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

Diagnosis: Multiple Sclerosis
Treatment: Ocrevus
The insurer denied Ocrevus.
The determination is overturned.

The patient is a female who is requesting treatment with Ocrevus for relapsing remitting multiple sclerosis. The drug was denied because there was not adequate documentation that the member could ambulate 100 feet (ft) or has had the required number of multiple sclerosis flares during a certain time. The provider appealed the determination. At issue is the medical necessity of Ocrevus.
Ocrevus is medically necessary for treatment of this patient's relapsing remitting multiple sclerosis. Ocrevus is Food and Drug Administration (FDA) approved for treatment of both relapsing remitting and primary progressive multiple sclerosis. The treatment guidelines and literature do not require that a patient has tried and failed any prerequisite drugs for treatment of multiple sclerosis. Ocrevus can be a first-line medication. The plan denied this drug because there was not documentation that the patient could ambulate 100 ft and has not had to multiple sclerosis flares in the past year. However, the provider submitted records and a letter of medical necessity showing that the patient is able to walk the required number of feet and did have the required number of flares. As such, this drug is medically necessary for treatment of this member's condition. This drug is considered to be a highly effective medication and is appropriate for patients with both brain and spinal cord involvement to prevent the accumulation of neurologic disability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Kidney Failure
Treatment: Inpatient Hospital
The insurer denied Inpatient Hospital.
The determination is overturned.

The patient has a history of hypertension (HTN), hyperlipidemia, fatty liver, chronic kidney disease (CKD) stage 3 and a recent admission for acute hypoxic respiratory failure secondary to heart failure with reduced ejection fraction (HFpEF), multifocal pneumonia and questionable pulmonary embolism who presented to the hospital with decreased oral intake, weakness, depression and loss of appetite. He was on 4 liters (L) of nasal cannula oxygen at home and his oxygen saturation dropped when his daughter tried to wean it down. On exam, he appeared cachectic but not in any acute distress. A chest x-ray showed improvement of pulmonary infiltrates. He was admitted for further management. His Lasix was held and he was given 500 cubic centimeters (cc) of intravenous (IV) fluids in the emergency room and an additional 500 cc of lactated ringers after admission. His oxygen was weaned down to 2 L via nasal cannula. His creatinine improved. He was seen by physical therapy who recommend sub-acute rehabilitation but the family and the patient preferred to go home. He was considered stable for discharge home. His Lasix was continued to be held on discharge. At issue is the medical necessity of an inpatient stay.

The inpatient admission was medically appropriate and necessary in this case based on the documentation provided. The patient presented with weakness, decreased oral intake and a loss of appetite. He was found to have an acute kidney injury. Given his presenting symptoms, his advanced age, and his comorbid conditions (including a recent prolonged hospital stay and rapid decline in his health), he was at high risk for further complications including worsening acute kidney injury, respiratory distress, cardiac arrhythmias and death. There was a reasonable expectation that he would require a prolonged hospital course given these factors. Medicare guidelines recommend an inpatient admission in cases where there is a reasonable expectation that the patient requires a longer than two midnight hospital stay. That expectation is clearly met in this case. Admission to a lower level of care would not have been safe or appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient is an adult with a benign past medical history. The patient presented to the emergency room (ER) with complaints of right hand swelling and erythema following injury to hand from a punch. 

Vitals on presentation included: temperature (T) 98.7 Fahrenheit (F), blood pressure (BP) 139/89, heart rate (HR) 78, respiratory rate (RR) 18 breaths per minute, and oxygen (O2) saturation of 99% on room air (RA). Laboratory results included the following: white blood cell count (WBC) 6.6, hemoglobin (Hgb) 15.6, hematocrit (Hct) 45.1, creatinine 1.3, glucose 85, C-reactive protein (CRP) 1.4, and procalcitonin 0.03.

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and Unasyn) for hand cellulitis. An x-ray of right humerus showed "mild periosteal reaction which may correlate with osteomyelitis in appropriate clinical setting." A right hand x-ray showed no acute fracture or dislocation. Infectious disease (ID) also consulted. The patient remained afebrile and hemodynamically stable. The patient clinically improved. The patient was discharged on oral antibiotics (Augmentin).

