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

Diagnosis: Pregnancy/Childbirth/Other-NAS
Treatment: Inpatient hospital stay
The health plan denied the extended stay in the hospital for this patient. 
The reviewer has overturned in part the health plan determination.

The infant was born by vaginal delivery. The neonate was 40.1 weeks estimated gestational age and her mother was a  Gravida 6 now Para 2  who had late prenatal care. Maternal serologies were negative, and the medical history was significant for chlamydia that was treated and oxycodone use. The mother had prescribed use of oxycodone for sciatica, and was taking 10-30 mg/day. Drug testing on the mother was positive for oxycodone only.
The infant's birthweight was 3365 grams, and the Apgar scores were 9 and 9 at one and five minutes, respectively. The neonate was taken to the Neonatal Intensive Care Unit (NICU) for observation related to neonatal withdrawal. A urine drug screen on the neonate was positive for oxycodone and methamphetamines. Social work contacted Child Protective Services (CPS).
The neonate was hemodynamically stable, breathing unassisted room air and able to orally feed. The neonate had some emesis and then tolerated the formula, Gentlease. The infant was noted to have a normal neurologic exam and experienced minimal withdrawal. Finnegan Scores were noted to be lower than those requiring medical treatment. A repeat urine drug screen was obtained on the neonate and was pending on prior to discharge. The neonate was cleared for discharge to the mother, and the only symptoms of neonatal drug withdrawal were mild tremors. The neonate was discharged to the care of the mother with CPS following up after discharge.
The requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient, in part. NICU level of care was not medically necessary, however an additional day in the hospital at a lower level of care prior to discharge would have been reasonable.

The neonate was in the hospital for signs of Neonatal Abstinence Syndrome (NAS). She was able to orally feed, was breathing unassisted room air, and had minimal signs consistent with NAS. However, the infant's Finnegan Scores (FS) increased to 7. Threshold for treatment of NAS in most protocols is 3 consecutive FS greater than or equal to 8. Although the patient still did not meet criteria for medical treatment of her NAS, with the FS increasing to 7, it would have been reasonable to allow one additional day in the hospital at a lower level of care prior to discharge.

The neonate was 7 days old and had not met criteria for medical treatment. Although neonates may exhibit withdrawal for up to two weeks after birth, the appropriate period of observation in the hospital depends upon the recent maternal drug use. In this case, the infant's urine drug screen was positive for oxycodone and methamphetamine. The exact dose and duration and type of maternal narcotic use was not clear in the medical record (mother was only positive for oxycodone). Therefore, the documentation presented supports the extension of the hospital stay at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, constipation
Treatment: Linzess
The insurer denied the Linzess.
The denial is upheld. 

The patient is a female who was seen in the hospital due to presumed irritable bowel syndrome.  Her evaluation at the facility did not reveal any infectious cause of her abdominal pain. The patient was previously prescribed Amitiza which was ineffective. The patient was noted to have responded well to Linzess previously and the provider reordered this medication.  

Additional information was provided in the form of progress notes. These reflect the patient's complaints of abdominal pain.  Significantly, the provider documented in a note that the Linzess had worked well initially, but then stopped being effective. Amitiza was also prescribed and noted to work well up until it was discontinued. 

No, the proposed Linzess (linaclotide) is not medically necessary.

The plan requires that the patient try Amitiza prior to use of Linzess.  There is no mandate to use Linzess over Amitiza as per the medical literature. The provider also noted in his note that 290 milligrams (mg) of Linzess was ineffective in the additional material provided for review. To add, the patient was previously on Amitiza which worked well for at least a year per the notes. As such, the request for Linzess is not medically necessary. There was no information to show that the patient had tried and failed a current trial of Amitiza.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class III, prognathic mandible, maxillary and mandibular crowding, and anterior crossbite)

Treatment: The insertion of braces (comprehensive orthodontic treatment)

The insurer denied coverage for the insertion of braces (comprehensive orthodontic treatment).

The denial is upheld.

This is a male child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class III, prognathic mandible, maxillary and mandibular crowding, and anterior crossbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) 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 to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 11 points on review by internal reviewers. 

