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

Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is upheld.

The patient is a male who presented to the emergency department complaining of non-exertional burning chest pain. His medical history was remarkable for familial hypercholesterolemia. Two days prior he had a computed tomography (CT) scan for coronary calcium scoring. His score was 85, which placed him in the 95th percentile for his age, race and gender. In the emergency department his blood pressure was 203/108 millimeters of mercury (mmHg). This fell to 135/85 mmHg after sublingual nitroglycerin, which also relieved his pain. His heart rate was 87 beats/minute. His physical exam was unremarkable. His electrocardiogram was normal. His serum troponin level was normal and remained normal when re-measured twice. The patient was admitted to the hospital. A stress echocardiogram was performed and showed no evidence of ischemia. The patient was discharged the same day.
The subject under review is the medical necessity for an inpatient hospital admission.

The health plan's determination is upheld.

This patient presented with atypical chest pain. He was hemodynamically stable, with a normal electrocardiogram and normal cardiac biomarkers. Based on his HEART score, he was at low risk for major adverse cardiac events (0.9-1.7%). He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary Arterial Hypertension
Treatment: Revatio, Pre-service
The insurer denied the Revatio, Pre-service.
The denial is overturned. 

The patient is a male child with complex medical history significant for autism, type II diabetes mellitus, dilated cardiomyopathy with severe biventricular systolic dysfunction status post HM3 (HeartMate 3) left ventricular assistive device (LVAD) placement with ongoing heart failure, and feeding difficulties status post gastrostomy tube placement. His heart failure was initially managed via PICC (peripherally inserted central catheter) with milrinone parenteral therapy as well as digoxin. Sildenafil was added to help improve right ventricular function. He has been stable with use of sildenafil (Revatio) since that time.

Yes, the treatment with Revatio is medically necessary.

Sildenafil is a phosphodiesterase-five inhibitor that functions as a pulmonary vasodilator. It is frequently used for patients with pulmonary artery hypertension. It is also used for patients dependent upon left ventricular assist devices to unload the right ventricle and improve right ventricular failure.

This patient was diagnosed with dilated cardiomyopathy and severe biventricular heart failure. At that time, following multiple medication trials, he was started on milrinone with some improvement. However, the improvement was short-lived and he returned to the hospital with recurrent vomiting and respiratory distress. Cardiac catheterization at that time revealed very high filling pressures. He remained critically ill.

The patient underwent placement of an HM3 (HeartMate 3) LVAD (left ventricular assist device), with post-operative infusions of milrinone, dobutamine, inhaled nitric oxide, and diuretics. Upon discontinuation of the dobutamine infusion, he was started on digoxin. He was also weaned from the inhaled nitric oxide.

The patient was started on sildenafil to help with his ongoing heart failure and has remained on sildenafil since. Adjustments have been made for depressed right ventricular function, and as of a year later, he was taking 20 mg (milligrams) three times a day. While still in heart failure, at that time it was considered to be well-compensated, with both digoxin and sildenafil for chronic right heart failure. Sildenafil is life-saving for this patient as well as being standard of care, managing both baseline heart failure as well as any complications of right heart failure from LVAD (left ventricular assist device) use.

Therefore, given the above, the treatment with Revatio is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth Decay.
Treatment: D2752 White Glass With Gold Crown, Tooth 14 and 15, Pre-service.

The insurer denied the D2752 White Glass With Gold Crown, Tooth 14 and 15, Pre-service.  The denial is overturned. 

The patient is a male requesting crowns, code D2752, on teeth #14 and #15.

Yes, the proposed D2752 White Glass with Gold Crown, Tooth #14 and #15, is medically necessary.

The existing restorations in teeth #14 and #15 are large. There is new decay under these fillings, and once the old fillings and decay are removed, crowns will need to be placed to properly restore these teeth and keep them from breaking.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis. 
Treatment: Cosentyx Sensoready (300 mg) 150mg/ml SC SOAJ, Pre-service. 

The insurer denied the Cosentyx Sensoready (300 mg) 150mg/ml SC SOAJ, Pre-service. 
The denial is upheld. 

The patient is a male with psoriasis for whom Cosentyx is requested. He has tried and failed multiple topical steroids, vitamin D derivatives, and methotrexate (per note); however, the drug was prescribed but there is no pharmacy record it was filled). Phototherapy is not feasible due to the patient's work schedule. 

No, the proposed treatment with Cosentyx is not medically necessary. 
The patient was prescribed methotrexate. Based on that, the provider thought it an adequate treatment option. The pharmacy records do not show that the patient filled this prescription. There is no documentation of trial, failure, or contraindication to methotrexate. 

The folic acid antagonist methotrexate has been used successfully in the treatment of psoriasis for over 50 years. It is also effective for the treatment of psoriatic arthritis and psoriatic nail disease. For patients with one or more risk factors for hepatotoxicity from methotrexate, the use of a different systemic drug should be considered. 

Risk factors for hepatotoxicity from methotrexate include: 
History of more than moderate alcohol consumption, 
Persistent abnormal liver function test findings, 
History of liver disease, including chronic hepatitis B or C, 
Family history of inherited liver disease (eg, hemochromatosis), 
Diabetes mellitus, 
Obesity, 
History of exposure to hepatotoxic drugs or chemicals, 
Hyperlipidemia.

There is no documentation that any of the above risk factors are present.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Aplastic anemia, hypertension, gait ataxia and recurrent falls.
Treatment: Increase Personal Care Services to 24-Hour Personal Care Services (two 12-hours shifts) (split shift or live-in) for a Total of 168 Hours.
The insurer denied the Increase Personal Care Services to 24-Hour Personal Care Services (two 12-hours shifts) (split shift or live-in) for a Total of 168 Hours.
The denial is overturned.

The patient is a female with a history of aplastic anemia, hypertension, gait ataxia and recurrent falls. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of an increase in Personal Care Services to 24-Hour Personal Care Services (two 12-hours shifts) (split shift or live-in) for a Total of 168 Hours to offer increased activities of daily living support.

Yes, the proposed treatment of 168 hours per week Personal Assistance Services is deemed medically necessary.

This is a female with a history of aplastic anemia, hypertension, gait ataxia and recurrent falls.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living. An assessment of the patient's functionality and ability to perform activities of daily living was completed and revealed that the currently approved plan of 60 hours total Personal Assistance Services is sufficient to meet the patient's current needs. 

However, review of the patient's medical records, including emergency room notes indicate that the patient has been suffering from progressively worsening gait ataxia with recurrent falls due to leg weakness. She has been noted to have an increasingly shuffling gait and currently has to alternate dragging her right and left legs across the floor in order to make significant progress while ambulating. 

For these reasons, the proposed treatment of 24-Hour Personal Care Services (two 12-hour shifts) (split shift or live-in) for a Total of 168 Hours to offer increased activities of daily living support is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder/Headache
Treatment: Inpatient Hospital
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female who presented to the emergency department (ED) with sudden onset of a headache accompanied by dysarthria as well as weakness and numbness in bilateral upper extremities. The patient had no prior headache with neurologic symptoms previously. Vital signs (VS) on admission included a blood pressure (BP) of 117/72 millimeters of mercury (mmHg), a heart rate (HR) of 70 beats per minute (bpm), a respiratory rate (RR) of 20/minute, and an oxygen saturation of 98% on room air (RA). Physical exam noted no abnormalities, 5/5 strength noted in upper and lower extremities. Labs noted a sodium (Na) of 141, a potassium (K) of 3.6, a carbon dioxide (CO2) of 23, a blood urea nitrogen (BUN) of 11, a creatinine of 0.44, a white blood cell count (WBC) of 6.18, a hemoglobin of 14.0, and platelets of 189. In the ED, a stroke code was activated. A head computed tomography (CT) was negative for an acute process. Neurology was consulted and recommended admission for evaluation for transient ischemic attack (TIA)/cerebrovascular accident (CVA). The patient had a magnetic resonance imaging (MRI) which was negative for an acute CVA. She was discharged home with recommendations for lipid management and antiplatelet therapy.

At issue is the medical necessity of the inpatient stay.

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

The inpatient stay was not medically necessary. She presented with a headache, but no persistent neurologic deficits. She had a normal head CT. She did not have hemodynamic instability, high risk etiology (such as a mass), or persistent neurologic deficits. It would be appropriate to admit the patient to an observation level of care for neurologic checks and to obtain an MRI to determine if TIA/CVA was the cause of her presentation vs a complex migraine. The reporting of transient slurred speech indicates a high-risk clinical feature and discharge from the ED without observation level of care and an MRI would not be appropriate [1].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-abdominal wall hernia.
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld in whole. 

The patient is a female who presented to the emergency department (ED) at the recommendation of her primary doctor due to concern about an abdominal wall hernia. She reported a 10 out of 10 abdominal pain and nausea of one-week duration. Her heart rate at the time of presentation was 119 beats/minute. Her other vital signs were normal. The abdomen was diffusely tender. The patient had been evaluated with a computed tomography (CT) scan of the abdomen and pelvis that showed multiple dilated small bowel loops with a transition point in the right lower abdomen. The white blood cell (WBC) count was elevated on at 17. The patient was admitted to the hospital and treated with intravenous (IV) fluid, antibiotics, and pain medication. The admitting diagnosis was abdominal pain secondary to inflammatory bowel disease.
The WBC count had normalized to 7.8.
The abdominal pain was improved. The WBC count was 9.2. She was considered stable for discharge home with instructions for short-term follow up with the surgery service and gastroenterology for management of colitis.
At issue is the medical necessity of the Inpatient stay.

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

No, the requested health service/treatment of Inpatient stay was not medically necessary for this patient.
The medical records support that this patient presented to the ED with acute abdominal pain. She was tachycardic at the time of presentation and had CT scan findings of pathology involving the small bowel. The precise nature of this pathology was uncertain; however, inflammatory bowel disease was considered. It was not thought that acute surgical intervention would be required. The patient was appropriately evaluated for her presenting condition with a surgical consultation. The patient was not deemed to require emergent surgery or other intervention. The patient was clinically stable, and the aberrations of tachycardia and leukocytosis had normalized. The records support that the abdominal pain improved, and she was stable for discharge from the hospital with plans for further outpatient evaluation. 
This patient was afebrile, clinically stable, tolerating a diet and oral medications, and was without signs of persistent infection. Per the generally accepted standards of care, an inpatient hospital stay was not medically necessary.
Therefore, the Inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Neupogen 480 mcg/1.6 ml vial for medical necessity. 
The denial was upheld. 

The patient is a female, gravida (G) 5 para (P) 0, with a history of recurrent pregnancy loss (RPL) and recurrent implantation failure (RIF). She has been prescribed Neupogen 480 micrograms (mcg)/1.6 milliliters (ml) vial for the treatment of RPL and RIF.
At issue is the medical necessity for the Neupogen 480 mcg/1.6 ml vial.

The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Neupogen 480 mcg/1.6 ml vial is not medically necessary for this patient.
Though there is some data that may support a link between improving pregnancy outcomes with patients who have RPL/RIF, there is no strong data that confirms a significant improvement in pregnancy outcomes with colony-stimulating factor agents like Neupogen. Use of Neupogen or similar agents is also not approved for use in these clinical scenarios. Though Neupogen has been found to be an effective treatment in a number of health disorders, there is not enough definitive evidence of a positive impact in RPL/RIF patients to conclusively determine that this treatment is medically necessary in this case.
Thus, Neupogen 480 mcg/1.6 ml vial is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep Apnea. 
Treatment: Nerve Stimulator, CPT 0466T and CPT 64568. 

The insurer denied coverage for nerve stimulator, CPT 0466T and CPT 64568. 

The denial is overturned. 

This patient is a male with a long history of obstructive sleep apnea (OSA). The patient underwent a sleep study and repeat study years later. Recent study revealed that the patient had an apnea hypopnea index (AHI) of 41.4. The patient's body mass index (BMI) was 26.6, and it was documented that the patient could not tolerate continuous positive airway pressure (CPAP) use. The patient's fiber endoscopic examination for drug-induced sleep endoscopy did not find any complete closure of the airway. 

There is an extensive literature showing the efficacy of hypoglossal nerve stimulation and the treatment of obstructive sleep apnea. [1-7] The use of hypoglossal nerve stimulation has been approved by international and national professional societies. [8-12] The Food and Drug Administration (FDA) has twice approved the use of hypoglossal nerve stimulation for the effective treatment of obstructive sleep apnea (OSA). [13,14]  The patient fulfilled all of the FDA requirements for the use of hypoglossal stimulation which included apnea hypopnea index (AHI) of greater than or equal to 15 and less than or equal to 65; the patient's AHI was 41.4. The patient was also confirmed to fail and/or cannot tolerate CPAP use. The patient does not have a complete concentric collapse at the soft palate level, which was documented by the endoscopy. The two FDA approvals do not include any statement about a BMI. An early 2014 study excluded BMI > 32.1  This is not included or has been noted to be exclusion in any of the numerous studies, reviews, guidelines and meta-analysis subsequent including the two issued by the FDA. [2,4-8,11,14-17] However the patient has a BMI of 26.6 which is less than the maximum noted in the 2014 study. 

The use of the nerve stimulator, CPT 0466T and CPT 64568, to treat sleep apnea from at the outpatient level of care is considered medically necessary for the patient. The patient has severe OSA and cannot tolerate the use of CPAP. 

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

The insurer's denial of coverage for a nerve stimulator, CPT 0466T and CPT 64568, to treat sleep apnea should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class III malocclusion.
Treatment: Braces.

The insurer denied braces. The health plan's determination is overturned. 

The patient in question is a male with a Class III malocclusion, moderate spacing of the upper and lower arches and anterior crossbite of teeth #7-#10. Teeth 13 and 14 are in crossbite. Teeth 8 and 9 have very short roots. He is treatment planned for 36 months of orthodontics to correct his malocclusion.

Braces are medically necessary for this patient. The patient has significant maxillary anterior spacing with teeth #7-#10 in crossbite. These teeth have a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Tooth #9 is already mobile due to the traumatic bite. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, braces are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Incomplete Abortion.
Treatment: inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

The patient is a female with a past medical history of asthma who presented to the emergency room at 6 weeks gestation with a diagnosis of an incomplete abortion.  The patient underwent a dilation and curettage (D&C).  The procedure was reported as uncomplicated and that the patient's blood loss was minimal.

As per medical record, this patient had an incomplete abortion necessitating a D&C. However, D&C are ambulatory procedures. D&Cs are done in offices and surgical centers.  Dilatation and curettage can be performed safely in the office or other outpatient setting using manual vacuum aspiration or sharp curettage. Admission to an acute level of care is not customary or medically necessary.  There was no reason submitted to justify for this patient's admission.  Postoperatively, the patient was stable.  The patient was not anemic, and she was able to void and tolerate oral intake without difficulty. The patient's procedure was uncomplicated and there was no concern for a surgery complication like injury to the bladder, bowel or uterine perforation.  Following this patient's D&C procedure, the patient could have been observed in the recovery room like all patients undergoing an ambulatory procedure, and once the provider ascertained that the patient was stable, the patient could have been sent home. 

Based on all the information submitted, the inpatient hospital admission is not considered medically necessary for this patient.

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

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

Diagnosis: Central Nervous System/Neuromuscular Disorder/Migraine
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription drug as not medically necessary. 
The health plan's determination is upheld.

The patient is a female who is under the care of a neurologist/neurology practice for a diagnosis of chronic migraine headaches.

The patient presented for Botox injections. The patient also reported neck pain for which she had reportedly been seen by a chiropractic provider.

Notes provided for review indicate that the patient had had prior trials of Aimovig, Ajovy and Emgality, all without benefit. The patient also reported daily headaches with exacerbations (in terms of severity). At the time of that visit, she also underwent infusion of Vyepti and underwent Botox injections for migraine prophylaxis.

A request has since been made of the patient's health plan for coverage of Vyepti infusions.

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

No, based on current medical literature, it cannot be determined that the requested service would be medically necessary and/or standard of care. All the pre-market studies of Vyepti (and the other CGRP [calcitonin gene related peptide] prophylactic medications) required trial participants not to have received Botox injections for at least 4 months prior to trial participation. The requested drug (Vyepti) has not yet been formally evaluated for concurrent use with Botox in any well-designed clinical studies. Rather, as Pellesi and colleagues noted: "There is currently only indirect preclinical evidence suggesting a role for dual therapy with anti-calcitonin gene related peptide monoclonal antibodies and botulinum toxin type A for chronic migraine prevention. Rigorous studies evaluating clinical efficacy, safety, and cost effectiveness are needed." In as much, based on the (limited) clinical information provided for review and current literature, medical necessity is unable to be established at this time. The plan used sound medical judgement based on current medical literature in reaching their determination in this case.