.6 x 1.1 cm abscess while a computed tomography (CT) scan showed it to be 2.9 x 1.3 x 1.3 cm without extension to the peritoneal cavity. She was admitted, started on antibiotics, and underwent bedside incision and drainage of approximated 5 cubic centimeter (cc) of purulent fluid. On hospital day 1, her WBC count was 7.3 and on hospital day 2, it was 6.9. She was discharged to home with antibiotics with a discharge diagnosis of cutaneous abscess of the abdominal wall.

No, admission at the acute in-patient level of service was not medically necessary for this patient. This was an uncomplicated cutaneous abdominal wall abscess that could have been managed at a lower level of care. A lower level of care would have been appropriate with bedside incision and drainage performed, and discharge to home on oral antibiotics, as occurred in this situation. A lower level of care would have been safe and effective for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This patient has a past medical history that includes coronary artery disease with a history of prior stent (or stents) to the left anterior descending (LAD), hypertension, hiatal hernia, hyperlipidemia, and obesity. She presented to the emergency department via ambulance with fatigue, nausea, shortness of breath for three (also reported as four) days, palpitations, chest pressure, near syncope, anxiety and exertional dyspnea which resolved with rest. Symptoms occurred while gardening and ambulating outdoors. 

At the hospital, the electrocardiogram (EKG) was normal. Troponin levels were normal X (times) 3 Covid antibody was positive, but subsequent testing was negative. Chest x-ray was unremarkable other than possible hiatal hernia. Vital signs were unremarkable. She was treated with aspirin, clopidogrel, metoprolol, and atorvastatin - all of which were taken as part of her home regimen. The emergency department (ED) planned to admit her "given cardiac Hx [history]".  Obstructive sleep apnea was noted with a recommended outpatient sleep study. Symptoms were attributed to deconditioning and to weight gain during covid pandemic. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The patient presented with atypical symptoms with normal EKG and troponin. These findings do not support a diagnosis of ACS [acute coronary syndrome]. 

For patients who present with symptoms suggestive of an acute cardiac ischemia event, a period of observation is recommended during which electrocardiogram (EKG) and Troponin levels are obtained. If these tests do not indicate the presence of an acute ischemic event, the patient can be further managed as an outpatient.  Acute inpatient management is not supported.  

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Remicade 100mg vial every four weeks. 
The denial is overturned.

The patient is a male. He has a history of inflammatory bowel disease, most likely Crohn's disease. He was started on infliximab (Remicade) at 10 milligrams (mg) per kilogram (kg) every 8 weeks, however, his infliximab level was noted to be low. The requested service is infliximab (Remicade) dose escalation to 10 mg per kg every 4 weeks. The subject under review is the medical necessity for the increased dose.
 
Escalation of infliximab (Remicade) to 10 mg per kg every 4 weeks is appropriate and consistent with the generally accepted medical practices.
The management of inflammatory bowel disease is very complicated, and the available treatments are limited. It is very common for patients with Crohn's disease to lose response to their biologic over time or to require higher than standard dosing. The standard practice in the management of inflammatory bowel disease to try to rescue the treatment by increasing the dose and/or the frequency (dose escalation).
There are many peer-reviewed literature reports showing that low infliximab levels were associated with poor clinical response. The experience with dose escalation of infliximab has been extensive in both adult and pediatric patients. The available scientific evidence strongly supports the safety and efficacy of this approach.
According to the clinical practice guidelines: "Intravenous administration of infliximab (Remicade) is usually at 5 milligrams per kilogram (mg/kg) with three induction doses over 6 weeks [weeks 0-2-6], followed by maintenance therapy of 5 mg/kg every 8 weeks. However, there is ample evidence that children less than 30 kg, and those with extensive disease and low serum albumin levels, require higher induction doses up to 10 mg/kg, shorter dosing intervals, or both, to reach target trough levels" (Van Rheenen et al.).
This patient was started on the standard dose of infliximab. However, his drug level is significantly below the recommended target. If dose escalation is not performed rapidly, treatment failure is expected, which will lead to disease flares and complications.
Therefore, dose escalation and optimization are the most appropriate next step.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: pharmacy/prescription drugs. 
The insurer denied: Stelara 90mg/ml every 4 weeks. 
The health plan's determination is overturned. 