According to documentation, the patient presented with right hand pain and erythema. Otherwise, the patient was afebrile, hemodynamically stable, with unremarkable laboratory results including a normal 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 an 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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: General anesthesia - each 15 minutes, Extraction of impacted tooth with some bone for teeth number (#) 16, #17 and #32
The insurer denied general anesthesia - each 15 minutes, extraction of impacted tooth with some bone for teeth #16, #17 and #32. 
The determination is overturned.

The patient is a male who is requesting removal of wisdom teeth under deep sedation/general anesthesia. At issue is the medical necessity of D9223 general anesthesia - each 15 minutes, D7230 extraction of impacted tooth with some bone for teeth number (#) 16, #17 and #32. 

The requested services are medically necessary. The dentist notes that tooth # 32 is impacted, there is decay in all of the wisdom teeth and the patient cannot keep the wisdom teeth clean. The patient in his most recent letter states that he has had recurring pain in the wisdom teeth and is unable to keep them clean. The standard of care in adults is to not restore wisdom teeth in adults who are unable to keep them clean. The removal of the requested wisdom teeth plus the anesthesia time as submitted is medically necessary in this patient. Anesthesia starts when the monitors are placed and an intravenous (IV) is started and ends when the patient can safely be moved to the recovery area. The American Society of Anesthesiologists (ASA) defines start and end time as "It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient is safely placed under postoperative care. Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service." The amount of time is based solely on the anesthesia start time, the length and complexity of the treatment as determined solely by the surgeon performing the procedure and the amount of time that it takes for the patient to recover and safely be moved to the recovery area.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Scrotal Pain/Swelling.
Treatment: Inpatient Admission.

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

This is the case of an adult male, who presented to the emergency department (ED) for right scrotal pain/swelling. The patient's past medical history was significant for heroin use via inhalation, peripheral vascular disease (PVD), hypertension, and recent umbilical/inguinal hernia repair. Of note, the patient has had ED visits almost daily since the hernia repair one month prior with various complaints, mostly pain. The patient was recently in a methadone clinic for three months but relapsed with heroin use approximately 1-2 weeks before admission.

In the ED, the patient's vitals were: blood pressure (BP) 167/98, heart rate (HR) 94, respiratory rate (RR) 18, temperature (T) 98.2 degrees Fahrenheit (F), and oxygen (O2) saturation 100% (percent) on room air (RA). The patient's labs revealed lactate 2.0, hemoglobin (Hgb) 11.6, hematocrit (Hct) 38.6, alkaline phosphatase 144, erythrocyte sedimentation rate (ESR) 50, C-reactive protein (CRP) 10.8, and urine culture positive for Escherichia coli (E. coli).

A computed tomography (CT) scan completed in the ED showed findings significant for a subsegmental right lower lobe (RLL) pulmonary embolism (PE) and an increased amount of subcutaneous fluid and fat stranding along the right inguinal canal indicative of inflammation along with twisting of the right spermatic cord. A scrotal ultrasound showed small right, and trace left hydroceles and asymmetrically slightly increased arterial peak systolic velocity within the right testicle as compared to the left, possibly representing some degree of incomplete/intermittent right testicular torsion. A computed tomography angiogram (CTA) of the chest showed multiple pulmonary emboli within the segmental and subsegmental branches of the right upper and lower lobes.

In the ED, the patient was given intravenous (IV) Toradol, Tylenol, IV ceftriaxone, azithromycin, and Subutex and began a heparin drip. Before further evaluation and treatment could be completed, the patient signed out against medical advice (AMA).  

The insurer denied coverage for an inpatient admission as not medically necessary, stating that the patient failed to meet guidelines for admission based on the Milliman Care Guidelines (MCG) Health Urologic Disease (GRG) and MCG Health Pulmonary Embolism guidelines.  

The appeal on behalf of the hospital is noted and read in detail. 

The patient did not meet the criteria for admission per the MCG Health 27th Ed., Guidelines of Urologic Disease or Pulmonary Embolism. This patient could have been admitted to observation status.

