Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma. 
Treatment: Formulary Exception for Asmanex to Treat Severe Asthma. 
The insurer denied coverage for the Formulary Exception for Asmanex to Treat Severe Asthma. 
The denial is upheld. 

This patient is a male child with a history of moderate persistent asthma.  He had two hospitalizations in the past; one requiring admission to the Pediatric Intensive Care Unit (PICU).  He also had required 5 treatments with oral steroids for exacerbations of his asthma in the past.  He was initially treated with albuterol and prednisone and subsequently started on Flovent 44 micrograms (mcg) 2 puffs twice daily (BID).  This dose was increased to 3 puffs BID.  Following ongoing asthma symptoms, the dose of Flovent was then increased to 110 mcg 2 puffs BID. 

The patient was seen for a consultation visit with a pulmonologist who performed a pulmonary function test which was normal with no improvement noted after administration of albuterol.  The pulmonologist determined that the patient was not responding to his previous treatment and prescribed a step up in asthma therapy to Asmanex at a dose of 200 mcg 2 puffs BID.  The pulmonologist submitted a request for continuation of Asmanex. 

The formulary drugs are not expected to cause adverse effects.  The formulary drugs were not prescribed at the same dosage level and it is likely that if prescribed at the same dose as the current prescribed Asmanex that the child's asthma would continue to be well controlled.  All the inhaled steroids are effective in controlling asthma symptoms if used appropriately.  The pulmonologist is correct that Arnuity Ellipta, Flovent Discus, Pulmicort Flexhaler and Qvar RediHaler are not appropriate for administration for this patient's age group because of the benefit of administering inhaled steroids using an aerochamber device.  Flovent metered-dose inhaler (MDI) at a dose of 220 mcg 2 puffs BID would be a suitable alternative therapy which is on formulary.  The improvement in symptoms and asthma control when Asmanex was prescribed by the pulmonologist could have been due to the step up in dosage and a comparable dose of Flovent MDI would be appropriate for ongoing treatment.

There are alternative medications on formulary which will provide suitable replacement for Asmanex and should continue to provide adequate control for this child's asthma.  If the alternative therapeutic inhaled steroid Flovent MDI is administered according to guidelines with an aerochamber device and oral hygiene after administration to eliminate the medication from the oral pharynx then asthma control should not be adversely affected.

Ongoing monitoring of symptoms and lung function by pulmonary function testing will be important to assess the impact of switching from Asmanex to Flovent.  If there is clinical or spirometric evidence of decline in control of this child's asthma during a 2 to 3 month trial of Flovent MDI then the insurer should cover the non-formulary inhaled steroid Asmanex. 

The carrier's denial of Request for Formulary Exception for Asmanex to Treat Severe Asthma is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite.
Treatment: Braces .
The insurer denied the braces. 
The denial is overturned. 

The patient is a female. The request is for orthodontic benefits.

Yes, the braces are medically necessary.

The patient has a deep, impinging overbite with soft tissue damage to her palate. This is an "automatic qualifier" according to the handicapping index scale. The braces are, therefore, medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Leg Pain and Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient in this case is a male who has a history of recurrent deep vein thrombosis and pulmonary embolism.  He was maintained on chronic coumadin anticoagulation prior to presentation to the emergency department.  He presented with a complaint of worsening leg pain (left more than right) and also worsening chest pain and dyspnea.  Symptoms had been present three to four days; chest pain was worse with inspiration. 

On initial evaluation, heart rate and blood pressure were normal. The patient had a respiratory rate of 20 and was not hypoxic.  He noted taking his Coumadin regularly but international normalized ratio (INR) was subtherapeutic.  Evaluation revealed bilateral lower extremity deep vein thormbosis of unspecific chronicity.  The clots were not described as acute. The international normalized ratio was 1.1.  There was no evidence of acute pulmonary embolism on computed tomography (CT) of the chest.  The patient was admitted and started on Lovenox, 1 milligram per kilogram (mg/kg), twice daily.  