The patient is a male with severe ileocolonic Crohn's disease with prior bowel resection. He has previously tried and failed two anti-tumor necrosis factor (TNF) alpha agents (infliximab and adalimumab). He has also failed immunomodulators (azathioprine and mercaptopurine [6-MP]) as well as steroids. He was started on Stelara and discontinued due to insurance issues but was restarted on Stelara. He was initially doing well on Stelara at standard dosing every 8 weeks but started losing response. He had a new fistula and active disease seen on colonoscopy. He required courses of steroids to treat his flare. Therefore, the attending provider would like to escalate the dose of Stelara to 90 milligrams (mg) every 4 weeks to treat his severe Crohn's disease. The subject under review is whether the increased dose is likely to be more beneficial for the patient than any standard treatment.

The health plan's determination is overturned in whole.

Since this patient was not responding to standard dosing of Stelara, it is reasonable to increase the dose of Stelara to 90mg every 4 weeks. Dose escalation in biologic therapy used in inflammatory bowel disease can be done either based on clinical symptoms or laboratory markers or endoscopic or radiological features with or without therapeutic drug monitoring. Dose escalation is done either by increasing the dose of the medication or shortening the interval between doses or sometimes a combination of both. This patient has medically refractory Crohn's disease and has tried and failed two other Food and Drug Administration (FDA) approved biological agent used to treat Crohn's disease. There are only a finite number of biological agents used to treat inflammatory bowel disease and the standard of care is to optimize dose before switching to another agent. Therefore, it is likely to be more beneficial for this patient to use Stelara 90mg SQ every 4 weeks to treat his severe Crohn's disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: pharmacy/prescription drugs. 
The insurer denied: Stelara 90mg/ml every 4 weeks. 
The health plan's determination is overturned. 

The patient is a male with Crohn's disease. status post ileocecectomy and sigmoid colectomy to address fistula and stricture, and ileocolic resection and diverting loop ileostomy. He has failed mesalamine, azathioprine, 6-mercaptopurine, high-dose infliximab, and adalimumab. He started Stelara, he was found to have ileitis with stricture, peri-enteric abscess, and new perianal fistula. Computed tomography scan of the abdomen and pelvis showed active ileal inflammation with likely ileocolonic fistula, and colonoscopy showed ileal ulcers and a fistula. He has had 4-6 loose bowel movements daily and postprandial right lower quadrant abdominal pain. The subject under review is the requested for Stelara 90 milligrams (mg) every 4 weeks for the treatment of Crohn's disease.

The request for Stelara to 90 mg every 4 weeks is supported as likely to be more beneficial than any standard treatment or treatments by 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].
In this case, the patient has severe disease based on extensive disease complicated by fistula and stricture. 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 efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted [7]. Additionally, 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 failed Stelara every 8 weeks, with ongoing symptoms and multiple objective findings of active disease on imaging and colonoscopy; dosing every 8 weeks or discontinuation of Stelara (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this patient with moderate to severe disease. For all of these reasons, the request for Stelara 90 mg every 4 weeks is supported as likely to be more beneficial than any standard treatment or treatments in this case.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease without esophagitis.
Treatment: Sucralfate suspension.
The insurer denied Sucralfate suspension.
The determination is overturned.

The patient is a male with gastroesophageal reflux disease (GERD) complicated by Barrett's esophagus, hiatal hernia status post Nissen's fundoplication, peptic ulcer disease with duodenal ulcer, and gastroparesis. He has had chronic dyspepsia and abdominal discomfort. He could not tolerate sucralfate tablets. Coverage is being requested for sucralfate suspension.

A formulary exception is indicated in this case. The submitted documentation reports that the patient attempted and failed sucralfate tablets in the past. Sucralfate (Carafate) is effective for the treatment of gastroesophageal reflux disease (GERD) symptoms. It is also effective for the treatment of peptic ulcer disease and dyspepsia associated with duodenogastric reflux. Sucralfate is available in tablet and liquid suspension forms, with similar reported efficacy and adverse effects, although the suspension has different physical characteristics which can result in easier traversion of the esophagus and different physical distribution in the stomach. As the patient has failed the tablet form, use of the suspension can be effective.