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

Diagnosis: Duchenne Muscular dystrophy

Treatment: Emflaza

The insurer denied Emflaza. The denial was reversed.   

This patient is a male with a diagnosis of Duchenne muscular dystrophy with mutation of exon 68. He was consulted by a neuromuscular specialist for complaints of right foot weakness and a waddling gait and reduced verbal output. Emflaza was recommended due to the patient's significant weight fluctuation and his inability to meet milestones as well as elevated creatinine phosphokinase (CPK) level. It was suggested that prescribing prednisone to the patient may lead to weight gain and increase unnecessary load on this patients already deteriorating muscles. Further documentation indicated that the patient was below the 50th percentile for height. Documented research indicated there is a link between shorter stature and prednisone use. 

According to medical literature, Emflaza (deflazacort) is a corticosteroid indicated for the treatment of Duchenne muscular dystrophy (DMD) in patients 2 years of age and older. According to current peer-reviewed literature, while prednisone and deflazacort have similar efficacy with regard to improved muscle strength, deflazacort, is associated with less weight gain than prednisone given that the patient is already above the 95th % for age. Based on this literature review, this patient's progressive muscle weakness due to his diagnosis of Duchenne Muscular Dystrophy and the concern for weight gain due to his history of being in the 95th percentile for weight, literature supports the use of Emflaza (deflazacort) over prednisone to treat this patient's medical condition. 

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

The carrier denial of coverage for Emflaza is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a female with a history of left hip surgery. She presented to the emergency room with complaints of an odd visual sensation, lightheadedness, and numbness and tingling of the left arm. The visual symptoms and lightheadedness resolved in minutes, but the left arm paresthesia persisted. The vital signs were normal. One examiner noted some mild left arm weakness. The computed tomography (CT) scan was unremarkable. The case was discussed with the neurology consultant and an magnetic resonance imaging (MRI) and electroencephalogram (EEG) were recommended. The patient was admitted for further evaluation. The MRI and EEG were unremarkable and the patient was discharged the following day. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld.

No, based on a thorough review of the information provided, the requested inpatient stay was not medically necessary for this patient. 

Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required an acute inpatient admission. The MRI and EEG did not require an inpatient level of care for completion. Based on the standard of care and peer reviewed literature, the acute inpatient stay was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders
Treatment: Pharmacy/Prescription Drugs
The insurer denied: Dupixent
The denial is: Upheld in whole

The patient is a male with past medical history for asthma, eczema, and food allergies who is being treated for severe atopic dermatitis. The patient has been treated with triamcinolone and tacrolimus topical ointments with minimal improvement. The patient's provider is requesting to treat the patient with Dupixent. The subject under review is the medical necessity of Dupixent in this case.

The health plan's determination is upheld, in whole.

Dupixent is not medically necessary for this patient. Dupixent is not yet approved for this age range (currently under investigation), and the patient has not demonstrated an adequate trial and failure to all other standard of care measures which would be considered first and second line therapies. Based on the standard of care, certain systemic medications can also be used in atopic dermatitis. While oral immunosuppressive medications may not be specifically Food and Drug Administration (FDA) approved for the treatment of atopic dermatitis, their use is considered standard and well supported in the medical literature. Therefore, Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell crisis
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the inpatient admission was not medically necessary. 

The patient is a woman with sickle cell disease and a history of avascular necrosis status post (s/p) primo hip replacement.  Her history is also notable for prior acute chest syndrome, pulmonary embolism and stroke.  She presented to the emergency department with back pain, right sided weakness and blurred vision in the left eye.  She had no other complaints.  

Exam was notable for mild right upper extremity weakness.  Stroke alert was called.  Computed tomography (CT) was done and revealed no hemorrhage.  Repeat neurologic examination was notable for resolved neurologic deficit.  Brain magnetic resonance image (MRI) revealed no acute stroke.  She had continued pain and was admitted to the hospital for pain control and also for continued transient ischemic attack (TIA) evaluation.  Progress note, written after admission, noted that there were no neurologic deficits and that she was not in distress and physical exam was unremarkable. She was seen by neurology and again there were no neurologic abnormalities on examination. Blood pressure control and continued Lovenox (she was on Lovenox before hospitalization) were recommended.  The patient was seen by the general medicine attending and was noted to be clinically stable. Discharge was recommended and she was kept until the following day because it was noted that the patient wanted to stay and leave early the next morning.