The patient was seen in consultation by hematology. The hematologist noted that he had been taking Xarelto and not Coumadin.  It was also noted that he had undergone thrombophilia testing and had been found to have a mutation in Factor V Leiden.  The hematologist recommended lifelong anticoagulation.  The patient was also seen by cardiology  and noted to be chest pain free since admission without any evidence of active ischemic heart disease or heart failure.  Outpatient stress test was recommended.  Continue anticoagulation was also recommended.  The patient was restarted on Xarelto and was discharged.

This patient had pain due to chronic deep vein thrombosis (DVT).  There was no acute deep vein thrombosis diagnosed.  He had chest pain but had no coronary ischemia and also did not have an acute pulmonary embolism (PE).  He was treated with Lovenox and then transitioned to Xarelto.  Both are outpatient medications for which acute care hospitalization is not required.  He had no hemodynamic instability, hypoxia, congestive heart failure or active coronary ischemia noted at any time during his initial evaluation or hospital admission.  Acute care inpatient admission was not medically necessary
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancytopenia and Acute gastroenteritis.
Treatment: Full Hospital Admission.

The insurer denied coverage for the Full Hospital Admission.  The denial is overturned. 

This is a male patient with asthma who presented to the Emergency Department (ED) with fever, nausea, vomiting, diarrhea, chest pain, abdominal pain, weakness, and 3 syncopal episodes after being discharged from ED one-day prior with fever and abdominal pan. The patient's fever spiked to 103.5. The patient reported moderate abdominal pain and had dry skin. The patient's bloodwork showed pancytopenia: white blood cell (WBC) of 2.4, hemoglobin/hematocrit (H/H) of 13.6/41.2, and platelet of 129. The patient's repeat bloodwork showed: WBC of 1.9 with absolute neutrophil count of 1.2, H/H of 12.9/39.1, and platelet of 124. Given this patient's pancytopenia in the setting of fever, Hematology/Oncology services recommended that the patient start empiric treatment with antibiotic (i.e., ceftriaxone). Inpatient admission was medically necessary for this patient due to failure of outpatient management, dehydration, concern for bacteremia and further evaluation of this patient's pancytopenia.

In this case, the patient presented with a fever of 103.5, clinical signs of dehydration and mild neutropenia (with normal WBC count one day prior). In the setting of normal heart rate (HR) and blood pressure (BP) with absence of high risk conditions and factors that increase this patient's risk of invasive bacterial infection, inpatient hospitalization for concern of bacteremia and further evaluation of neutropenia was not medically necessary. However, given this patient's diagnosis of acute gastroenteritis, clinical signs of dehydration and acute onset of pancytopenia, inpatient admission was medically necessary for this patient's diagnosis of uncertainty. 

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. This patient presented with high fever, emesis, and abdominal pain after being seen in the ED one day prior with similar symptoms. Given this patient's pancytopenia (of note, this patient's WBC count and hemoglobin/hematocrit levels were normal one day prior to this admission), the treating physician had concerns of bacteremia in addition to dehydration for this patient. The decision was appropriately made to admit the patient for continuation of intravenous (IV) antibiotics pending blood culture, IV fluids, and close monitoring and evaluation for this patient's acute pancytopenia.  

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

The carrier's denial of coverage for the Full Hospital Admission should be overturned. The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Right ankle pain.
Treatment: Surgery (right ankle total arthroplasty/total ankle replacement (CPT 27702)).
The insurer denied the Surgery (right ankle total arthroplasty/total ankle replacement (CPT 27702)).
The denial is overturned

The patient is a male with a long history of right ankle pain. He has significant functional limitation. Conservative treatment has not provided benefit.

The patient's physical examination was significant for a cavus foot and valgus heel. Subtalar motion was limited. Range of motion was 10-30. X-rays were interpreted as end stage ankle osteoarthritis. Surgical option were discussed. Ankle arthroplasty was recommended.

Yes, the health plan should cover the Surgery (right ankle total arthroplasty/total ankle replacement (CPT 27702)).

The scientific literature has demonstrated benefit from use of the total ankle replacement. The procedure has been performed for over several decades. There have been several studies showing benefit. Direct comparisons have been made to fusion with equivalent or better outcomes. It is standard of care in the Orthopedic community and clearly is not Investigational nor Experimental. The Position Statement of the American Orthopedic Foot and Ankle Society clearly supports its use.

