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



Diagnosis: Constipation
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of constipation. She presented to the hospital for abdominal pain and constipation. She was given Miralax, enemas and was started on Golytely via a nasogastric tube. The patient responded well and was discharged home in a stable medical condition.
At issue is the medical necessity of an inpatient stay.

This patient has a history of constipation and did not respond to treatment with Miralax as an outpatient. The standard of care in the management of fecal impaction and encopresis is to perform a bowel cleanout. The cleanout can often be done as an outpatient via a large volume of laxatives or rectal enemas.
The clinical practice guidelines for the management of constipation in children recommend using oral polyethylene glycol or enemas for the treatment of fecal impaction.
The patient was in a stable condition on presentation. She did not have signs of a bowel obstruction or concerning exam findings. The vital signs were unremarkable and the laboratory studies were not abnormal. There is no documentation of failed cleanout attempts as an outpatient using large volume of osmotic laxative (such as Miralax) or via enemas. This patient had no documented contraindications for outpatient management or significant comorbidities that required inpatient care.
The care provided during the admission included oral Miralax and enemas. She also received a nasogastric tube for the bowel cleanout. These treatments could have been effectively and safely provided at observation level of care. The diagnostic barium enema is a common outpatient procedure and did not require an inpatient stay.
Therefore, the admission to an inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: N-methyl-D-aspartate receptor (NMDAR) encephalitis 
Treatment: Brain MRI (magnetic resonance imaging)
The insurer denied the brain MRI (magnetic resonance imaging).
The denial is overturned.

The patient is a teenage male. He developed behavioral changes and unresponsiveness. He was evaluated with a lumbar puncture and diagnosed with N-methyl-D-aspartate receptor (NMDAR) encephalitis 3 years ago. He underwent treatment with intravenous immunoglobulin (IVIG), plasmapheresis, steroids, and physical therapy. He has recovered fully since then. He has problems with argumentative behavior and may have been diagnosed with attention-deficit/hyperactivity disorder in the past. His neurologist requested a magnetic resonance imaging (MRI) of the brain with and without contrast due to the NMDAR encephalitis. Records of his evaluation and treatment of NMDAR encephalitis are not included. The request for MRI of the brain was made 2 months ago.

The request for MRI was denied coverage by the health plan due to not meeting clinical guidelines. The denial specified that the plan would need to know how the MRI would change the treatment plan. This decision was appealed with a statement that the patient had an encephalopathy with no prior imaging on the appeal form. There is also an appeal letter noting that the MRI is needed to assess for tumors or lesions. This review is in regard to MRI of the brain use.

The requested health service is medically necessary.

The patient had NMDAR encephalitis. Standard of care for autoimmune encephalitis includes neuroimaging of at least the brain to assess for inflammatory lesions and masses/tumors during the initial course of evaluation. The documentation states an MRI of the brain was not completed for this patient. In this case, although the patient had the NMDAR diagnosis three years prior, he has ongoing behavioral problems. Though these may have predated his illness, imaging can help to evaluate for signs of active inflammation, past brain injuries that could contribute to his behavioral symptoms, and evidence of other disorders, such as multiple sclerosis, for example, which has been described as co-existing with NMDAR encephalitis. (1, 2) Therefore, as the treating provider has attested that the patient did not have prior imaging, MRI of the brain is indicated. The MRI brain is considered medically necessary per current standards of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Blood Sugar
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult male with hypertension and schizophrenia who presented to the emergency department for polyuria, polydipsia, lightheadedness, and hyperglycemia with 
glucose up to 475 milligrams per deciliter (mg/dL) at home while on antibiotics for toe cellulitis. Vitals noted temperature 98.0, heart rate 66, blood pressure 125/66, and oxygen saturation 95 percent. The patient was alert, calm, and oriented times three. Labs showed creatinine 1.57, carbon dioxide 28, potential of hydrogen (pH) 7.38, glucose 527 milligrams per deciliter, beta hydroxybutyrate 1.329, and positive urine ketones. He was treated with intravenous fluids and subcutaneous insulin. Endocrinology was consulted. The request for inpatient admission is under review. The prior request was denied because: "To approve this service, certain criteria have to be met. These criteria are from the guideline named 'Diabetes.' This can be found in the nationally recognized medical reference called MCG (26th edition). Based on the information provided, 
you did not have any conditions to meet these criteria such as: Unstable vital signs that did not improve. Abnormal mental status (coma, confusion, excessive drowsiness) that is severe or 
persistent. Evidence of high acid buildup in your blood with related complications. Extremely high blood sugar levels over 600 with brain dysfunction. Severe bloodwork abnormalities that 
did not respond to treatment during an observation period. Inability to tolerate drinking fluids or diet beyond the observation timeframe. The medical necessity for paying for your hospital stay at the 'Inpatient' level of care has not been established. We have approved your hospital stay at an 'Observation' level of care. These levels of care refer to how the facility is paid, not to care received. The request to approve your stay as an inpatient is denied on appeal." The provider is appealing this determination.

