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

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

This is a female patient who presented to the emergency department (ED) with severe abdominal pain and was found to have calculi of the gallbladder with chronic cholecystitis. The patient was hospitalized for symptoms of biliary colic.

No, the proposed inpatient admission was not medically necessary.

This patient presented with complaints of biliary colic since the day before. This patient was afebrile, had normal white blood cells (WBCs), was in mild distress, and was not septic. She had a gallbladder ultrasound showing gallstones with normal wall thickness, and no pericolic fluid. This patient was made nothing by mouth (NPO). There is no well documented indication why this patient later did not have a laparoscopic cholecystectomy. This patient met no indications for an acute inpatient admission.

As per the Milliman Care Guidelines National Guidelines, admission for abdominal symptoms include signs of sepsis such as elevated white blood cells (WBCs), fevers or a significant finding by abdominal examination. This patient had none of these, including a relatively benign gallbladder ultrasound not at all consistent with acute cholecystitis. 

As per the letter of appeal, all the medical care provided to the patient including nothing by mouth (NPO), ambulation, monitoring bowel movements (BMs), Lovenox, pain control, intravenous (IV) fluids, and intravenous medications including antibiotics all could have been provided safely, effectively, and efficiently as observation care while this patient should have had a laparoscopic cholecystectomy. Rescheduling surgery for a later date is not documented as medically necessary and is depicted by the documentation as for provider convenience.

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

The acute admission was denied as there was no indication for this acute inpatient admission for biliary cholic and especially with a delay in surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, hematuria. 
Treatment: Inpatient admission. 

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

The patient is a female patient who underwent an acute inpatient hospital admission. The patient has a history of hyperlipidemia, hypertension, chronic obstructive pulmonary disease (COPD) and a cerebral vascular accident (CVA). The patient had been brought in via ambulance with the complaints of worsening abdominal pain with hematuria. Increased heart rate and rate of breathing were reported as well as chills. An examination revealed tachycardia and left lower quadrant abdominal pain. A report of bloody diarrhea was noted by the general surgical consultant and pain in the left lower quadrant after eating. There was a concern for ischemic colitis. 

The patient was admitted. Mild hypoxia on exertion was noted. The patient was empirically started on antibiotics. The patient was discharged on oral antibiotics once deemed stable. 

No, the proposed inpatient admission was not medically necessary.  The treatment as rendered was medically appropriate but not necessary at the level at which it was rendered. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had one episode of rectal bleeding with abdominal pain, yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care in its entirety could have been rendered at a lesser level. 

Yes, the health plan act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep impinging overbite with severe soft tissue damage

Treatment: Comprehensive orthodontic treatment

The insurer denied coverage for comprehensive orthodontic treatment.

The denial is upheld. 

This male patient has no documented history.

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met, as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the Handicapping Labio-Lingual Deviation index of the insurer, attaining 11 points (5 points overjet, 5 points overbite, 1 point labio-lingual spread).
 
Regarding the validity of the Handicapping Labio-Lingual Deviation 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 referenced 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 clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care. The health care plan acted reasonably, with sound medical judgement, and in the best interest of the patient.

The carrier's denial of coverage for comprehensive orthodontic treatment is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overjet, overbite, anterior crowding, labio-lingual spread, posterior unilateral crossbite

Treatment: Comprehensive orthodontic treatment of adolescent dentition and periodic orthodontic treatment visits

The insurer denied coverage for comprehensive orthodontic treatment of adolescent dentition and periodic orthodontic treatment visits.

The denial is upheld. 

This female patient has no significant documented history.

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 Labio-Lingual 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 28 points to justify orthodontic care.  

This reviewer concurs with the index completed by the insurer attaining a total of
24 points on the HLD index (3 overjet, 4 overbite, 10 anterior crowding, 3 labio-lingual spread, 4 posterior unilateral crossbite), which is below the threshold of 26 points to support orthodontic care.

