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

Diagnosis: Abdominal Pain
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Upheld

This patient is a female who presented to the emergency department (ED) with the complaint of abdominal pain of 1-day duration. Examination revealed right lower abdominal tenderness. Vital signs were normal at the time of presentation. The white blood cell (WBC) count was elevated at 17 thousand (K). Surgical consultation was obtained. Computed tomography (CT) scan was completed showing findings of acute appendicitis. The patient was started on intravenous (IV) antibiotics. The patient underwent laparoscopy with appendectomy for the condition of appendicitis.
Following surgery, the patient was treated with IV fluid and analgesia. Vital signs were consistently normal in the perioperative period. She was transitioned to oral medications and diet. She was discharged from the hospital following a period of recovery.
The subject under review is the medical necessity for the inpatient admission.

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

Inpatient admission was not medically necessary as the care and treatment provided could have appropriately rendered with a lower level of care status. This patient presented with abdominal pain. Her evaluation with examination, lab data, and CT scan supported the diagnosis of acute appendicitis. She underwent uncomplicated appendectomy. She was admitted to an inpatient level of care and was discharged from the hospital later in the day.
The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care designation would have provided for presurgical assessment, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring (if needed).
Milliman Care Guidelines (MCG) criteria indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the procedure may be performed without inpatient admission. In this case the patient tolerated oral hydration, diet and medication and pain was well controlled. A lower level of care would have appropriately provided for presurgical assessment, laparoscopic appendectomy, and post-surgical monitoring. Inpatient care was not required or medically necessary in this case per the referenced criteria or generally accepted medical standards.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Stelara. 

The insurer denied Stelara 90MG (milligrams) every 4 weeks. The health plan's determination is overturned. 

The patient is a female with fistulizing and stricturing Crohn's disease. She has failed mesalamine, budesonide, and Remicade. A Colonoscopy showed ileal stricture which could not be traversed and magnetic resonance enterography showed thickened and narrowed distal/terminal ileum consistent with active ileitis. She has been on Stelara since two years ago, with significant improvement documented. Stelara level was low at 1.7 and lack of anti-Stelara antibodies. She has had onset of symptoms (bloating and urgency) 4 weeks after her injections. 

Stelara 90 milligrams every 4 weeks is medically necessary in this case. In this case, the patient had a good initial response to Stelara and has now failed Stelara every 8 weeks, with symptoms of active disease in the setting of a low Stelara level. Continuation of dosing every 8 weeks, or discontinuation of Stelara (even if an alternative therapy such as Entyvio or Humira is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications of Crohn's disease. For all of these reasons, the request for Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of Crohn's disease in this case.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Acne vulgaris
Treatment: Winlevi (clascoterone)
The insurer denied the Winlevi (clascoterone)
The determination is upheld.

The patient has acne vulgaris. The acne affects her face. She has tried and failed Duac gel. She was also prescribed dapsone gel and tretinoin 0.25 percent (%) cream. The medication under review is Winlevi.

The formulary drugs have not been ineffective, would be as effective as the non-formulary drug, Winlevi, and would not have adverse effects.
Clinical guidelines for the management of acne vulgaris recommends topical therapies such as over the counter adapalene (1-3). Zaenglein et al writes in the "Guidelines of care for the management of acne vulgaris," published in the Journal of the American Academy of Dermatology, that "Topical retinoids are vitamin A derivatives that are prescription agents with randomized, double-blind, placebo-controlled trials supporting their use for acne treatment...Three active agents are available: ... adapalene (0.1%, 0.3% cream, or 0.1% lotion), and tazarotene (0.05%, 0.1% cream, gel or foam)...." (1). Topical therapies such as adapalene are listed as a first line treatments within the acne guidelines, and throughout the dermatology literature as an effective treatment for acne (1-3). There is no documentation provided that the patient has tried and failed over the counter adapalene.

It is noted that the patient has failed several therapies, however, the patient should try and fail adapalene prior to Winlevi.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain.
Treatment: Intraosseous basivertebral nerve (BVN) ablation.
The insurer denied coverage for intraosseous BVN ablation.
The denial is upheld.

The Intracept procedure is "intraosseous ablation of the basivertebral nerve (BVN)". It has been proposed to address low back pain identified by Modic changes. The procedure is performed within the vertebral body. It has been proposed that pain relief is manifested by patients that no longer require their narcotics. For one level of disc disease each vertebral body requires precise targeting. The operation is not recognized by practicing neurosurgeons or spine surgeons. There are no national organizations which provide guideline nor indication. The procedure is not mainstay nor current accepted treatment by the practicing medical community. 

The procedure is essentially a thermoablation performed within the vertebral body. 
There are several level 1 studies showing the benefit of this procedure up to 2 years after treatment compared to controls. However, all of these studies were either funded by the manufacturer and/or authored by consultants from the manufacturer. No high-quality study exists that does not have a significant conflict of interest with the manufacturer. 

