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

Diagnosis: Atopic dermatitis.
Treatment: Dupixent 300 milligram (mg)/2 milliliter (ml) Pen.

The insurer denied coverage for Dupixent 300 mg/2 ml Pen.  The denial is overturned.

The patient is an adult male with a diagnosis of atopic dermatitis. The patient has failed topical steroids as well as prednisone. The severity of the patient's disease is such that the caring physician believes that systemic therapy is needed. The patient's past medical history is notable for urticaria and asthma. The requested medication is Dupixent.  

The patient has atopic dermatitis (AD) which requires systemic therapy, given the extent of involvement, and the use of Dupixent would appear to be reasonable, given that it is FDA approved for the treatment of atopic dermatitis. The request for Dupixent is supported by the medical literature and specialty society guidelines. Dupixent is an effective systemic therapy approved by the Food and Drug Administration (FDA) for the management of atopic dermatitis. In early 2017, the FDA approved Dupixent for adults with moderate-to-severe AD who are inadequately controlled with topical treatments. (1-3) According to consensus guidelines "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe AD .... Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment ... with moderate-to-severe AD who are uncontrolled with topical therapies." (1) Furthermore, the patient has a diagnosis of asthma, for which Dupixent is FDA approved. As such, the decision is reversed and Dupixent is approved based on the standard of care and the provided medical documentation.   

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 Dupixent 300 mg/2 ml Pen is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Venous Thromboembolism. 
Treatment: Eliquis. 

The insurer denied: Eliquis. 
The denial is upheld. 

This is a male with a history of recurrent venous thromboembolism. Eliquis has been recommended by the provider as he has previously failed Xarelto. Eliquis is under review. 

The health plan's determination is upheld. 

Neither Xarelto nor warfarin have been demonstrated to be inferior to Eliquis. However, it should be noted that Xarelto has a similar mechanism of action to Eliquis and resistance to Xarelto would imply the potential for resistance to Eliquis. The included documentation does not indicate that this patient is intolerant of the formulary alternative (warfarin) nor that he has failed it; similarly, there is a paucity of documentation indicating this patient has a contraindication to the formulary alternative. Neither the authors of UpToDate nor the peer-reviewed literature recommend one of these agents as being superior to another and thus given their relative equivalency, the formulary options are reasonable and would not have adverse effects that the non-formulary alternative would.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neuromuscular Scoliosis
Treatment: Durable Medical Equipment (E0637x1)
The insurer denied coverage for Durable Medical Equipment (E0637x1)
The denial is overturned.

The patient is a child with neuromuscular scoliosis. Recent surgical procedures included bilateral Tendon Achilles Lengthening (TAL) and left distal femur hemiepiphysiodesis.  The patient is receiving post-surgical physical and occupational therapy (via video tele-therapy).  

The requested Durable Medical Equipment (DME) (E0637x1) -Standing frame, is reasonably supported as medically necessary. Treatment goals such as improving upright positioning, alignment, preventing worsening of contractures and managing positional spasticity are relevant, clinically appropriate and medically necessary in this case. The requested DME (standing frame) is particularly important and medically necessary for this patient who is receiving post-surgical physical and occupational therapy (via video tele-therapy); given the lack of access to similar DME if she were receiving face-to-face outpatient therapies.  

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

The insurer's denial of coverage for the Durable Medical Equipment (E0637x1) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tinnitus
Treatment: Hospital admission
The insurer denied coverage for the hospital admission.
The denial is overturned.

This case involves a female child who presented to the emergency department (ED) for evaluation after sudden onset vision loss and tinnitus. On initial assessment in the ED, the attending physician was unable to test extraocular movement with the patient not appearing to respond to visual stimuli. She did not appear to respond to confrontation but was not suspected as having overdosed on salicylates. This was a consideration for which salicylate levels were ordered. Etiology of symptoms was unclear and given the acute onset of vision loss with tinnitus, the patient will require neurologic evaluation. Urinalysis was normal, with the laboratory report showing low hematocrit at 35.8. Computed tomography (CT) of the head without contrast was normal. Creatinine was 0.4, aspartate aminotransferase (AST) was 38, with low salicylates at less than 1.0. Vital signs were stable with urine intake and output normal. Record stated the patient had previously tested positive for Cryptosporidium. The patient was subsequently admitted for a full neurological work-up and treatment. The patient endorsed that the vision loss occurred suddenly, was not progressive, with reports of progressive vision loss intermittently after the diagnosis of intestinal parasite. Magnetic resonance imaging (MRI) of the head was unremarkable, and tinnitus subsequently resolved.