The proposed inpatient stay was not medically necessary.

This patient presented with new onset type II diabetes. He had hyperglycemia that improved with hydration and subcutaneous insulin therapy. He had an elevated creatinine in the setting of 
dehydration that improved with hydration. He had a normal potential of hydrogen (pH) of 7.38 and he did not meet criteria for diabetic ketoacidosis. He was awake and alert and did not meet criteria for hyperglycemic hyperosmolar state. He was hemodynamically stable. The records do not support that the patient tried and failed a lower level of stay. Therefore, no, the requested inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Throat Pain and Vomiting
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is a school age female with a history of a foreign body sensation. She presented with throat pain and an episode of emesis. The patient's symptoms began after eating a fish ball. Otolaryngology (ENT) was consulted, and a fishbone was noted in the tonsil. The patient was taken to the operating room, where no fishbone was found but a loose tooth was removed. The patient was seen in the emergency department and admitted as an inpatient and discharged the next day. The inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The Inpatient admission was not medically necessary.

The patient was seen after a possible fishbone ingestion. There was no oral bleeding or respiratory difficulty noted. The patient's vital signs were stable in the emergency department. There were no preoperative or post-operative complications documented. Therefore, the medical necessity of the inpatient stay is not confirmed, as the patient's care could have been performed as a lower level of care, Observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoporosis
Treatment: denosumab (Prolia)
The insurer denied denosumab (Prolia). The health plan's determination is upheld. 

The patient is a female being prescribed denosumab (Prolia) for the diagnosis of osteoporosis. She states that her first dose of the requested medication was administered in her doctor's office. Her second dose was administered at the infusion center of the hospital. There were no letters of medical necessity provided for this review. The office visit notes that were provided state that the requested medication was being prescribed for osteoporosis. There were no Dual-Energy X-ray Absorptiometry (DEXA) scan results available for review. There is a notation that the patient tolerated the first injection well without any side effects. No further clinical details were provided as part of this review.

At issue is the medical necessity of denosumab (Prolia).
The health plan's determination of medical necessity is upheld, in whole.

The requested health service of denosumab (Prolia) has not been demonstrated to be medically necessary for this patient.

There was insufficient documentation of the patient's clinical need for the requested medication. Typically for patients with osteoporosis, bisphosphonate medication is administered as the first line treatment due to a strong volume of evidence of its efficacy, lower cost, and general tolerability. The requested medication is used when other medications cannot be tolerated. According to expert opinion, "Initial therapy for most patients with osteoporosis includes lifestyle measures and oral bisphosphonates. Denosumab is not considered initial therapy for most patients." [1] It is unclear if the patient had ever had a trial of bisphosphonate therapy or other treatment for her osteoporosis. Additionally, DEXA scan results regarding her osteoporosis diagnosis were not available for review. There was no information provided regarding prior pathological fractures. Therefore, there is insufficient evidence that the requested medication, Prolia, was medically necessary for the patient.

The health plan states, in order to cover this medication, they require that patients be at least 18 years of age. They have to have a diagnosis of osteoporosis with a t-score of -2.5 or less. They also require one of the following criteria to be met: either a prior pathologic fracture, risk for fractures due to factors other than osteoporosis, or trial of another medication that was considered first-line and could not be tolerated. The patient has not met this criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female who presented to the emergency room with chest pain for two days. The patient had a past history of hypertension, iron deficiency anemia, gastric ulcers, and arthritis. Her hemoglobin was 9.2. Stool guaiac was positive. The patient received intravenous famotidine 20 milligrams (mg) and pantoprazole 80 milligrams (mg). Gastroenterology and cardiology were consulted. During the hospital course, no further bleeding was reported/noted, and the patient's lab studies showed stable hemoglobin levels. A computed tomography (CT) scan of the abdomen / pelvis showed distal small bowel inflammatory change suggestive of terminal ileitis with adjacent adenopathy. The plan was magnetic resonance enterography as outpatient. 