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, the HLD 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. Upon review of the documentation, this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 11 points (10 points mandibular protrusion and 1 point labiolingual spread).

Regarding the validity of the HLD index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

Based on the above, the medical necessity for the insertion of braces (comprehensive orthodontic treatment) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine headaches.
Treatment: Sumatriptan Succinate 6/0.5 milliliter injection.
The insurer denied the Sumatriptan Succinate 6/0.5 milliliter injection.
The denial is upheld. 

The member is a female with migraine headache disorder. She has been treated with sumatriptan oral and sumatriptan injection for abortive therapy. 

No, the requested Sumatriptan Succinate 6/0.5 milliliter injection is not medically necessary. 

There is no reason the member cannot be treated with the preferred formulary agents. All of the preferred agents are Food and Drug Administration (FDA) approved for migraine abortion and are considered first line, standard of care abortive agents.  There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Sumatriptan Succinate 6/0.5 milliliter injection relative to the preferred agents.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with no past medical history. He presented to the ED (emergency department). The patient was complaining of nausea and abdominal pain. The prior evening, the patient was having a headache. He had consumed 4000mg (milligrams) of acetaminophen at 5pm (post meridiem) the prior evening. He took this medication to relieve his headache. There was no intent to harm himself. The patient was concerned that his symptoms might be due to the acetaminophen he had ingested the evening before. 

In the ED (emergency department), the patient was tachycardic but otherwise had normal vital signs. His physical examination was otherwise normal. Lab tests revealed an undetectable acetaminophen level. There were minimal increases in the transaminases. All the other LFTs (liver function tests) were normal. Poison Control was consulted. It is documented that Poison Control recommended treatment with N-acetylcysteine (NAC). This treatment was started in the ED (emergency department). 

The following day, the patient felt better. His liver function tests did not worsen. The patient was discharged home.

No, the Inpatient admission was not medically necessary.

Following this patient's ED (emergency department) evaluation, he was clinically stable. He had ingested 4000mg (milligrams) of acetaminophen approximately 18 hours prior to presenting to the hospital. He was tachycardic but had normal blood pressure. This amount of acetaminophen would not be expected to cause hepatotoxicity in an otherwise healthy patient (reference below). Lab testing in the ED (emergency department) showed no detectable acetaminophen. There were trivial increases in the transaminase levels. The AST (aspartate aminotransferase) level was 43, with a normal value extending to 41. The ALT (alanine aminotransferase) was 54, with a normal value of less than 40. All other tests were normal. With no detectable acetaminophen still present, there would be no reason to believe that this patient would progress to develop hepatotoxicity.

Appropriate management would have been to repeat liver function tests after several hours in the ED (emergency department), with or without the administration of NAC (N-acetylcysteine). If a short course of NAC (N-acetylcysteine) was felt to be beneficial, the patient could have received a short infusion of NAC (N-acetylcysteine) under observation status. At the time this stable patient was kept in the hospital, it would have been reasonable to believe that he would be discharged the following day. As such, an inpatient admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Palpitations, Sinus Bradycardia, Heart murmur.
Treatment: Color-flow Doppler echocardiography in adults (code 93325- TC).
The insurer denied coverage for color-flow Doppler echocardiography in adults (code 93325- TC). The denial is overturned.

This is female patient with no significant past medical history and no history of dyspnea, decreasing exercise capacity or chest pain/pressure. She was seen by her primary care physician and then a cardiologist for a 1 week history of heart pounding, worse with lying down to sleep, but no sense of heart racing, and occasional sensations of heart fluttering lasting 3 seconds at rest.  She had an episode of nausea, lightheadedness and pre-syncope, seeking medical attention for these symptoms. Her vital signs included blood pressure (BP) 112/69, heart rate 62, and oxygen saturation 100% on room air. An electrocardiogram (EKG) revealed sinus bradycardia but no significant abnormalities. 

The patient was referred for echocardiography, including stress echocardiography, which was performed. She exercised for a total of 13 minutes and 30 seconds using a standard Bruce protocol, with maximum heart rate 151 (88% predicted), BP 151/67, and no significant segment abnormalities or regional wall motion abnormalities with exercise. Resting echocardiography was normal, including color flow Doppler, with left ventricular systolic function at rest 65% and after exercise 75%.  