During the course of the patient's hospital stay, she experienced lower extremity weakness with inability to bear weight in the lower extremities. The patient remained on inpatient status until discharge. She received a notice of adverse determination denying her inpatient stay with the indication that there were no severe problems warranting a full hospital admission. 

According to the Milliman Care Guidelines, clinical indications for admission to inpatient care include individuals who have visual loss that is a new onset or progressive. The information provided for the review noted that the patient had endorsed intermittent loss of vision since she became ill with parasitic ailment earlier in the year. Given the sudden vision loss, tinnitus, and lower extremity weakness she was a candidate for inpatient admission. The documentation of multiple neurological abnormalities was sufficient to allow for inpatient level of care should the patient's condition progress, with concerns regarding seizures and/or stroke. The inpatient stay allowed for appropriate monitoring, testing, and treatment until the patient was stable for discharge. 

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 hospital is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peritoneal cancer

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

In the documentation given for review it shows the patient has gastroesophageal reflux disease (GERD), and peritoneal cancer with peritoneal ascites that was planned for drainage, but not yet drained, starting chemotherapy that week. 

The white blood cell (WBC) was 25, spontaneous bacterial peritonitis (SBP) was suspected, and intravenous (IV) antibiotics were given. Triage noted that the patient was sent for paracentesis, and denied fever, acute distress, and pain. Exams showed no rebound, tenderness, guarding, and normal bowel sounds.

The notes show evidence of ascites but no evidence of infection. The patient was sent in for paracentesis and had no signs of anything more than that. She was unable to eat. The white count may be elevated because of the recovery from chemotherapy. The patient appears to have needed nothing more than a paracentesis. The following day, there was minimal ascites.     

There was little to indicate bacterial peritonitis at admission, and no fluid on paracenteses. An emergency department evaluation should have ended with a discharge. 

"SBP is an acute infection of the abnormal accumulation of fluid in the abdomen (ascites) without an identifiable source of infection. It can occur in adults and children, and the majority of isolated organisms being gram-negative enteric organisms (e.g. ["for example"], Escherichia coli or Klebsiella pneumonia), pointing to the gastrointestinal (GI) tract as the main source of infection. This activity reviews the diagnosis and management of spontaneous bacterial peritonitis and explains the role of the interprofessional team in managing patients with this condition." (Ameer, M. A., et al, 2022)

"Spontaneous bacterial empyema (SBEM) is a complication of hepatic hydrothorax, which is itself a complication of cirrhosis. SBEM carries a high mortality rate and requires a high index of suspicion to diagnose. We aim to increase awareness of this potentially fatal entity so early diagnostic thoracentesis and early antibiotics may be considered in a patient with clinical features suggestive of developing SBEM." (Soin, S., et al, 2018)

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

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

Diagnosis: Retracted rotator cuff tear

Treatment: rotator cuff repair (CPT 29823; 29826; 29827; 29828)

The insurer denied coverage for rotator cuff repair (CPT 29823; 29826; 29827; 29828)

The denial is overturned.

This is a patient with a history of shoulder pain. The records show she had sustained two dislocations and had ongoing problems with activities of daily living. She had taken medications for pain. Her physician reported her laxity. Her most recent examination showed + (positive) Impingement, - (negative) apprehension, decreased motion and crepitus. Her strength was 4+/5 with no acromioclavicular (AC) tenderness. Anterior shoulder tenderness. Magnetic resonance imaging (MRI) showed Bankart lesion, Hills Sachs deformity, full tear to rotator cuff and biceps tendon fraying. The cuff tear was retracted. 

The medical record demonstrates a complex clinical condition. The patient has significant pathology to several structures. She has an instability problem manifested by the dislocations and subluxations. The condition has become chronic with limitation to function. Minimally a procedure would be indicated for her laxity. She also has a retracted rotator cuff tear with biceps tendon pathology. This contributes to her functional loss. Consideration of nonoperative treatment is always an option but, in her case, not likely to be effective. The recommendations of her surgeon are appropriate and consistent with standards of practice. 

Recurrent instability with functional loss would benefit from surgery. A person with a retracted rotator cuff tear would not likely benefit from physical therapy. Surgical management and restoration of anatomy would likely provide the best result. The biceps tendon pathology should also be addressed. 