The proposed treatment was not medically necessary.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. An observational level of stay would have been more appropriate for this patient. An observational level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have active and ongoing gastrointestinal bleeding, did not have acute coronary syndrome, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Partial denture support
Treatment: Crown (D2740) on Tooth number 05
The insurer denied: Crown (D2740) on Tooth number 05
The denial is upheld.

The patient is an adult male. The request is for a crown on tooth #5. The health plan denied coverage of the request due to the patient both wearing an upper partial denture and having more than eight teeth touching in the posterior areas of his mouth. The denial is being appealed.

The proposed treatment is not medically necessary.

The patient has more than eight posterior teeth in contact in his posterior region. As noted in plan documents, there can be no treatment with a crown on tooth #5. The crown on tooth #5 is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nasal Valve Collapse
Treatment: Repair of Nasal Valve Collapse With Latera (30468)
The insurer denied: Repair of Nasal Valve Collapse With Latera (30468)
The denial is overturned.

The patient is an adult female with a history of bilateral nasal congestion. Her symptoms are prevalent during exercise. The patient endorses trying nasal steroids for four months. The patient has a history of nasal trauma at age eight, when she sustained a nasal bone fracture. A physical exam was notable for septal deviation, hypertrophy of the inferior turbinates, and collapse of the nasal valve. A modified Cottle maneuver was positive. The patient was recommended to undergo septoplasty, inferior turbinate reduction, and nasal valve repair with the "Latera" absorbable nasal implant. This was recommended as more invasive functional septorhinoplasty. This procedure was denied coverage by the health plan on grounds that the procedure was experimental/investigational. This decision has been appealed.

The health plan should cover the requested health service.

"Latera" bioabsorbable implants are a US Food and Drug Administration (FDA)-approved device and have been demonstrated to have efficacy in addressing nasal valve collapse in patients with documented nasal valve collapse. It is reasonable to attempt bioabsorbable implants for nasal valve collapse as an alternative to invasive open functional septorhinoplasty. A literature base supports their use as a less invasive option for nasal valve collapse. Therefore, the health plan should cover the requested health service. 
The requested health service or treatment is more beneficial than any standard treatment for the patient's condition or disease. The standard treatment for nasal valve collapse is open functional septorhinoplasty. This procedure, however, is invasive and carries additional medical and aesthetic risks. Further, expertise to complete open functional septorhinoplasty may not be available depending on location. Therefore, bioabsorbable implants for nasal valve collapse are a medically reasonable alternative for a patient who does not wish to have an invasive open functional septorhinoplasty.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nasal Valve Collapse
Treatment: Repair of Nasal Valve Collapse With Latera (30468)
The insurer denied: Repair of Nasal Valve Collapse With Latera 
(30468)
The denial is upheld.

The patient is an adult female. She presented with long history of nasal obstruction, worse with exercise that failed to improve with four months of medical management. She was noted on exam to have dynamic valve collapse, caudal septal deflection off nasal crest, and large turbinates. Her surgeon planned for septoplasty, turbinate reduction, and Latera implant to address her valve collapse. The prior denials cited the investigational use of this nasal implant. The reason for appeal is at the request of the patient citing medical literature suggesting improvement with the nasal implant.

The health plan should not cover the Repair of Nasal Valve Collapse With Latera (30468).

There are limited studies suggesting the efficacy of the lateral nasal wall implant. The studies are of low evidence case series and cohort studies with a relatively low number of patients and short duration of follow up. There are no randomized controlled trials comparing the implant versus standard of care. In this case, this would be septoplasty and cartilage grafting utilizing spreader or butterfly graft. Given this, currently the lateral nasal wall implant would be considered investigational in nature. The health plan should not cover the requested health service.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nasal Valve Collapse
Treatment: Repair of Nasal Valve Collapse With Latera (30468)
The insurer denied: Repair of Nasal Valve Collapse With Latera (30468)
The denial is overturned.