There are several other National Guidelines which include use of the TAR (total ankle replacement) in management of end-stage arthritis. The opinion provided by the Medical Director does not have credence.

Yes, the Surgery (right ankle total arthroplasty/total ankle replacement (CPT 27702)) is likely to be more beneficial.

See above, There have been several references demonstrating benefit and acceptance by the orthopedic community.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Right ankle pain.
Treatment: Surgery (right ankle total arthroplasty/total ankle replacement (CPT 27702))
The insurer denied the Surgery (right ankle total arthroplasty/total ankle replacement (CPT 27702)).
The denial is overturned. 

The patient is a male with a history of right ankle pain.  He has tried physical therapy, bracing, inserts, and nonsteroidal anti-inflammatory medications.  He has bone-on-bone arthritis of the ankle.  He is an active man who works and does recreational activities such as hiking.  A total ankle replacement was recommended for him.

Yes, the health plan should cover the Surgery (right ankle total arthroplasty/total ankle replacement (CPT 27702)).

Total ankle replacements have been performed for several decades.  Initially, outcomes were poor. However, in the last two decades, the technology has advanced to where ankle replacements are viable alternatives to arthrodesis in which the ankle is fused.  There are ample examples in the literature of clinical trials that show that an ankle replacement is equivalent or better in terms of functional scores for patients with ankle arthrosis.  There is also evidence that when the surgeon performing the ankle replacement is experienced and has performed a sufficient number of total ankle replacements, outcomes are significantly better and complications are reduced significantly as well (4).  In this particular case, the surgeon has performed over 100 total ankle replacements.

Yes, the Surgery (right ankle total arthroplasty/total ankle replacement (CPT 27702)) is likely to be more beneficial.

An ankle replacement provides the patient with mobility and range of motion at the ankle.  This is preferred in an active patient such as this patient.  Also it is preferred to an arthrodesis when there is adjacent subtalar joint arthritis, as there is with this complaint.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient with a past medical history notable for coronary artery disease, coronary artery bypass grafting x 4 vessels, and uncontrolled diabetes mellitus with complications including neuropathy, hypertension and hyperlipidemia. The patient had undergone coronary stenting of the left circumflex artery, and presented to the Hospital for elective outpatient coronary stenting of the ramus intermedius branch. The patient underwent placement of a Resolute Onyx 2.5 x 8 millimeters (mm) drug-eluting stent to the proximal ramus intermedius. There were no procedural complications, and the patient was then admitted for further monitoring. The patient remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no vascular access complications. The patient was subsequently discharged home after an uneventful, brief overnight hospital stay. 
 
Based on the review of the medical record and literature, inpatient admission status is not considered medically necessary for this patient. Per Milliman Care Guidelines (MCG) Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one. The clinical presentation and peri-procedural course did not require acute inpatient level monitoring. Following the procedure, the patient was admitted for overnight observation post-percutaneous coronary intervention (PCI). The patient exhibited paroxysmal nocturnal dyspnea, and was screened for possible outpatient sleep study. The patient was ambulatory and tolerating oral intake, without vascular access site complications. There were no other extenuating circumstances in this case which warranted inpatient admission status following this patient's elective cardiac catheterization and stent placement. The patient's care could have been safely provided with 23-hours of monitored care under the ambulatory surgical status.

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

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

Digestive System
Inpatient hospital

Diagnosis: Abdominal pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a woman who was previously admitted to the hospital for evaluation and management of acute cholecystitis during pregnancy. During that hospital admission, she underwent a magnetic resonance cholangiopancreatography (MRCP) that showed a dilated common bile duct (CBD) but no bile duct stones. She was managed with antibiotics and was discharged to home. After this, she continued to have intermittent symptoms of abdominal pain and reflux symptoms, and she reported continued poor by mouth (PO) intake. She was re-admitted to the hospital and was brought to the operating room on that same day for an elective laparoscopic cholecystectomy with intraoperative cholangiogram. 