Appropriate Use Criteria for Multimodal Imaging in the Assessment of Cardiac Structure and Function in Nonvaluvular Heart Disease, published in 2019 by a multi-societal team of experts, supports the use of complete transthoracic echocardiography, which includes two dimensional imaging color flow velocity doppler, in patients with symptoms of presyncope and palpitations.  Complete transthoracic echocardiography with two dimensional imaging and color flow velocity Doppler is appropriate for this patient.  

Based on this patient's clinical presentation of palpitations and presyncope, color flow Doppler velocity echocardiography was the best available treatment for this patient at this time, was the most beneficial use of services, and would be expected to result in improved health outcomes for this patient. Color-flow Doppler echocardiography was likely to be more beneficial than any other standard treatments/procedures.

The carrier's denial of coverage for color-flow Doppler echocardiography in adults (code 93325- TC) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Palpitations, Sinus Bradycardia, Heart murmur.
Treatment: Color-flow Doppler echocardiography in adults (code 93325- TC).
The insurer denied coverage for color-flow Doppler echocardiography in adults (code 93325- TC). The denial is upheld.

This is a female patient with a past medical history of heart murmur, insomnia, and vasovagal syncope. She was evaluated at an urgent care clinic for heart palpitations that started a week prior, as well as nausea and dizziness that started a few hours before the office visit. The cardiopulmonary examination was normal. An electrocardiogram (EKG) revealed sinus bradycardia with possible left atrial enlargement. 

The patient was referred to cardiology for further evaluation. The plan was for an echocardiogram to evaluate for structural heart disease, as well as a stress test. A two dimensional transthoracic echocardiogram with color and spectral Doppler was performed and the results were normal. An exercise stress echocardiogram was also performed. She exercised on the Bruce treadmill protocol, and had no ischemic EKG changes. The stress echocardiogram portion was negative for inducible wall motion abnormalities. 

Color flow Doppler technology is part of a comprehensive two dimensional echocardiography study. It has been proven to improve qualitative and quantitative information about blood flow through the heart and across the heart valve structures. Color flow Doppler technology is an approved technology by regulatory bodies when used in the appropriate clinical context. There is a normal cardiac examination; therefore there is no indication for color-flow Doppler echocardiography in this patient. For the patient's symptoms, a stress echocardiogram was performed. This was appropriate for the clinical indication. 

The use of color-flow Doppler echocardiography is not likely to be more beneficial than the treatment the patient received. There are no clinical or documented indications whereby it would be appropriate to employ color-flow Doppler echocardiography, namely no symptoms or physical examination findings. Thus color flow Doppler is not likely to be more beneficial than any other standard treatment or procedure.

The carrier's denial of coverage for color-flow Doppler echocardiography in adults (code 93325- TC) should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left forearm amputation
Treatment: myoelectric upper limb prosthesis replacement

The insurer denied coverage for myoelectric upper limb prosthesis replacement.
The denial is upheld.

This is a male child with a medical history of arteriovenous malformation which occurred when he was in utero and necessitated the amputation of his left forearm; the patient has been lacking his left forearm since his newborn period.  More recently the patient has been experiencing socket discomfort issues with both his passive and body powered prosthesis; attributed to normal pediatric growth.  The insurer denied coverage for a replacement of the myoelectric upper limb prosthesis.

Each type of prosthesis has its own advantages and disadvantages. For example, body-powered prostheses excel in durability, training time, frequency of adjustment, maintenance, and feedback. Myoelectrics excel in cosmesis, decreased phantom-limb pain, fine manipulation adjustments and are more accepted for light intensity work. In this particular case, the patient has an acquired below elbow amputation. The sockets and prostheses no longer fit due to normal pediatric growth and should be replaced. The replacement (body powered and passive) prostheses should meet the functional needs of this patient. However, specific utilization of the myoelectric upper limb prosthesis was not described in the patient's clinical records. It is not clear if the patient was actually using the myoelectric prosthesis. The clinical records do not indicate when the patient last utilized the myoelectric prosthesis.  In addition, the clinical records also do not provide a compelling case for the medical necessity of a requested myoelectric prosthesis.  