Regarding the validity of the HLD, 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.

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

The carrier's denial of coverage for comprehensive orthodontic treatment of adolescent dentition and periodic orthodontic treatment visits is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Constipation

Treatment Linzess 145 mcg (micrograms) or caps (capsule)

The insurer denied coverage for Linzess 145 mcg or caps

The denial is overturned
	
The patient had cirrhosis and chronic constipation. Her symptoms were controlled on the Linzess. The progress notes document that she has cirrhosis and chronic constipation. There is a note in the submitted chart that Amitiza was tried but it didn't work.

UpToDate has an article titled 'Management of Chronic Constipation in Adults.' The article discusses linaclotide. It states that linaclotide has been approved by the FDA (Food and Drug Administration) for the treatment of chronic idiopathic constipation. In two large trials, the linclotide treated group had significantly higher rates of spontaneous bowel movements per week as compared to placebo.

Linzess is an FDA approved indication for the treatment of chronic constipation. This medication is medically necessary for the patient given her history. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the Linzess 145 microgram or caps is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia Areata. 
Treatment: Xeljanz. 

The insurer denied coverage for Xeljanz. 

The denial is upheld. 

The patient has a diagnosis of alopecia areata.   According to the appeal letter, the patient has failed therapy with steroids.  No documentation is provided to demonstrate which actual steroid the patient has previously tried, what dose, and the results of these treatments.  Similarly, no medical documentation is provided regarding the length of time the patient has been treated with these medications.  The provider is requesting Xeljanz. 

As a result, Xeljanz is not medically necessary for the claimant's condition, alopecia areata. The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possibly improve alopecia areata, including light therapy, squaric acid, diphencyprone (DPCP), calcipotriene, and anthralin.  Although case reports have demonstrated possible efficacy of Xeljanz for alopecia areata and related conditions, further studies are needed to demonstrate the long term efficacy and safety of Xeljanz.  It is noted that the Food and Drug Administration (FDA) released a statement finding increased risk of deep vein thrombosis and pulmonary embolism in patients enrolled in a phase 4 clinical trial of Xeljanz at a dosing of 10 mg (milligrams) bid (twice per day) (1). 

The standard of care for treatment of alopecia areata would necessitate an attempt to use the above mentioned options for the treatment of alopecia areata.  The patient has not failed or shown to have a contraindication to numerous therapies known to possible improve his condition, including light therapy, squaric acid, DPCP, and anthralin. 

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

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

Diagnosis: Synovial sarcoma.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is modified.

This is a male with a history of a connective and soft tissue malignant neoplasm. He had a gastric/mixed tumor. The patient had reconstruction of a left lower extremity defect with a pedicled left gastrocnemius muscle flap and a split thickness skin graft. During the admission, routine postoperative care was rendered. Pain was well controlled with intravenous patient-controlled analgesia. The patient was later transitioned to oral pain medication. Two Jackson Pratt (JP) drains, and a wound vac (vacuum-assisted closure device) were placed. Intravenous Cefazolin was started. The patient was non-weight bearing on the left lower extremity with a long leg splint. The left lower extremity was elevated and remained in extension at all times. There was increased swelling and pain in his left knee. Methadone was started. Incision vacuum assisted closure was removed by Plastic Surgery. Ambulation was encouraged with the help of crutches. There was left lower extremity swelling with ambulation. The brace was adjusted without issues. An ultrasound revealed a left leg, mid-calf, deep vein thrombosis. Lovenox was started. The patient worked with physical therapy. He was able to tolerate an advancing diet. The patient was discharged home with home nursing services.  

The health care plan acted reasonably in part and with sound medical judgment and in the best interest of the patient. The initial admission was necessary, but a continued stay was not medically necessary.