In summary, the denial of procedure (intraosseous BVN ablation) to treat low back pain and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain.
Treatment: Intraosseous basivertebral nerve (BVN) ablation.
The insurer denied coverage for intraosseous BVN ablation.
The denial is overturned.

This case involves a patient with a request for intraosseous basivertebral nerve (BVN) ablation. The clinical note reported the patient had intermittent low back pain for many years with occasional radiating symptoms to the right buttocks. Past treatment included physical therapy and medication management. A physical examination noted 4/5 bilateral hip extension strength with sensation intact, symmetric deep tendon reflexes, and a negative bilateral straight leg raise. The patient did have diffuse tenderness over lumbar paraspinals and a positive Kemp test. A review of a prior magnetic resonance imaging (MRI) noted Modic type I and type II changes at the lumbar (L) 4-5 level as well as Modic type I changes at the L5- sacral (S) 1 level. The provider noted Modic type II changes seen at the L2-3 and L3-4 level. The assessment was vertebrogenic low back pain. The treatment plan was for an Intracept procedure as well as a medial branch block while awaiting approval.  

Scientific literature supports radiofrequency (RF) ablation of the BVN for chronic low back pain (CLBP). Per the International Society for the Advancement of Spine Surgery guideline, intraosseous ablation of the BVN from the L3 through S1 vertebrae may be considered medically indicated for individuals with CLBP of at least 6 months duration when there is failure to respond to at least 6 months of nonsurgical management, and an MRI demonstrated Modic change 1 or Modic change 2 in at least 1 vertebral endplate at 1 or more levels from L3 to S1. In this case, the patient has a history of CLBP with failure of conservative care. The patient has radiologic findings of Modic type I and type II changes consistent with causing vertebrogenic pain. The request for the Intracept procedure is appropriate and medically necessary at this time. The scientific evidence in peer-reviewed literature does support a result of improvement in the health outcome. The patient is a good candidate for a procedure (intraosseous BVN ablation) to treat low back pain and the procedure is the best available treatment for this patient at this time. The adverse risks are not increased over standard treatment/services. The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of the procedure (intraosseous BVN ablation) to treat low back pain and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease (GERD).
Treatment: procedure code 43239, esophagogastroduodenoscopy (EGD).
The insurer denied coverage for procedure code 43239, EGD.
The denial is upheld.

The patient was complaining of intermittent reflux. She also required a screening colonoscopy. She had just completed a 14-day course of Prilosec. An endoscopy revealed mild esophagitis and gastritis. Two small colonic polyps were removed. 

Clinical indications for upper gastrointestinal (GI) endoscopy are listed in Milliman Care Guideline (MCG) ACG: A-0203. GERD is an indication for an EGD if certain criteria are met. Failure of medical therapy, such as a poor response to empiric twice daily proton pump inhibitor (PPI) therapy for 4 to 8 weeks, is an indication. This patient was not treated with twice daily PPI therapy for 4 to 8 weeks. Other indications for the procedure include having anemia, dysphagia, GI bleeding, and a history of severe erosive esophagitis. There was no documentation submitted that the patient had these conditions.

This patient had GERD symptoms but did not fail a 4 to 8-week trial of PPI therapy twice a day. She did not meet MCG criteria for doing an endoscopy.

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

The insurer's denial of coverage for procedure code 43239, esophagogastroduodenoscopy (EGD) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces and Monthly Visits
The insurer denied Braces and Monthly Visits.
The determination is upheld.

The patient has a Class II malocclusion, mild maxillary crowding and mild mandibular crowding and moderate overjet and severe overbite. The issue under review is whether the requested health service/treatment of braces and monthly visits is medically necessary.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 12 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters(mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment for braces and monthly visits are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental issues.
Treatment: braces/monthly visits.
The insurer denied braces/monthly visits. 
The health plan's determination is overturned. 

The patient in question is a male with a Class III malocclusion. He has minor crowding in both arches. Teeth 7 and 8 are in crossbite. He is treatment planned for Braces and Monthly Visits to correct his malocclusion. 

Braces and monthly visits are medically necessary for this patient. The patient has significant spacing with teeth #7 and #8 in crossbite. These teeth have a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. He is already damaging his tooth #8 due to its position in the arch. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, the requested orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep bite, severe overjet with lip incompetence 
and impacted lower permanent canines
Treatment: D8080 Braces, D8670 Monthly Visit
The insurer denied: D8080 Braces, D8670 Monthly Visit
The denial is overturned.

The patient is a school aged female. The request is for orthodontic benefits and monthly visits. She has a Class II skeletal occlusion, deep bite, severe overjet with lip incompetence and impacted lower permanent canines. The health plan's denial of coverage was due to handicapping index score of 21.

The braces and monthly visits are medically necessary.

The patient has an overjet of more than 9mm (millimeters) with incompetent lips and well as impacted lower permanent canines. Both of these conditions are automatic qualifiers according to the handicapping index scale. This case has medical necessity for the orthodontic treatment and the monthly follow up visits.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Migraine
Treatment: 64615 - Injection of chemical (botox) for destruction of facial and neck nerve muscles on both sides of face
The insurer denied 64615 - injection of chemical (botox) for destruction of facial and neck nerve muscles on both sides of face.
The determination is overturned.