Based upon the unique clinical condition and functional loss, surgery would be appropriate. 

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 rotator cuff repair (CPT 29823; 29826; 29827; 29828) services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient presented with abdominal pain, vomiting, and diarrhea. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The white blood cell (WBC) count was 18.0. An abdominal computed axial tomography (CAT) scan revealed acute appendicitis. She was kept on nothing by mouth (NPO) status and given intravenous (IV) antibiotics. It was decided that she would have an elective appendectomy since this was the second attack within 12 months. She responded well to the treatment and the leukocytosis resolved. 

Milliman Care Guidelines (MCG) for Gastroenterology GRG: MG-GAS 26th edition discusses clinical indications for admission. The guideline states that acute appendicitis with planned non operative management or interval appendectomy is an indication if there is a hemoperitoneum. This patient did not have a hemoperitoneum. 

MCG guideline for Undiagnosed Abdominal Pain M-05 lists clinical indications for admission. These include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient had acute appendicitis and it was decided that it was best to treat her with NPO and IV antibiotics. She did not have peritoneal signs and improved quickly with the IV antibiotics. She was then able to be discharged on oral antibiotics. This treatment could have been given with observation status. She did not meet MCG criteria for admission for Gastroenterology or Undiagnosed Abdominal Pain.

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: Upheld

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

The patient is a girl who injured her left index and long fingers playing basketball. She was seen in the emergency room and found to have fractures through the growth plates at the base of her left index and long fingers. Closed reduction was attempted in the emergency room but was unsuccessful. She was admitted to the hospital and underwent an attempt at closed reduction of both fingers, followed by open reduction and internal fixation of the index finger, which could not be reduced by closed means.

The inpatient hospital admission is not medically necessary. Fractures of the phalanges of the fingers are very common injuries in children, often occurring in the context of sports. While closed reduction followed by splint or cast immobilization is successful for most of these injuries, occasionally an injury will require surgical treatment. The surgical treatment is straightforward, and there is no need for prolonged monitoring afterward. These injuries can be managed at a lower level of care without inpatient hospital admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastric Ulcers
Treatment: Gastric service procedure [sequential or repeat EGD (esophagogastroduodenoscopy)]
The insurer denied the gastric service procedure (sequential or repeat EGD).
The determination is overturned.

This is a female patient with gastroesophageal reflux disease (GERD). She was found to have gastric ulcers on a prior endoscopy. She presented  with persistent dyspepsia and epigastric pain. Gastric sleeve surgery was planned. An esophagogastroduodenoscopy showed mild erosions with nodular mucosa in the antrum, mild patchy erosions in the fundus, small area of nodular mucosa at the gastroesophageal junction, and a small hiatus hernia; biopsies were positive for Helicobacter pylori. At issue is the medical necessity for an esophagogastroduodenoscopy.

The requested procedure was medically necessary. The patient presented with symptoms consistent with persistent or recurrent gastric ulcer disease two months after an endoscopy showed gastric ulcers [1,2]. Gastric ulcers can be malignant, and the "current practice of repeat gastroscopy is warranted in the absence of patient-based and lesion-based predictors of malignancy" [3]. Therefore, the requested esophagogastroduodenoscopy is supported in this case. Additionally, the patient was potentially going to undergo gastric sleeve surgery, and the presence of a gastric ulcer would be important to ascertain before surgery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient Stay
The insurer denied the Inpatient Stay.
The determination is overturned.

This is a male patient with a history of active tobacco use who was brought by Emergency Medical Services (EMS) to the emergency department (ED) for evaluation of acute onset left sided chest pain radiating to the back associated with shortness of breath and diaphoresis. The patient was treated by EMS with nitroglycerin (NTG) spray and aspirin. In the emergency department (ED), the initial electrocardiogram (ECG) showed inferior ST depression. The high sensitivity (HS) cardiac troponins were elevated and up trended consistent with a non-ST(segment) elevation myocardial infarction (NSTEMI). The patient was admitted to the hospital and underwent an emergent coronary angiogram demonstrating high grade stenosis, 90-95 percent (%), of the second diagonal artery which was stented with a drug-eluting stent (DES). There was non- obstructive disease of the distal circumflex. Post procedure, the patient was monitored in the coronary care unit (CCU) overnight. An echocardiogram showed normal cardiac function with left anterior descending (LAD) territory regional wall motion abnormalities. The patient was initiated on appropriate medical therapy post percutaneous coronary intervention (PCI) and was then discharged home in stable condition. At issue is the medical necessity of an inpatient stay.