The medical records demonstrate the patient had a unique and complex clinical condition. He had been diagnosed with a synovial sarcoma and required complex reconstructive surgery. His post-surgical course demonstrated several factors to substantiate necessity of ongoing acute hospitalization. He was found to have ongoing pain not responsive to initial pain management consultations. He required multiple medications with ongoing pain levels of 10/10. He required wound care and had a drain. There was continuous output for several days after his operation. It would be important to monitor evidence of bleeding and/or wound problems. He received wound care on a continual basis. His operative site was at high risk for complication. A person with a draining wound should not be discharged to a lower level of care. He also required ongoing intravenous antibiotics. Discharge planning was not completed until he was advised to apply for subacute rehabilitation.

Based upon the complexity and extent of his condition with high risk for complication, admission during the first 9 days would be medically necessary (ongoing pain, presence of drain, ongoing intravenous antibiotics, wound care).

Based on the above, the medical necessity for the continued inpatient hospital admission is partially substantiated. The insurer's denial is modified. Approve for initial 9 hospitalization days and uphold denial of the last 7 days of hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin/Psoriasis.
Treatment: Pharmacy/Prescription Drugs. 
The health plan denied the requested medication, Otezla, as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with moderate to severe psoriasis (30% body surface area involvement) distributed on the thighs, abdomen, lower back, and buttocks. The patient has tried and failed topical creams and steroids prescribed by her primary care provider. The patient was given samples of Otezla with significant improvement. Methotrexate and Cyclosporine have been avoided because of concerns over damage to the liver or kidneys, or for increased risk of infection. The patient does not drink alcohol, as per the clinic notes.
The medical necessity of treatment with Otezla is under review for medical necessity.

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

No. The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, Acitretin, and/or Phototherapy. Particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, these preferred agents are appropriate for this patient's clinical scenario, and are as effective, safe, and well-tolerated as the requested Otezla. Patient and/or provider convenience is not the same as true medical necessity.
While Cyclosporine does have potential long-term renal and hypertensive risks if used beyond 3-12 months, Methotrexate is safe for those who do not imbibe significant amounts of alcohol (such as this patient) and is medically acceptable and appropriate for patients with this particular treatment history. Acitretin is another alternative for patients such as this one if concerns of immunosuppression exist for the patient and/or provider. Both Methotrexate and Acitretin (supplemented, perhaps, with light therapy) have as much or greater efficacy and have no significantly greater incidence of adverse events associated with use, than the requested Otezla.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Failing teeth.
Treatment: Implant Placement for Teeth 4, 5, 12, and 13.
The insurer denied the Implant Placement for Teeth 4, 5, 12, and 13.
The denial is overturned.

The patient is a female with request for extractions of teeth #s 4, 5, 12 and 13, and to place implants in those areas. 

The health plan denied because there is no medical reason stating why fixed bridges or a partial denture would not be appropriate treatment.

Yes, the proposed treatment is medically necessary.
The extraction of these four failing teeth and the placement of four implants is the more conservative treatment in this case. No other teeth will need to be treated as would be the case if fixed bridges were placed (i.e. other teeth would need to be ground down for no other reason than to place bridges). The implants are also more conservative and stable than a partial denture. There is medical necessity for the implants in this case.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Febrile Urinary Tract Infection (UTI).

Treatment: hospital admission.

The insurer denied coverage for hospital admission.

The denial is upheld.

This is a girl with a history of chronic constipation, seen in the emergency department (ED) two days prior and diagnosed with a febrile urinary tract infection (UTI), and was prescribed cephalexin, but mother did not pick up the prescription and returned reporting persistence of symptoms, which included several bouts of emesis and loose stools, dysuria, and decreased activity and appetite.

On physical examination she had mild tachycardia (117/beats per minute (bpm)), low grade fever at a maximum of 100.3 Fahrenheit, was crying with pain and uncomfortable, the abdomen was soft with bilateral cerebrovascular accident (CVA) tenderness and generalized abdominal tenderness. Lab work: her white blood cell count (WBC) was within normal limits and creatinine was normal. Urinalysis confirmed presence of a UTI and the culture was reported as E. coli (escherichi coli) resistant to ampicillin and intermediate to Unasyn. Renal sonogram reveled debris in the bladder, mild fulness of the left collecting system, mild elevation of the visualized distal right ureter upstream of a punctate calculus, but no ipsilateral hydronephrosis.

