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

Diagnosis: Bradycardia

Treatment: Inpatient hospital

The insurer denied coverage for inpatient hospital.

The denial is overturned.
 

Asked to review the case of an adult male that was sent to the hospital due to bradycardia with heart rates in the 30s.  Past medical history was significant for atrial fibrillation, coronary artery disease with right coronary artery (RCA) stent, and hypertension. The patient was sent to the hospital after electrocardiogram (ECG) revealed junctional rhythm with a heart rate of 30.  He reported occasional episodes of lightheadedness.  Upon presentation the patient was bradycardic with pulse of 36. Blood Pressure was 147/68. Physical examination revealed no other abnormality. ECG revealed atrial fibrillation with a heart rate of 36, right bundle branch block and left axis deviation. Serum blood testing demonstrated normal troponin (15).  The patient did not respond to atropine injection.  The patient was admitted to the hospital for monitoring and treatment.  Echocardiogram revealed a preserved left ventricle (LV) ejection fraction (55-60%) without wall motion abnormalities.  Exercise perfusion study demonstrated that the patient could get heart rate up to 84% of maximally predicted rate and revealed a small anterior wall perfusion defect.  The patient was referred for cardiac catheterization and was found to have a patent RCA stent and non obstructive coronary artery disease.  The patient was ultimately discharged home with cardiology follow up. 

This patient reported lightheadedness and had evidence of Purkinje conduction system disease on electrocardiogram.  Periods of junctional rhythm also suggested complete atrioventricular (AV) block.  This patient falls into a high risk group for syncope.  According to guidelines patients with symptomatic conduction system disease should be evaluated and treated in a hospital setting. (Reference 1)  In a study of individuals presenting to the emergency room, patients with evidence of Purkinje disease and AV block were classified as high risk for cardiac events and required admission to the hospital for further evaluation and treatment. (Reference 2).  Although patients presenting to the hospital with syncope can often be rapidly discharged, those with cardiac syncope are at high risk for future events that result in increased morbidity and mortality. (Reference 1,2) Admission to the hospital for treatment was medically necessary.

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 full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  New Onset Diabetes.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This is a patient who has no significant medical history. The patient presented to the emergency room (ER) with complaints of hyperglycemia, polydipsia, and urinary frequency X2 weeks and weight loss. The patient's doctor had told them the month before that they had borderline diabetes. The patient's fasting sugar in the ER was greater than 500. The patient's labs were: Creatinine 1.61, Venous partial pressure of carbon dioxide (PCO2) 54, partial pressure of oxygen (PO2) 30, bicarbonate (HCO3) 29, Sodium 129, Potassium 4.4, Chloride 91, glucose 717, beta-hydroxybutyrate (BHB) 0.6, and Hemoglobin A1c 14. Urine analysis with glucose was > (greater than) 1000. The patient's anion gap was 10 and estimated glomerular filtration rate (eGFR) was 52. The patient's admission labs included a glucose of 741 and venous pH of 7.35. The patient was admitted for hyperglycemia management and assessment for diabetic ketoacidosis (DKA) and acute kidney injury (AKI).  The patient was diagnosed with new onset of type II diabetes. The patient was educated on lifestyle changes and medications.

Diabetes education consists of several components, such as nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components (1,2). 

Practice patterns differ depending on the availability of educators etc. Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen. The majority (75% [percent]) of medical centers in the United State (3) that treat new onset diabetes admit their patients. According to the American Diabetes Association (ADA) statement on treatment of diabetes (4), hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education."  There are no randomized controlled trials comparing inpatient to outpatient diabetes education in type 2 diabetes. Arguably, a patient with polyuria, polydipsia, ketosis and a glucose in the 700s and AKI, ought to receive rehydration and insulin therapy to achieve the fastest and best control of their diabetes (5-8). 

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: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces, Retainer, Monthly Visit
The insurer denied: Braces, Retainer, Monthly Visit
The denial is overturned.

The patient is an adolescent male. The request is for orthodontic benefits, including retainer and monthly visits. Has a Class II molar and canine malocclusion. Severe mandibular crowding and moderate maxillary crowding, along with anterior open bite, are documented. The health plan's prior denial of coverage was due the patient having a score of 8 points on the handicapping index scale. The denial is being appealed.