An inpatient level of was medically necessary and appropriate and in this case for evaluation and treatment of NSTEMI to relieve ischemic symptoms and reduce the risk of myocardial infarction and cardiovascular related death with aggressive medical therapy and coronary revascularization (3, 4).
This patient presented with signs and symptoms of NSTEMI placing the patient at high risk for major adverse cardiac events including death, myocardial infarction, and need for coronary revascularization. According to the well-validated HEART [history, electrocardiogram, age, risk factors, troponin] pathway, given the patient's high HEART score, 6, along with elevated cardiac troponins, admission at an inpatient level of care was recommended (1, 2). Furthermore, according the 2014 American College of Cardiology (ACC) /American Heart Association (AHA) guideline for the management of patients with non-ST-elevation acute coronary syndromes and 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department, admission of this patient at an inpatient level of care would be standard of care for evaluation and treatment of NSTEMI to relieve ischemia symptoms and reduce the risk of myocardial infarction and cardiovascular related death (3, 4). Management of this patient at a lower level of care would have been medically inappropriate and unsafe in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: transient ischemic attack (TIA)
Treatment: Full hospital admission
The insurer denied the full hospital admission
The denial is upheld.

The patient is a male with a past medical history significant for hypertension, hyperlipidemia, chronic kidney disease, and obstructive sleep apnea who presented to the hospital with acute onset of right hand and forearm weakness and tightness that started on the day of admission. The patient was sitting on the couch watching television when his symptoms started. There were no prodromal symptoms. The patient stated that the day when his symptoms started he played golf for the first time in his life and used his right hand. The patient had no previous similar episodes. Upon initial evaluation in the emergency department, the patient underwent a computed tomography (CT) scan of the head that demonstrated 80% stenosis in the right internal carotid artery (ICA) and 1-2 millimeter (mm) posterior cerebral artery (PCA) aneurysm.

The patient was admitted to the hospital with right arm weakness and was suspected to have transient ischemic attack (TIA). Another clinical diagnosis was right ICA stenosis and 1-2 mm PCA aneurysm.

Additional admitting diagnoses included hypertension, hyperlipidemia, obstructive sleep apnea, and chronic kidney disease stage III a with a baseline creatinine of 1.4.
In the hospital, the patient was seen by a vascular surgeon who suggested that the patient's symptoms were unlikely related to right ICA stenosis since the patient's reported deficits were likely not related to the right internal carotid artery stenosis since the symptoms were on the ipsilateral side of the lesion.

The vascular surgeon recommended continuation of a workup for stroke/transient ischemic attack (TIA) including neurology and cardiology consults, echocardiogram, and magnetic resonance imaging (MRI) of the brain. The MRI of the brain was negative for acute stroke.

It was suggested that the patient's symptoms were most likely related to the overuse of his right hand, which caused muscle tightness and possibly affected the ulnar nerve.
During the hospital stay, the patient's symptoms improved and the patient was discharged home in stable clinical condition.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient. The review of the medical records clearly demonstrated that in this clinical case the patient had no circumstances listed above. Even though he was diagnosed with 80% ICA stenosis, he did not need surgical intervention during this hospital stay. The patient's abnormal kidney function represented chronic kidney disease and his creatinine was near the baseline.

Taking into consideration these facts, the admission for monitoring was definitely indicated to rule out acute stroke and perform the necessary workup which was indicated considering the clinical circumstances. However, the workup and clinical monitoring could have been performed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II crowding
Treatment: Braces and monthly visits
The insurer denied the braces and monthly visits.
The health plan's determination is overturned. 

The patient in question is a female with a diagnosis of Class II crowding. Tooth # (number) 29 is impacted and blocked out of the arch. Tooth #6 is blocked out to the labial. The patient was treatment planned for 30-36 months of orthodontics to create space to bring teeth 6 and 29 into the arch. 

Braces and monthly visits are medically necessary.

Impacted teeth can lead to bone defects of the adjacent erupted teeth. It is a generally accepted practice guideline to address the impacted tooth by attempting to surgically remove it or to gain space to allow the impacted tooth to erupt.

Impacted teeth can cause damage to the roots of adjacent teeth, which could lead to expensive restorative treatments. Braces and monthly visits are medically necessary to correct this patient's issues.