The justification in the appeal "antibiotic resistant E. coli" and "failing outpatient treatment for a UTI" are incorrect, as she was on no therapy at all. Moreover, this is a standard and common resistance pattern for E. coli, so the cephalosporin therapy prescribed initially was appropriate. She would have benefited from intravenous (IV) hydration, a single IV dose of ceftriaxone, and could have been treated as an outpatient as she was not toxic appearing, not in renal failure, and after a trial of oral fluids she could have been sent home to complete treatment on oral cephalexin. 

Inpatient treatment was not medically necessary. She was not toxic-appearing, and it is not documented that she could not tolerate oral fluids.  Both references below specify that the clinical assessment of a child with UTI is the most important factor is deciding whether to administer IV antibiotics.  

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

The hospital admission is not considered medically necessary for this patient.

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

Diagnosis: Prostate Cancer. 
Treatment: Positron Emission Tomography Scan with Computed Tomography for Attenuation (PET/CT). 

The insurer denied Positron Emission Tomography Scan with Computed Tomography for Attenuation (PET/CT). The health plan's determination is upheld. 

This is the case of a male patient who underwent a radical prostatectomy and was found with high risk node positive cancer. He was found to have a rising prostate-specific antigen (PSA). A positron emission tomography (PET)/computed tomography (CT) was ordered to determine the extent of disease and help guide radiation therapy (RT) treatment. 

The Positron Emission Tomography Scan with Computed Tomography for Attenuation (PET/CT) is not medically necessary for this patient. 
The standard of care in this case would be that the patient undergoes conventional imaging to detect recurrence first. A PET/CT scan for cancer recurrence is not in accordance with generally accepted standards of medical practice in the United States. National Comprehensive Cancer Network (NCCN) guidelines mentions this scan as an alternative to standard imaging bone and soft tissue. They also state that PSMA (prostate specific membrane antigen) PET can serve as an equally effective, if not more effective front line imaging tool for these patients. The standard of care would be for the patient to undergo conventional imaging to detect recurrence first.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Juvenile idiopathic arthritis (JIA)

Treatment: Humira 40 milligram

The insurer denied coverage for Humira 40 milligram

The denial is overturned.

According to the medical records, the patient has a history of uveitis and juvenile idiopathic arthritis. The patient failed Humira every 2 weeks and is stable on Humira every 12 days which is the topic of this review.

Correll, C. K. et al., "Weekly adalimumab dosing is used to treat juvenile idiopathic arthritis (JIA), uveitis, and other pediatric rheumatic diseases, but the safety of such dosing has not previously been studied. A retrospective chart review was conducted to assess the safety of weekly adalimumab. Demographic and clinical data were collected." 

Horneff, G. et al., "Conclusions: The safety profile of adalimumab in pediatric patients with polyarticular juvenile idiopathic arthritis, enthesitis-related arthritis, psoriasis, and Crohn's disease was generally similar across indications; no new safety signals were identified in the treatment of pediatric patients with adalimumab." 

Humira Highlights of Prescribing Information, "Juvenile Idiopathic Arthritis (JIA) Reducing signs and symptoms of moderately to severely active polyarticular JIA in patients 2 years of age and older."                                                         

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Uveitis and JIA are 2 diseases with high mortality and morbidity. 

Humira 40 milligram is considered medically necessary for this patient. Uveitis and JIA are 2 diseases with high mortality and morbidity. It is recommended to continue the same treatment if it is working. It is common and standard of care among rheumatologists to increase the dose of Humira to obtain optimal clinical response.

The insurer's denial of coverage for Humira 40 milligram is overturned. Medical necessity is substantiated.