The requested Braces, Retainer, Monthly Visit are medically necessary.

The patient has an impacted permanent anterior tooth (#22, lower left canine) where extraction is not indicated. The patient also has an overjet of more than 9 millimeters with lip incompetence. Both of these issues are grounds for automatic qualification for orthodontic benefits, according to the handicapping index scale. The retainer will be needed after the treatment is done, in order to prevent relapse, and the monthly visits are needed to make sure the treatment progresses properly. This case has medical necessity, and orthodontic treatment is needed to correct these problems.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain.
Treatment: Assistant surgeon - code 20930/AS (allograft, morselized, or placement of osteopromotive material, for spine surgery only.
The insurer denied: Assistant surgeon - code 20930/AS (allograft, 
morselized, or placement of osteopromotive material, for spine surgery only.
The denial is upheld.

The patient is an adult male. The patient had surgery for an anterior lumbar fusion of L4-L5 last year. This is a review for an assistant surgeon for code 20930/AS (allograft, morselized, or placement of osteopromotive material, for spine surgery only [List separately in addition to code for primary procedure]).

The requested health service was not medically necessary.

The procedure was performed with co-surgeons. Since there are two surgeons present for the procedure, a surgical assistant would not be necessary. The need for a third surgeon would not be medically necessary. This procedure can be safely completed with the two co-surgeons. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal bleeding. 
Treatment: Inpatient hospital stay. 
The insurer denied the inpatient hospital stay. 
The determination is overturned. 

The patient is a male with a history of iron deficiency anemia and hemorrhoids, who presented to the emergency department (ED) for anemia (hemoglobin (Hb) of 6.8). The review of systems was positive for fatigue. 
The patient was afebrile and was not in acute distress. 
The patient was admitted for symptomatic anemia likely secondary to chronic gastrointestinal (GI) bleed. The patient was transfused 1-unit of packed red blood cells (PRBC) and underwent a colonoscopy. The patient was recommended to have outpatient colorectal surgery for hemorrhoids. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital admission was medically necessary. 
Based on the documentation provided, the patient was not able to conduct an outpatient esophagogastroduodenoscopy (EGD) and colonoscopy. The patient presented for symptomatic anemia associated with weakness and fatigue. He warranted inpatient admission for gastrointestinal (GI) workup and blood transfusion for severe anemia in the setting of chronic bleeding. 
The patient was admitted for symptomatic anemia that presented with fatigue and weakness. As such, he required procedural intervention and serial monitoring of complete blood count. Despite hemodynamic stability, he had multiple risk factors for severe bleeding: age, prior GI bleed and known hemorrhoids. The intensity of care and duration of monitoring required was beyond the scope of a lower level of care. Inpatient level of care was warranted based on the presence of symptomatic anemia, decrease in hemoglobin/hematocrit, and the need for a colonoscopy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chron's Disease 

Treatment: Avsola 100mg (milligram) vial

The insurer denied coverage for Avsola 100mg vial.

The denial is overturned.

The patient has severe Crohn's colitis. The patient has bloody diarrhea, and abdominal cramps. The patient has previously been treated with Entyvio and infliximab 5 milligrams (mg)/kilogram (kg). On the infliximab, the patient had initial improvement but then developed a flare with bloody diarrhea. The patient's physician now plans to give Avsola at 10 mg/kg and then to check for therapeutic blood levels. Several journal articles have been submitted by the physician supporting dose intensification of infliximab to 10 mg/kg in patients who remain with active disease on the 5 mg/kg regimen. 

The physician has submitted an article from the American Journal of Gastroenterology titled "Loss of response and requirement for infliximab dose intensification in Crohn's disease." The conclusion was that more than 10% (percent) of infliximab treated patients will lose response and will require an increase in dose or decrease in interval of the infliximab infusion. 

Clinical Gastroenterology and Hepatology has an article titled "An accelerated infliximab induction regimen reduces the need for early colectomy in patients with severe ulcerative colitis." The conclusion was that an accelerated infliximab induction strategy reduces the need for early colectomy. 