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

The medical necessity for inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower extremity pain and erythema
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male who was hospitalized secondary to the presence of left lower extremity pain and erythema. His prior medical history includes chronic venous stasis of the lower extremities, chronic obstructive pulmonary disease (COPD), diabetes mellitus type 2 (DM-2), hypertension (HTN), hepatitis C virus infection, opioid use disorder, and polysubstance abuse. Initial laboratory data noted anemia (hemoglobin 10.9), hyperglycemia (serum glucose 128), and acute kidney injury (serum creatinine 1.49). A computed tomography (CT) scan of the left lower extremity demonstrated diffuse subcutaneous and intramuscular edema but no abscess or osteomyelitis. Initial treatment included the provision of intravenous fluids, wound care, and intravenous antibiotic therapy. There was clinical improvement and the patient requested hospital discharge. He was discharged with prescribed oral antibiotic therapy. At issue is the medical necessity of an inpatient stay.

Based on the information provided, the requested health service (i.e. acute inpatient care) was not medically necessary for this patient. This patient was afebrile, hemodynamically stable, and tolerating oral intake. Imaging of the left lower extremity did not demonstrate a complicated soft tissue infection as there was no evidence of an abscess, bone involvement, or a necrotizing process. This patient had not received and failed prior treatment efforts in the outpatient setting. While it is clear this patient required medical treatment, it was not medically necessary for this treatment to be provided in the acute inpatient care setting. The medical treatment provided could have safely and effectively been delivered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Peripheral Artery Disease.
Treatment:  Inpatient admission.

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

The patient has a history of coronary artery disease (CAD) with previous ST-elevation myocardial infection (STEMI) and percutaneous coronary intervention (PCI), hyperlipidemia, hypertension, heart failure, paroxysmal atrial fibrillation on Eliquis, diabetes and peripheral artery disease (PAD), who presented to the hospital for an elective endovascular intervention. The patient had complained of bilateral claudication (Fontaine class IIb), right greater than left on 2 blocks of walking. Ankle-brachial indexes (ABIs) were markedly abnormal, with the right at 0.56 and the left at 0.6. Peripheral angiography showed significant stenosis of the right superficial femoral artery (SFA) and Tibi peroneal trunk (TPT) and total occlusion of the right anterior tibial artery. The left anterior and posterior tibial arteries were occluded. The right SFA and TPT were intervened on successfully. The SFA underwent atherectomy, drug-coated ballooning, and drug-coated stenting. The patient had an atherectomy of the TPT. The patient was observed overnight uneventfully and discharged.

Considered for this case were the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards, and associations. 

The patient had an elective peripheral intervention which could have been managed without full in-patient admission. After the procedure, it was appropriate to observe the patient in the hospital for several hours to ensure that no complications or untoward events occurred as a result of the procedure. This monitoring could have been performed in observation status as the expected complication rate would be expected to be very low and the discharge time would be less than 24 hours after completion of the procedure. As such, a full inpatient admission was not necessary.

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 an inpatient admission is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: High blood presure

Treatment: Edarbi 40 milligram (mg) tablets

The insurer denied coverage for Edarbi 40 milligram (mg) tablets

The denial is upheld 

This patient has a history of essential hypertension. The patient is currently treated with nebivolol and Edarbi to control blood pressure.  Review of office records documented a normal physical examination and an echocardiogram with a preserved ejection fraction and no hypertrophy.  In the past, treatment with labetalol and metoprolol resulted in therapeutic failure or caused lightheadedness.  The patient's physician has requested that the patient be treated with Edarbi 40 milligram (mg) tablets (Azilsartan medoxomil). The requesting physician documented side effects of lightheadedness on alternative agents. No documentation is provided demonstrating treatment failure or side effects with formulary drugs that are angiotensin receptor blocking agents.

Trials of antihypertensive medications that may not be effective may result in adverse reactions such as poorly controlled hypertension and even hypertensive urgency (1). This patient has failed to tolerate or respond to Toprol, Norvasc and labetalol.  Formulary drugs such as losartan, candesartan and irbesartan and other angiotensin blockers have not been utilized according to review of the medical records provided. The American College of Cardiology (ACC)/American Heart Associations (AHA) guidelines for the prevention, detection, evaluation and management of high blood pressure state that angiotensin receptor blocker should be utilized as one of the primary agents for treatment of hypertension (2). The formulary drugs which include seven different angiotensin receptor blocking agents are not likely to cause an adverse reaction.  There is no documentation regarding trial and failure of other angiotensin receptor blocking agents. The requested drug would not be more effective than the alternatives on formulary. An attempt to treat with an alternative angiotensin blocking agent is reasonable in this case.