This patient presented with findings concerning for stroke.  Stroke was ruled out on the day of presentation based on imaging studies, and notably her neurologic deficits resolved while in the ED before admission.  She did not have poorly controlled pain as records state her pain improved with doses of intravenous (IV) pain medication.  Inpatient records do not state that she had poorly controlled pain while in the hospital.  She was noted appropriate for discharge and she was kept until the following day.  She did not have acute infection, hemodynamic compromise or severe anemia.  As noted above, neurologic symptoms resolved spontaneously. Given these considerations, the acute care inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary
Treatment: Inpatient hospital stay
The insurer denied the Inpatient hospital stay
The health plan's determination is overturned in whole. 

The requested treatment of inpatient stay is medically necessary for this patient based on the clinical documentation submitted for review, professional guidelines, and the peer reviewed literature. The need for NIV for work of breathing, which was extended beyond 24 hours at the recommendation of pulmonology, and the fact that the patient also had mild acidemia noted on multiple blood gases supports an inpatient stay. Per the Milliman Care Guidelines (MCG) inpatient guidelines, copd management as inpatient, any person with a ph less than 7.35 should be considered for admission This patient had a ph of 7.32 in the ED.  Furthermore, the episode of abdominal pain within the first 24 hours of admission was concerning for an acute abdomen. The patient needed urgent imaging, evaluation with GI and a surgery consultation. The recommendation was for urgent colonoscopy for ileus / partial obstruction, which the patient declined. For these reasons, Inpatient stay was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a history of hyperlipidemia, pre-diabetes, glaucoma, and left shoulder arthroscopy.  She presented to the Emergency Department (ED) with complaints of left sided chest pain radiating to the left arm for 1 hour with associated dizziness, nausea, headache and dyspnea.  Her presenting vital signs were: BP 142/82, heart rate 78, respiratory rate 16, temperature 97.5 F, and oxygen saturation on room air 100%.  Cardiology was consulted. An electrocardiogram (EKG) was performed that revealed normal sinus rhythm with premature atrial complexes and was normal.  A chest x- ray was done that was noted to be normal.  Laboratory test was performed that revealed WBC 7.74, hemoglobin 12.8, creatinine 0.73, BNP 59, and troponin <0.015, with subsequent troponin levels that were also <0.015.  Echocardiography performed with normal results. A pharmacological nuclear stress testing was performed with normal left ventricular systolic function, no wall motion abnormalities, and no myocardial perfusion defects.  She was discharged to home on her home medications. 

There is no evidence that this patient required an acute inpatient level of care to determine that her chest discomfort was not related to acute coronary syndrome.  This could have been completed in the ED or at an observation level of care.  The healthcare plan acted reasonably, with sound medical judgement, and in the best interest of the patient.

Denial of coverage for the inpatient admission is upheld because there is no evidence that this patient was at increased risk for short term adverse cardiovascular events requiring inpatient monitoring and management, based on her clinical presentation and results of testing performed in the emergency department (ED).

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: Upheld

Diagnosis: Severe Diastema, Deep Overbite.

Treatment: D8080 braces and D8670 monthly visit x4.

The insurer denied the D8080 braces and D8670 monthly visit x4.

The denial was upheld.

This is a patient who consulted an orthodontist for orthodontic care. Diagnostic imaging was performed that included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images. The orthodontist identified several clinical findings including severe diastema and deep overbite and has recommended orthodontics. The Orthodontist has completed the HLD index attaining 11 total points to support orthodontic care. The patients HLD index score of 8 points on the HLD index. 

It is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 11 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist attaining a total of 11 points on the HLD index (2 points overjet, 7 points overbite, 2 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note in this case, is that the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.

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

The health plan acted reasonably with sound medical judgment in the best interest of the patient. In this case the patient's own orthodontist completed HLD index total score of 11 points remains below the threshold of 26 points to justify orthodontic care.

Coverage for D8080 braces and D8670 monthly visit x 4 is considered not medically necessary for this patient.

Based on the above, the medical necessity for D8080 braces and D8670 monthly visit x4 is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prolapsed painful hemorrhoids.
Treatment: Inpatient admission.

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

The patient is a male who presented to the Emergency Department with prolapsed painful hemorrhoids. He had been treated for rectal bleeding two weeks prior and received transfusions for same. About five days prior to his arrival in the ED, he experienced prolapse of the hemorrhoids and has been unable to reduce them. 

The patient's physical exam in the ED was confirmatory of strangulated prolapsed internal hemorrhoids. Efforts made to reduce them were unsuccessful. The patient was noted to be on both ASA (aspirin) and Plavix, and he was admitted to the surgical service acute in-patient status with a diagnosis of prolapsed internal hemorrhoids. 