The Journal of Crohn's Colitis has an article titled "High dose infliximab therapy in Crohn's disease: clinical experience, safety, and efficacy." The conclusion was that high dose infliximab therapy may benefit Crohn's patients who have failed standard doses. 

This patient remains with active colitis after being treated with Entyvio and then infliximab 5 mg/kg. Dose escalation of infliximab to 10 mg/kg is well established in the medical literature. The health care plan did not act in the best interest of the patient. Giving Avsola 100 mg vial is medically necessary for 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 Avsola 100mg vial is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis

Treatment: Zoryve 0.3%(percent) external cream

The insurer denied coverage for Zoryve 0.3% external cream

The denial is overturned

The patient has a diagnosis of chronic psoriasis.  The patient is currently controlled with oral Sotyktu and topical Vtama and Zoryve.  The patient has multiple plaques on the back, chest, abdomen, and extremities.  The request is for topical Zoryve.  

Zoryve cream is the first and only Food and Drug Administration (FDA) approved topical phosphodiesterase-4 (PDE4) inhibitor which is FDA approved for the treatment of psoriasis.  Based on the submitted documentation Zoryve is medically necessary for the topical treatment of the patient's psoriasis.  The patient is currently being treated with oral Sotyktu as well as topical Vtama.  The patient requires additional topical therapy for plaque resolution.  The patient would likely not receive benefit from calcineurin inhibitors such as tacrolimus or pimecrolimus, topical agents which are not FDA approved for treatment of plaque psoriasis.  The use of Zoryve is a reasonable next medical treatment based on its FDA approval for psoriasis.  The decision is reversed and the use of Zoryve is approved for topical use.    

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 Zoryve 0.3% external cream is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis

Treatment: Rinvoq 45mg extended-release tablet

The insurer denied coverage for Rinvoq 45mg extended-release tablet

The denial is overturned

The patient has ulcerative colitis. The patient has had abdominal pain, diarrhea, weight loss, and anemia. The patient has previously failed an anti-tumor necrosis factor (TNF) biologic and ustekinumab. The patient has had multiple hospitalizations and required transfusions. The patient's physician is now requesting to give the patient Rinvoq. The insurance company has denied this since the patient is under 18 years old. 

The physician has provided several articles supporting the use of Rinvoq in irritable bowel disease (IBD) patients. Gastroenterology 2020 Jun;158(8):2123-2138 has an article titled "Rinvoq Efficacy in Crohn's Disease." The conclusion was that Rinvoq induced endoscopic remission in a significant proportion of patients with Crohn's disease as compared to placebo. Subsequent to this article, the Food and Drug Administration (FDA) also approved Rinvoq for ulcerative colitis. The U-ACHIEVE study found that "Consistent with the primary analysis done among a smaller population, both maintenance doses of upadacitinib showed a positive benefit-risk profile in patients with moderately to severely active ulcerative colitis. Upadacitinib represents an effective treatment option for this population."

The FDA has approved Rinvoq for patients 12 years and older for severe atopic dermatitis. The drug was found to be safe in an adolescent population. The physician has now presented an abstract that was submitted for publication in Pediatric IBD: Clinical and Translational Studies September 2023 titled "Single Center Experience with Upadacitinib for Refractory Pediatric Inflammatory Bowel Disease." The conclusion was that there were no new safety concerns giving upadacitinib to teenage patients in a very refractory group of IBD patients. Nearly all achieved clinical and biomarker remission. 

This patient has active ulcerative colitis and has already failed anti-TNF treatment and ustekinumab. The patient requires additional biologic therapy. Rinvoq has been shown to be beneficial for patients with refractory disease. The safety profile of the FDA has led to it being approved for teenagers with atopic dermatitis. The abstract that is being published in the supplement of Pediatric IBD: Clinical and Translational Studies journal supports the use of upadacitinib in adolescent patients with IBD. In view of the results of these studies in patients with refractory IBD, giving Rinvoq is medically necessary. The insurance company has not acted in the best interest of the 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 Rinvoq 45mg extended-release tablet is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cytomegaloviral disease, unspecified; Status post 
Kidney Transplant recipient
Treatment: Prevymis 480mg (milligram) Tablet
The insurer denied: Prevymis 480mg (milligram) Tablet
The denial is upheld.