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Edarbi 40 milligram (mg) Tab to treat high blood pressure is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: medial meniscus root tear

Treatment: Durable Medical Equipment (L1833RTx1) (knee brace)

The insurer denied coverage for Durable Medical Equipment (L1833RTx1) (knee brace)

The denial is overturned
 
The patient has right knee pain, sent for magnetic resonance imaging (MRI) that showed a medial meniscus root tear. The patient wishes to proceed with the recommended surgical procedure, right knee arthroscopy, medial meniscus root repair, and will require the T-scope (knee brace) to offload the area of pain and help with post-operative recovery and healing. 

The patient's condition, characterized by a tear in the root of the medial meniscus, has resulted in significant pain and limited range of motion in the affected knee. The use of the T-scope brace is medically necessary to offload the area of pain, thereby reducing stress on the torn meniscus. This stress reduction is crucial for alleviating pain and facilitating the healing process. Furthermore, post-operative recovery is expected to be enhanced with the use of the T-scope, as it provides the necessary support and stabilization to the knee joint during the healing phase. The brace's adjustability and custom fit ensure that the patient can achieve optimal alignment and knee support, which is essential for effective rehabilitation and the prevention of further injury. In summary, the L1833RTx1 T-scope knee brace is a vital component in the treatment plan for this patient, offering both pain relief and support to the knee, thereby promoting healing and aiding in a more effective and swift recovery.

"According to the American Academy of Orthopedic Surgeons (AAOS), rehabilitative knee braces allow controlled and secure motion of injured or surgically repaired knees. The braces provide either immobilization of the knees or controlled flexion and extension in predetermined arcs to control excessive varus-valgus rotation and range of motion"(Kemker BP 3rd., et al 2021)

"in the early rehabilitation period, knee braces protect the healing meniscus tissue by providing a rotational control of the affected leg, respecting the fact that most meniscus injuries occur by combined rotational and flexion forces. Additionally, it compensates initial quadriceps weakness caused by pain or effusion and protects the meniscus repair from deep-flexion weight bearing"(Koch M., et al 2020)

"For tears greater than 3 centimeters (cm), weight-bearing was allowed in a locked brace. Range of motion (ROM) was limited to 0 degrees-125 degrees until 6 or 8 weeks. Return to sport was allowed after 3 months. For complex and radial tears, patients were required to wear a brace in which they were weight-bearing as tolerated ranging from 0 degrees to 125 degrees for 6 to 8 weeks. They returned to sport between 4 and 5 months."(Spang Iii RC., et al 2018)

Based on the above, the insurer's denial must be overturned. 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 Durable Medical Equipment (L1833RTx1) (knee brace) is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Rosacea

Treatment: Rhofade (oxymetazoline cream)

The insurer denied coverage for Rhofade (oxymetazoline cream)

The denial is overturned
 
This is an adult with a diagnosis of rosacea. The patient is noted to have failed topical metronidazole, Ivermectin, tacrolimus, and oral Doxycycline. The requested medication is topical Rhofade cream.  

Rhofade is Food and Drug Administration (FDA)-approved for treatment of the facial erythema associated with adult rosacea. The use of topical Rhofade is within the standard of care for the patient's condition.  

The patient has failed formulary medications including topical therapy with metronidazole, ivermectin and oral therapy with doxycycline.  Per the visit note, the patient was prescribed Ivermectin topical cream twice a day. At the visit, the patient was noted to have perioral dermatitis inadequately controlled, melasma, acne rosacea and verruca plana.

Rhofade would be more effective for this particular indication compared to formulary alternatives. The addition of Rhofade cream is within the rosacea guidelines and would be a reasonable additional treatment to the patient's rosacea regimen for enhanced disease control.  

The formulary drugs are not expected to cause adverse effects. 

Some of the formulary drugs were tried. While the patient did not have an adverse reaction or contraindication, they did not control the patient's symptoms.

The requested drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Rhofade (oxymetazoline cream) to treat other rosacea is overturned.