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

The carrier's denial of coverage for a replacement of the myoelectric upper limb prosthesis should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Attention deficit hyperactivity disorder (ADHD).
Treatment:  Vyvanse.

The insurer denied coverage for Vyvanse.  The denial is overturned.

This is a female patient with attention deficit hyperactivity disorder (ADHD), who presents with difficulties paying attention and focusing.  It was reported by her provider that she was not having efficacy with Concerta and that she had increased anxiety and tension, decreased eating, and had sleeping problems.  It was reported that the patient had tried both generic and brand Adderall in the past, and she had adverse effects including nausea/vomiting and unstable mood.  The patient also had reports of depressive and anxiety symptoms.  It was reported that her symptoms worsened during menses.  It was reported that Vyvanse helped her focus and decreased her ADHD symptoms, and there were no reports of medication side-effects from Vyvanse.  It was reported that with Vyvanse the patient also had improved mood and sleep. 

The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with ADHD reports that pharmacotherapy with psychostimulants are considered first line treatment for ADHD.  In this case, the patient has a diagnosis of ADHD and reported improvement with Vyvanse, which is a Food and Drug Administration (FDA)-approved medication for ADHD.  

Vyvanse is a brand name medication and is called Lisdexamfetamine dimesylate (generic), and it is an inactive prodrug in which d-amphetamine is pharmacologically activated after oral ingestion.  This has a different mechanism than the other mentioned psychostimulant, as it is a prodrug needing to be activated after ingestion.  This medication gets activated after ingestion, as it is a prodrug, so abuse potential is considered less than other psychostimulants.  Also, in this case, the patient's symptoms were unresponsive to main psychostimulant classes, such as Concerta, which is a methylphenidate extended-release (ER), and she also had reports of increased anxiety and tension, decreased eating, and had sleeping problems.  The patient has also tried both the generic and brand versions of Adderall, but she was not able to tolerate them, due to adverse effects, including nausea and vomiting, as well as unstable mood.  The patient has tried and failed treatment with two main classes of psychostimulants.  The patient reports improvement in focusing and attention without adverse effects with Vyvanse use.  Considering this patient's ADHD symptoms refractory to Concerta and Adderall and the fact that she is responsive to Vyvanse, which is an FDA-approved drug from ADHD, Vyvanse is considered a medically necessary treatment for this patient. 

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

The carrier's denial of Vyvanse should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Fever, Metastatic pancreatic cancer.
Treatment:  Full hospital admission.

The insurer denied coverage for the full hospital admission.  The denial is overturned.

This is a male patient with a past medical history significant for metastatic pancreatic cancer, biliary obstruction, gout, esophagitis, and iron deficiency, who presented to the hospital for an elective endoscopic retrograde cholangiopancreatography (ERCP) for stent exchange.  The patient's vital signs on hospital presentation included: temperature 100.5, blood pressure 101/59, pulse 98, respiratory rate 16, and oxygen saturation 98% on room air.  The patient's laboratory values were notable for the following: white blood cell (WBC) count 26.6, hemoglobin (Hgb) 8.3, hematocrit (Hct) 24.8, creatinine 0.60, glucose 123, and sodium 120.  He was empirically started on broad-spectrum intravenous (IV) antibiotics (i.e., ciprofloxacin and metronidazole) for possible cholangitis.  The patient had an infectious work-up, including blood culture collection.  He was treated with intravenous fluids (IVF) for hyponatremia that gradually improved.  He remained afebrile and hemodynamically stable.  The patient was discharged to continue outpatient management including follow-up with oncology.  

According to medical records, the patient was admitted following an elective ERCP for concerns of infection.  He had a fever of 100.5 followed by a fever of 101.4 F the next day.  His laboratory results showed numerous abnormalities including an elevated WBC count, hyponatremia, anemia, and elevated liver function tests.  Considering these clinical findings in a high-risk, immunocompromised patient with metastatic cancer following a procedure, the literature review supports that inpatient admission was medically necessary for IV antibiotics and additional diagnostic evaluation. 

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

The carrier's denial of coverage for the full hospital admission should be overturned.  The medical necessity is substantiated.