The patient is an adult male. He has had a previous renal transplant. As per the health plan's original Letter of Denial, "We received your appeal for approval for Prevymis (letermovir); we are unable to approve that request. This medication can be approved for people who have had a bone marrow transplant. We need the provider that prescribed the medication to give us information about you such as that you had a bone marrow transplant. Your prescribing provider did not give us that information for you. For this reason, your appeal is denied as not medically necessary. We based this decision on your health plan's prior authorization criteria named BRAND (GENERIC) which can be found at https://www.empireblue.com/ms/pharmacyinformation/home.html". The health plan's denial is being appealed.

The requested Prevymis is not medically necessary.

The submitted medical records are dated from 2 months ago. While Prevymis has been now FDA (United States Food and Drug Administration) approved for renal transplants, it is not at all clear from the medical records why this medication Prevymis is being requested: CMV (cytomegalovirus) prophylaxis or an actual CMV (cytomegalovirus) infection. Furthermore, without further details or explanation, the position that, "Failure to proceed with the treatment of Prevymis may result in heart failure and/or rejection of the transplanted organ, thus resulting in the need of another transplant or death," does not make sense in relationship to a renal transplant. Therefore, based on the information provided for review, Prevymis would not be considered medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left lower extremity cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient has a past medical history significant for cellulitis and presented to the emergency department with complaints of left lower leg pain and swelling.

Vitals on presentation included: Temperature (T) 99.7 Fahrenheit (F), blood pressure (BP) 106/68, pulse (P) 72, respiratory rate (RR) 18, oxygen saturation (O2) 97% on room air (RA). Laboratory results included the following: white blood cell count (WBC) 14.0, hemoglobin (HGB) 14.5, hematocrit (HCT) 44.3, creatinine 0.75, glucose 88, and procalcitonin <0.05. 

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and clindamycin) for left lower extremity cellulitis/ulcer. Infectious Diseases consulted and adjusted antibiotics. Doppler ultrasound was negative for deep vein thrombosis (DVT). The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics (Keflex) as an outpatient.

According to documentation, the patient presented with left lower leg cellulitis. Otherwise, the patient was afebrile, hemodynamically stable, with unremarkable laboratory results except for a mildly elevated WBC. The patient had no evidence of a disseminated infection and no surgical intervention was required. Based on the above findings, the patient met criteria for observation level of management. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right sided numbness and weakness
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the hospital for evaluation of a three-week history of right sided numbness and weakness. The weakness was mild. The patient underwent a computed tomography (CT) and computed tomography angiography (CTA) of the head and neck in the emergency room. The patient had chronic occlusion of the left internal carotid artery, chronic occlusion of the left vertebral artery, and other atherosclerotic changes. The patient was admitted to the hospital for further evaluation of a possible stroke. However, the patient left the hospital against medical advice. The patient was recommended to take dual antiplatelet therapy with aspirin and clopidogrel and a statin drug. At issue is the medical necessity of an inpatient stay.
The patient was evaluated in the emergency room for a three-week history of right sided, numbness and tingling. The patient was admitted to the hospital for further evaluation of his symptoms. After a CT scan of the head showed no acute findings and a CTA of the head and neck showed chronic occlusions and atherosclerotic changes, no further work up was performed for the patient because the patient eloped. The patient did not have significant neurologic deficits that caused disability. The patient did not have significant abnormal vital signs that required inpatient treatment. He did not have significant imaging abnormalities that required inpatient treatment. There was no confirmation that the patient had a stroke. If the patient did have a stroke, the patient had symptoms for three weeks or more and likely did not require hospitalization. The patient could have been referred to an outpatient clinic for further work up and evaluation of symptoms given the chronicity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I occlusion 
treatment: Braces and Monthly Visits (x8) 
The insurer denied Braces and Monthly Visits (x8) 
The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion with 4 millimeter (mm) overjet and 3 mm overbite. She has moderate maxillary and mandibular crowding. 

Braces and Monthly Visits (x8) are not medically necessary for this patient.
There is no medical reason to correct her malocclusion with braces. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal but her overjet would not affect oral health related quality of life unless it was greater than 6 mm. If her teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, Braces and monthly visits are not medically necessary.