The patient is an adult female. The patient is reported to have an elevated septum with 70% (percent) obstruction, turbinate hypertrophy, and nasal valve collapse. The physician notes state that the patient failed medical management. The note says that dynamic nasal valve collapse improved with modified Cottle's maneuver. The provider states that septoplasty alone would not have resolved the nasal valve restriction.

The health plan should cover the Repair of Nasal Valve Collapse With Latera (30468).

Latera implants are well supported in the medical literature as a minimally invasive means to control nasal valve collapse. The provider notes medical failure and the anticipation that without management of the nasal valve collapse that septoplasty and turbinectomy would not control the airway obstruction. Given the support for the procedure in the medical literature and the clinical data, the plan should cover the requested health service.

The requested health service or treatment is more beneficial than any standard treatment for the patient's condition or disease. This is a standard therapy in the management of nasal valve collapse.
Appeal type: Medical necessity
Decision: Overturned

 Diagnosis: Right Distal Femoral Shaft Fracture

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The insurer has denied coverage for the inpatient admission as not medically necessary. In a Final Adverse Determination letter, they stated that the patient had surgery for a broken leg. The patient did not have any problems with the surgery. The requested admission is denied based on Milliman Care Guidelines 26th Edition using the guideline of Musculoskeletal Disease. 

The hospital is appealing. In an appeal letter it is stated that the patient was admitted to the hospital with a right distal femoral shaft fracture. The patient underwent an open reduction internal fixation (ORIF) of the right extra-articular distal femur fracture. The patient was taken to the post anesthesia care unit (PACU) after surgery. A knee immobilizer was placed. The patient was placed on postoperative antibiotics. The patient was discharged. The requested admission was warranted based on Milliman Care Guidelines 26th Edition using the guideline of Ambulatory Surgery Exception Criteria GRG: CG-AEC (ISC GRG). 

The medical records show a complex and major orthopedic procedure was performed. The open reduction internal fixation (ORIF) to the distal femur requires extensive dissection, fracture manipulation and application of fixation devices. The surgical procedure was 3 hours which did not take into account total anesthesia time. The post-surgical course was complicated by anemia to require transfusion. After the transfusion the hematocrit remained low at 26. This would cause concern for inadequate blood replacement or possible bleeding. The intravenous (IV) bolus requirement after transfusion supports this premise. 

A person after this type of surgery cannot weight bear. Physical therapy (PT) would likely be delayed secondary to the transfusion requirement. The report of wheelchair for home and discharge supports inability to be independent. 

Based upon the nature of surgery, need for transfusion, continued anemia and inability to progress with PT, the services were necessary and appropriate. A lower level of care would be inadequate to manage the needs of this patient 

Based on the above, the insurer's denial must be reversed. 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 the inpatient admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hepatocellular carcinoma
Treatment: Y90 Radioembolization
The insurer denied Y90 Radioembolization
The health plan's determination is overturned.

The patient is a male with multifocal hepatocellular carcinoma (HCC) and good performance status who presents for radioembolization procedure with Y-90 with dosimetry and necessary procedures, possible bridge to liver transplantation, possible palliative effort. This is unresectable disease. The patient has had an ultrasound and magnetic resonance imaging (MRI) imaging of the liver/abdomen along with computed tomography (CT) imaging.

Y-90 radioembolization is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The literature evidence is sufficient to confirm and demonstrate efficacy of Y-90 radioembolization in this patient for control of HCC. Y-90 is an effective treatment of primary unresectable liver cancer. Palliative loco-regional therapy is well tolerated and quite efficacious and is appropriate for patients who are not surgical candidates.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hepatocellular carcinoma
Treatment: Y90 Radioembolization
The insurer denied Y90 Radioembolization
The health plan's determination is overturned.

The patient is a male with hepatitis C virus (HCV), cirrhosis, and newly diagnosed hepatocellular carcinoma. Magnetic resonance imaging (MRI) shows multiple lesions throughout the liver, the largest being 6.5 centimeter (cm). He is not a candidate for curative resection. Currently Y90 radioembolization is being considered as a bridge or downstage the patient prior to transplant. 

The Y90 radioembolization is likely to be more beneficial than other options (standard embolization) that are available. Imaging response, survival benefit and longer times for progression is associated with Y90 radioembolization showing its superiority over standard embolization. Additionally, Y90 radioembolization has been shown to be more beneficial that standard embolization. Y90 Radioembolization will give this patient the best opportunity to stabilize/shrink the masses in his tumor.