The inpatient hospitalization was not medically necessary. She was admitted to the hospital for an elective cholecystectomy for management of symptomatic cholelithiasis/chronic cholecystitis. While she was tachycardic both before and after her procedure, this could be explained by both her documented anxiety prior to surgery as well as to volume depletion (which would be expected given a long period of poor PO intake). An electrocardiogram (EKG) was performed that showed sinus tachycardia, and she was given a 500cc intravenous (IV) bolus of albumin. She was awake and interactive throughout her hospital stay and there were no episodes of hypotension or hemodynamic instability. She was afebrile. Her operation was uncomplicated, as was her recovery. Although she remained in the hospital overnight following her operation due to her tachycardia, this required no intervention other than IV hydration. The care that she received was entirely appropriate. However, this care did not require an acute inpatient admission. The identical services could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Digestive system
Inpatient hospital

Diagnosis: Vomiting
Treatment: Inpatient hospital
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female with medical history of diverticulosis complicated by diverticulitis, osteoarthritis with chronic nonsteroidal anti-inflammatory drug use, cancer status post mastectomy, and two gastric ulcers. She presented to the emergency department with five days of melena and coffee-ground emesis, epigastric pain, lightheadedness, and dyspnea. She had been taking ibuprofen and meloxicam. Vital signs were notable for heart rate of 107/minute. Physical examination was notable for pale conjunctiva and a soft, non-distended abdomen with epigastric tenderness. Labs showed low hemoglobin of 7.0 and hematocrit of 22.1%, and elevated alanine aminotransferase of 42. She was briefly hypotensive in the emergency department. She was transfused with a unit of packed red blood cells. She was treated with intravenous pantoprazole. She was made nil per os (NPO) and admitted to the hospital.

The inpatient level of care is medically necessary. In this case, the patient presented with melena, coffee ground emesis, anemia, and symptoms of anemia. She had recent active gastrointestinal bleeding and significant anemia concerning for an upper gastrointestinal tract bleeding source such as inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease), or arteriovenous malformations. She had close monitoring, which was warranted as bleeding can be severe and sudden in onset. Additionally, her blood count continued to decline, and she had a poor response to blood transfusion, requiring a second blood transfusion two days after presentation. Given the risk of recurrent bleeding and hemodynamic decompensation, discharge within two days after presentation would not have been appropriate, and the inpatient level of care is supported.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Disorder.
Treatment:  Braces, monthly visit x (times) 8.

The insurer denied braces, monthly visit  x (times) 8.  The determination is upheld.

The patient has a Class I occlusion with appropriate overbite and overjet. He has mild maxillary and mandibular spacing. He is treatment planned for orthodontics to correct his malocclusion. At issue is the medical necessity of braces, monthly visit times (x) 8.
The patient has some minor spacing. His overbite is appropriate and there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows that he does not have a traumatic deep bite. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage).
There is no medical reason to correct his 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 not functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. (2) If his 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, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 2 diabetes mellitus.

Treatment: Jardiance.

The insurer denied coverage for Jardiance.

The denial is upheld. 

This is a male patient with type 2 diabetes mellitus on Amaryl 2mg [milligrams], Januvia 100mg, and metformin 1000mg.  The patient is obese; has hypertension and fatty liver. The patient's Endocrinologist wants to add Jardiance 25mg to the patient's medication to improve his glycemic control, but the insurer denied the request. The physician also mentions some changes in the patient's renal function. 

In review of the material provided, this reviewer did not see any lab work suggesting instability in the patient's renal function. The patient is reported to be obese, but the data shows a Body Max Index (BMI) of 28.7 that suggests overweight, not obesity. 

The health plan acted reasonably due to the following facts: Steglatro (Ertugliflozin) is a sodium glucose co-transporter 2 (SGLT2) inhibitor like Jardiance(empagliflozin), with the same mechanism of action, and it is the most recent SGLT2 inhibitor approved for treatment of diabetes; Steglatro like jardiance has shown cardiovascular and renal benefits; As summarized in Up to Date, "When a decision has been made to use an SGLT2 inhibitor, canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin are available options."
	
The carrier's denial of coverage for Jardiance is upheld.  The medical necessity is not substantiated.