The patient was taken to surgery where under general anesthesia, the prolapsed hemorrhoids were reduced. A hemorrhoidectomy was not performed at that time. He was discharged from the hospital to be followed in the clinic with plans for definitive hemorrhoidal treatment following resolution of the acute process. 

No, the Inpatient admission was not medically necessary. 

During surgery, a decision was made by the operating surgeon not to proceed with a hemorrhoidectomy at that time noting in the operative report, "He was admitted to surgical service with the plan for definitive operative repair," and then continues with, "After reduction there was a small external component, and he did not need a full hemorrhoidectomy." 

The severity of illness and intensity of services rendered do not rise to the level of care to substantiate acute inpatient services. The care rendered during that interval could have been accomplished on an outpatient basis, with a surgical hemorrhoidectomy performed as an ambulatory procedure. The proposed treatment was not medically necessary, and the denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmatics

Treatment: Inpatient Admission

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

This is a young female patient who presented to the Emergency Department (ED) after being evaluated at the Urgent Care Center for complaints of a cough for two days. It was reported that upon presentation the patient was noted to have moderate respiratory distress with increased work of breathing. Significant wheezing was noted on physical exam. Laboratory work up was performed revealing an elevated lactic acid level of 2.9. a respiratory viral panel was done which was negative. A computed tomography (CT) scan of the chest was done that showed a retrocardiac infiltrate versus atelectasis. She received nebulized treatments of albuterol and Atrovent, intravenous (IV) ceftriaxone, methylprednisolone and magnesium sulfate. It was reported that the patient continued with respiratory distress despite the medical intervention. She received IV fluid bolus and continuous albuterol for one hour. She was admitted to the Pediatric Intensive Care Unit (PICU) where she continued treatment with IV antibiotics, steroids and albuterol respiratory treatments. The patient was medically stabilized and discharged home. 

Based on the review of the literature, the patient was treated appropriately in the ER for wheezing, respiratory distress and shortness of breath from asthma and pneumonia.  However, it was noted that despite ER treatment with continuous albuterol and magnesium sulfate administration, the patient's symptoms was persistent and was concerning for respiratory deterioration. Literature indicates that patients, whose symptoms do not respond rapidly despite treatment with continuous beta-agonist nebulization therapy, should be closely monitored for worsening respiratory status.  The literature indicates that the use of magnesium sulfate should be limited to those with severe asthma exacerbations while in the emergency department or for those who require ICU care. 

At the emergency department, this patient received maximal care for her severe asthma exacerbation. This patient received continuous nebulizer treatment and magnesium sulfate. Despite this level of care, this patient's symptoms persistent, and required inpatient monitoring at the Pediatric Intensive Care Unit (PICU). Due to this patient's high risk for respiratory decline and potential need for ventilatory support, inpatient admission was medically necessary and consistent with the standard of care of treating for a pediatric patient with status asthmaticus.

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

The carrier's denial of coverage for the acute inpatient hospital is reversed.  The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD
Issue under review: Linx procedure

Determination:
The health plan should cover the Linx procedure.

The patient is an adult male with GERD (gastroesophageal reflux disease).Esophageal Manometry revealed normal motility according to the physician.  

Consultation with the physician discussed that chronic cough symptoms of the last five years possibly are related to reflux.   

EGD (esophagogastroduodenoscopy)/Bravo probe, Biopsy revealed mild esophagitis and DeMeester score of 46.8. 

Bronchoscopy was negative for lesions. 

This patient suffers from GERD causing chronic cough.   Even with maximal medical therapy, there would be refluxing gastric contents.   Surgical therapies exist that resolve this very well.  Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF make it a less than ideal operation.  Linx is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term.  It is approved by the FDA.  There is published data on patients who have had the device for six years, showing a very low complication rate and a high resolution of GERD.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD
Issue under review: Linx procedure

Determination:
The health plan should cover the Linx procedure.

The patient is an adult male with BMI 32 kg/m2. He has a long history of GERD (gastroesophageal reflux disease) with chronic cough. 24 hour pH study revealed an elevated DeMeester score consistent with GERD.   Manometry was normal. EGD (esophagogastroduodenoscopy) revealed) mild esophagitis and no significant hiatal hernia. 

LINX is considered a standard surgical treatment for GERD within the medical community and is recommended in updated published guidelines from the Society of Gastrointestinal and Endoscopic Surgeons to be a safe, effective and durable treatment for GERD for mid to long-term outcomes based on published findings. There are only a few exclusions to the treatment, of which the patient has none- he is at least 18 years of age, has a BMI <35 kg/m2 and does not have history of prior gastric or bariatric surgery. 

This patient has GERD refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure, which is FDA approved for treatment of GERD. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons.