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

Diagnosis: Pectus Excavatum. 
Treatment: Surgical Repair of Pectus Excavatum. 

The insurer denied Surgical Repair of Pectus Excavatum. The health plan's determination is overturned. 

The patient is a male with a Haller index of 3.26, normal echo (echocardiogram) and pulmonary function testing show mild lower airflow obstruction with decreased FEV1 (forced expiratory volume in 1 second) (79%) normal lung volumes. He presents for minimally invasive pectus excavatum repair. 

Surgical Repair of Pectus Excavatum is medically necessary for this patient. It has been well documented that pectus malformations have modest impact on cardiopulmonary function at rest without correlation to dyspnea on exertion or chest pain. Other studies have shown that repair of a pectus deformity will improve right ventricle (RV) global longitudinal strain rate immediately (3). Finally, resting pulmonary function test (PFT) patterns have poor correlation with the anatomic extent of the pectus defect. In summary, pectus deformities have cardiopulmonary impairment and can be modest and hard to detect. Basing the criteria on tests that can be normal despite severity of the corrective index is not a reliable method to determine eligibility for surgery. However, in this case, the patient did have mild obstructive airflow pattern. There were reports of shortness of breath (SOB) with exertion (basketball)-- these are soft signs of his cardiopulmonary impairment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Otezla 30 mg OR tablets
The insurer denied coverage for Otezla 30 mg (milligrams) OR (oral) tabs
The denial is overturned

The is a patient with mild-moderate psoriasis affecting 3-5% TBSA (total body surface area). The patient has failed therapy with topical steroids and UV (ultraviolet) therapy. The requested medication is Otezla 30 mg (milligram) tablet.

Based on the submitted documentation, the use of Otezla is medically necessary.  The patient has mild psoriasis that is borderline moderate with a 3-5% surface area of involvement. The patient has failed light therapy as well as topical steroids. Otezla is the most appropriate systemic therapy for mild psoriasis and has an FDA (food and drug administration) indication for mild and moderate psoriasis (5). The patient has failed reasonable alternatives. The use of alternative systemic agents, such as methotrexate, cyclosporin, or biologics, are generally reserved for more moderate to severe disease. The use of Otezla is approved for use in the management of the patient's psoriasis based on the standard of care.

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 Otezla 30 milligrams (mg) OR tabs is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient presented to the emergency department (ED) with acute onset abdominal pain, increased thirst, and headaches. He was found to be hyperglycemic with a blood glucose level of 500-600's, hemoglobin A1c (HbA1C) is over 14. The patient received intravenous (IV) fluids. The Beta-hydroxybutyrate (BHB) is 1.7, anion gap is 9, bicarbonate is 28, sodium is 126, and glucose is 601. No neurologic abnormalities noted on exam. Blood pressure (BP) is 151/86, and heart rate (HR) is 54. Creatinine level is 0.64. He was prescribed metformin previously but never started. Endocrinology was consulted and the patient was admitted for further evaluation and management. He was started on basal bolus subcutaneous insulin and continued IV fluids. Sodium improved to 134. His insulin and blood pressure medications were adjusted for hyperglycemia and hypertension respectively, and he was discharged.

This patient had worsened hyperglycemia with abdominal pain; however, did not have mental status changes or other end organ damage associated with uncontrolled hyperglycemia to qualify for hyperosmolar hyperglycemic state. He did not have acidosis or ketosis to qualify for diabetic ketoacidosis. The care the patient received, including IV fluids, subcutaneous insulin, and diabetic teaching could have been administered at an observation a level. Therefore, hospital stay at an inpatient level is not medically necessary, based on current peer reviewed literature and applicable guidelines.

According to Gosmanov AR et al. (2021), "Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management is key to the successful resolution of DKA and HHS. Critical components of the hyperglycemic crises' management include coordinating fluid resuscitation, insulin therapy, and electrolyte replacement along with the continuous patient monitoring using available laboratory tools to predict the resolution of the hyperglycemic crisis. Understanding and prompt awareness of potential special situations such as DKA or HHS presentation in the comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA, and risk of brain edema during therapy are important to reduce the risks of complications without affecting recovery from hyperglycemic crisis."

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: Atopic dermatitis.
Treatment: Opzelura cream.
The insurer denied Opzelura Cream. 
The health plan's determination is upheld. 

The patient is a female with atopic dermatitis. She has tried and failed Clobetasol. The medication under review is Opzelura cream.

The requested Opzelura Cream is not medically necessary for this patient.
There is no documentation that the patient has tried and failed, has a contraindication to, or intolerance to the preferred therapies such as topical tacrolimus (Protopic).
According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications such as tacrolimus ointment, are effective treatments for the management of atopic dermatitis.
A Cochrane Database of Systematic Reviews for Topical tacrolimus (which is a preferred, formulary drug) for atopic dermatitis concluded that "In summary, tacrolimus ointment seems to be safe and effective for moderate to severe atopic dermatitis in children and adults"
It is noted that the patient has tried and failed the topical steroid Clobetasol. However, the patient has no true contraindications to the other preferred, formulary medications which are effective for the treatment of atopic dermatitis. The preferred agents are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed before initiating Opzelura.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mycosis Fungoides (MF)
Treatment: Outpatient procedure (96900 x 36) Skin Phototherapy
The insurer denied the Outpatient procedure (96900 x 36) Skin Phototherapy
The health plan's determination is overturned.

The patient is a female with Mycosis Fungoides (MF), which has been described as a generalized form of Cutaneous T-Cell Lymphoma (CTCL). The condition is usually treated with 2-3 times a week of Narrowband ultraviolet B (UVB) light therapy and has been for years. The condition has involved the chest, back, abdomen, arms, and legs. The patient has persistent hyperpigmented patches consistent with Cutaneous T-Cell Lymphoma (CTCL). A letter states the patient still has hyperpigmentation and requires further phototherapy for maintenance of the patient's CTCL.

Skin Phototherapy (x36) is medically necessary for this patient.
The patient has diffuse hyperpigmented patches of the patches are consistent with Stage 1-2 CTCL/MF (Cutaneous T-Cell Lymphoma/ Mycosis Fungoides). Because they are so diffuse, topical therapies are usually not viable options, and oral medications have potential toxicity that is ideally avoided in a young patient such as this one. Based on current medical literature and standards of good medical practice, further light therapy is medically necessary.
The likelihood of remission of this patient's diffuse CTCL is small, and the description of this patient's hyperpigmented patches (consistent with persistent CTCL/MF) in the records supports medical necessity of further treatments of phototherapy. Years of persistent light therapy is the standard of care for this challenging condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Entyvio Intravenous (IV) infusion every 4 weeks
The insurer denied the Entyvio IV infusion every 4 weeks.
The denial is overturned.

The patient is a male with Crohn's Disease (CD). The patient has had Crohn's colitis for approximately 13 years. The patient failed oral medication including mesalamine and steroids and was placed on Entyvio at 300 milligrams (mg) every (Q) 8 weeks. On this therapy the patient had persistent residual symptoms and the dose was increased to 300 mg Q 4 weeks. On this higher dose the patient has done considerably better. The patient's Entyvio drug level at 4 weeks was only 12.1 micrograms per milliliter (ug/ml). The increase of Entyvio to Q 4 weeks is beyond the Food and Drug Administration (FDA) approved dose and is not considered the standard of care.

The health plan's determination is overturned.

The requested Entyvio intravenous (IV) infusion dose is medically necessary. Dose intensification of Entyvio for inflammatory bowel disease (IBD) has been looked at carefully in a systematic review and metanalysis. Peyrin-Biroulet, et al analyzed data from 10 eligible cohorts. The pooled incidence rates of loss of response to Entyvio were 47.9 per 100 person-years of follow up (95% [percent] confidence interval [CI], 26.3-87.0; test of heterogeneity [I2] = [equals] 74%) among patients with CD. Dose intensification to 300 mg Q 4 weeks restored response to the drug in 53.8% of secondary non-responders (95% CI, 21.8%-82.9%; I2 = 77%).

In a post-hoc analysis of data from the Gemini trial vedolizumab trough concentrations at week 6 or 10 were grouped in quartiles and clinical outcome rates calculated. The authors found that higher vedolizumab serum concentrations were associated with higher remission rates after induction therapy in patients with moderately to severely active CD.

The patient has had significant improvement on Q 4 week dosing. There are limited additional options for this patient and switching classes to, for example, an anti-tumor necrosis factor (TNF) would be premature. Adding an immune modulator such as azathioprine is not evidence based and would increase his level of immunosuppression.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ankle pain
Treatment: Inpatient admission 
The insurer denied: Inpatient admission 
The denial is upheld

The patient is an adult female evaluated in ED (emergency department). She was status post ORIF (open reduction internal fixation) of the left ankle and had been placed in a splint. She was referred from the SNF (skilled nursing facility) with problems to her splint.  She also was reported to have a psychiatric problem and scapula fracture.

The patient was admitted to the hospital where her splint was re-applied. She underwent imaging studies and received psychiatric consultations. She was discharged five days later.

The patient was noted to be at risk for developing an equinus contracture. She was admitted for observation to see if she could tolerate the new splint.

The inpatient admission was not medically necessary.

The records show no acute condition to warrant the level of service provided. There was no indication for admission to the hospital. The reported need to see if the splint would be tolerate could be provided by the SNF (skilled nursing facility) or outpatient service. The surgical incision was clean with no evidence of infection.

The records showed stable vital signs. There was no drainage. There were no open wounds to require care. The person was able to tolerate oral medications. The subspecialty consultations could have been complete in the ED (emergency department). There was no indication for imaging studies as inpatient. There were no other medical conditions to warrant the acute level of care.

Simply stated, the splint could have been removed, and reapplied without a hospital admission. There were no extenuating circumstances nor other facts to support level of care provided. Therefore, given the above, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myoclonic epilepsy
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
 The denial is upheld

This patient with a history of juvenile myoclonic epilepsy presented to the emergency room for seizure-like activities. She had multiple witnesses to convulsive seizures, which lasted approximately 1 minute each. After her initial episode, which caused her to fall from the couch, she appeared to be confused afterwards for several minutes before returning to her baseline. She had an additional episode lasting one minute consisting of shaking on the floor. At the emergency department, the patient had an episode of vomiting and was subsequently admitted whereupon she was monitored every 4 hours, given 500 mg (milligrams) of oral Keppra twice a day, intravenous (IV) lorazepam, and intravenous Zofran as needed. A video electroencephalogram was done, and she was then discharged. The emergency department report indicated that seizures have been ongoing for the past year and the patient was currently on Keppra. She was being seen by a neurologist who could not find anything obvious that was causing the seizures.  

The Milliman Care Guidelines (MCG) state that clinical indications for admission to inpatient care include those individuals who are hemodynamically unstable, have a febrile seizure, status epilepticus, have a brain disorder that requires monitoring or intervention available only at inpatient level of care, when the etiology requires monitoring or intervention available only at an inpatient level of care or that persist despite observation care, when the patient has altered mental status that is severe persistent, has a new focal neurologic deficit, a metabolic disorder that persists despite observation care, or there is a  recurrent seizure. It must include one of the following: the patient was not noted to have a seizure disorder, was having a recurrent seizure of a different type than previously known, the patient has a baseline of infrequent seizures and recurrence is not thought to be due to readily modifiable etiology. Other indications include outpatient antiepileptic regimen cannot be established, when there is cerebral bleeding, hydrocephalus, or vasospasm monitoring required, or when there is a need for increased intracranial pressure or cerebral edema monitoring. 

Given that the patient has a known history of a seizure disorder and has been under the care of a neurologist, there were no findings within the provided records to indicate that there were any exceptional factors or extenuating circumstances that would justify the inpatient stay. 

The health plan acted reasonably with sound medical judgment in the best interest of the 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: Chest pain.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult male with a past medical history of myocardial infarction, coronary artery disease, status post prior PCIs (percutaneous coronary interventions) and CABG (coronary artery bypass graft), stroke, diabetes, hyperlipidemia, and hypertension. He presented to the emergency department for evaluation of acute left-sided chest pain.

For the time he came to the ED (emergency department), the patient's chest pain had improved significantly. On arrival to the ED (emergency department), he was afebrile and hemodynamically stable. He was saturating well on room air. Initial EKG (electrocardiogram) demonstrated normal sinus rhythm without acute ST changes. Troponin was within normal limits. WBC (white blood cell) count was 8.9, hemoglobin was 13.8, platelet count was 160. Sodium was 135, potassium was 4.2, BUN (blood urea nitrogen) was 16, creatinine was 0.99.

The patient was admitted to the inpatient unit and serial troponins were checked, which were all within normal limits. He was evaluated by cardiology, and they recommended obtaining a stress test. This demonstrated evidence of mild ischemia, and no inpatient intervention was recommended. Medical management for coronary artery disease was continued, and he was discharged home with outpatient follow-up.

The inpatient admission was not medically necessary.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. He was ruled out for acute coronary syndrome with serial troponins. There was no evidence of heart failure or symptomatic arrhythmias. His stress test demonstrated evidence of mild ischemia without any "high risk" features. Per cardiology's recommendations, no inpatient intervention was needed. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care. Observation level of care would have been appropriate in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lennox Gastaut syndrome

Treatment is 54 physical therapy (PT) visits

The insurer denied coverage for 54 physical therapy (PT) visits
 
The denial is upheld

This is a male patient with diagnosed Lennox Gastaut syndrome, seizures and development delays. He is fully dependent for activities of daily living and is provided full care by aides and his family. He has received physical therapy for several years. Under review is the medical necessity for 54 physical therapy (PT) visits.

The clinical records do not support the medical necessity of 54 physical therapy (PT). Similar care has been provided over the past several years and consist primarily of passive range of motion and message therapy. There has been no significant functional improvement or therapeutic goals for future improvement.  The treatment is best described as custodial, maintenance, and can be provided by laypersons with routine instruction and therefore not considered medically necessary.  

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

The insurer's denial of coverage for the 54 physical therapy (PT) visits is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intra-abdominal mass
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld

Per the clinical documentation, the patient presented with left lower quadrant swelling with a mass. A CT (computed tomography) scan documented the presence of an intra-abdominal mass. The patient was admitted and underwent a diagnostic laparoscopy with excision of a pericolonic mass. The foley catheter was removed on postoperative day zero and the patient was started on a clear liquid diet. On postoperative day one, the patient was tolerating a soft diet and her pain was controlled with oral medications. The patient was ambulating and was voiding normally. The patient was subsequently discharged. 

According to MCG (Milliman Care Guidelines) criteria, potentially ambulatory surgery may proceed on an ambulatory basis due to the absence of ambulatory surgery exception criteria indicated by: no inpatient care needed, complex surgical approach not anticipated, low-risk procedure, no drug-related risks, and no inadequate outpatient care situation. [1] Observation status as defined by the Centers for Medicare & Medicaid Services (CMS) should not exceed 48 hours. Inpatient status is typically used for all hospital stays of two midnights or longer. [2] The health plan acted reasonably and with sound medical judgment. There were no reported complications after the procedure. An operative note is not provided that indicates a complex surgical approach. The patient does not meet any criteria for an inpatient admission or exceptions for ambulatory surgery. A full hospital admission was not medically necessary for this patient.

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

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

Diagnosis: obesity
Treatment: Gastric Restrictive Surgery (Weight Loss Surgery) 
The insurer denied Gastric Restrictive Surgery (Weight Loss Surgery). 
The health plan's determination is overturned. 

The patient is a woman who has medically complicated morbid obesity. Her weight was 248 lbs (pounds). She is 66 inches tall. This corresponds to a body mass index (BMI) of 40.03. The records indicate that the patient has been significantly overweight for many years. She has attempted weight loss with conventional diet programs. The patient has comorbid health conditions of gastroesophageal reflux disease (GERD) and hypertension. The submitted records include ongoing counseling for weight loss. 

Gastric Restrictive Surgery (Weight Loss Surgery) is medically necessary for this patient.
Given this patient's diagnosis, her current health condition, and guidelines for the care and treatment of medically complicated morbid obesity, the proposed procedure is medically necessary. She has a BMI in excess of 40. She has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has previously attempted weight loss with a nonoperative diet regimen that has a reduced calorie diet, behavioral modification, and exercise.

Sleeve gastrectomy is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the member's disease, is not cosmetic or experimental, is proven to be more medically effective than any standard nonsurgical care and treatment, and is not for the convenience of the member or physician. The proposed sleeve gastrectomy is medically necessary and is consistent with the standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class I bite, impacted canine.
Treatment: D8080 Braces and D8670 Monthly Visit x12. 

The insurer denied: D8080 Braces and D8670 Monthly Visit x12. 
The denial is overturned. 

The patient is an adolescent female with a skeletal Class I bite. The patient has a Class II canine relationship with a deep bite. She has an impacted upper right permanent canine. The health plan denial was due to a handicapping index score of 18. 

The proposed braces and monthly visits are medically necessary. 

The patient has an impacted upper right permanent canine, where extraction is not indicated. This is an automatic qualifier according to the handicapping index scale. It is very important to have the upper canines in their correct positions in the mouth. They help guide the lower teeth during the chewing cycle and when they are not present (as in this case because it is impacted - stuck in the bone) the other teeth will tend to grind together uncontrollably which will lead to fractures or excessive wear. Orthodontic treatment to pull this tooth in position is needed.  Monthly visits will allow for follow up to make sure treatment is on track.