The patient was diagnosed with chronic migraine. The drug was denied because the plan indicated that the member had inadequate trials of propranolol and venlafaxine. The provider appealed the determination. The medical necessity of Botox is the subject of this review.

The first notes demonstrate that the patient has chronic migraine. The patient's condition has been refractory to multiple treatments including topiramate, propranolol, venlafaxine, magnesium supplementation, and Emgality. The patient has tried and failed three standard oral migraine preventative therapies. These drugs have been from different medication classes (beta blockers, antidepressants, and anticonvulsants). The member has also tried and failed a calcitonin gene-related peptide (CGRP) inhibitor. Botox is Food and Drug Administration (FDA) approved for the prevention of chronic migraine and literature supported for prevention of chronic migraine. Botox is regarded as a second line therapy. The patient has tried and failed four agents prior to the request for Botox. As such, its use is appropriate and medically necessary in this instance. The patient had reasonable trials of the formulary alternatives and they were deemed ineffective by the provider. Continuation of an ineffective drug is not warranted or appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is: Upheld.

The patient is a female with a past medical history significant for hypertension, prediabetes, hyperlipidemia, uterine fibroids, vitamin D deficiency, gastritis, and gastroesophageal reflux disease (GERD) who came to the hospital with complaints of abdominal pain, nausea, vomiting, and bright red blood per rectum. The patient complained of pain in the lower abdomen that she rated as 8/10 in severity. The patient stated that she had red blood per rectum with some blood clots. While in the emergency department, the patient started to feel better, with a resolution of abdominal pain and vomiting. She denied headache, dizziness, chest pain, shortness of breath, palpitations, or urinary symptoms.

Computed tomography (CT) scan of the abdomen and pelvis with contrast showed no diverticular disease. There was an indeterminate hypoattenuating nodule in the medial spleen. The patient was admitted to the hospital with lower gastrointestinal bleeding likely secondary to hemorrhoids, acute gastritis, history of hypertension, hyperlipidemia, and uterus fibroids.
During the hospital stay the patient remained hemodynamically stable. She initially was kept nothing by mouth (NPO) but subsequently, her diet was advanced, and she tolerated her diet without difficulties. She received treatment with intravenous fluids, Reglan, and Protonix. The patient was seen by a gastroenterologist who recommended a follow-up at the gastrointestinal (GI) clinic for a colonoscopy. Since the patient's clinical condition improved, she was transitioned to outpatient care the next day after the day of admission.

The health plan's determination is upheld.

The inpatient admission was not medically necessary for this patient.
The patient presented to the hospital with signs of gastrointestinal bleeding that was most likely related to hemorrhoids.
The lower gastrointestinal bleeding stopped while in the hospital. There was no evidence that the patient had coagulopathy or a critically low platelet count. There was no suspicion of ischemic colitis.
There were no signs of hemodynamic instability or severe anemia requiring inpatient care. There were no complaints of severe pain requiring acute inpatient intervention.
The gastrointestinal bleeding was not associated with signs of intestinal obstruction. The patient did not need urgent inpatient surgery.
Overall, the hospital stay was very short and the patient was discharged home in stable clinical condition.
The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right knee pain
Treatment: Full hospital admission
The insurer denied the full hospital admission.
The denial is upheld.

The patient is a female patient with a complaint of right knee pain. She sustained an injury to her right leg which resulted in a depressed lateral tibial plateau fracture and torn lateral meniscus in the right knee. The patient underwent elective surgery for this injury for open reduction and internal fixation of this fracture with bone graft in addition to meniscal repair. The surgery was successful with no documented complications. She was admitted to the hospital for further post-operative care. She progressed well with physical therapy and had a surgical drain removed. She was discharged home the following day. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The requested inpatient stay was not medically necessary for this patient. The provided records document that the patient underwent open reduction and internal fixation surgery of a displaced and impacted tibial plateau fracture. The performance of the operation was consistent with the recommendations of the current, peer-reviewed orthopedic literature as documented by Mthethwa and colleagues in 2018. The surgery was completed successfully and without any documented complications. The patient had normal lab values and vital signs as documented in the progress notes. A surgical drain was successfully removed. There was no documentation of post-operative bleeding or infection and the patient made good progress with ambulation and gait training with supervised physical therapy on post-operative day #1. Based upon the documentation in the provided records and the conclusions of the peer-reviewed literature, the inpatient hospital admission was not medically necessary in this case. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient who initially was seen in emergency department (ED)  after sustaining a 10-centimeter (cm) laceration over the left knee from a fall on concrete. X-rays were negative for a fracture. The laceration required 19 sutures and was then covered with Bacitracin, telfa, gauze and an ace wrap. She was given a Tetanus booster and prophylactic cephalexin.
She returned to the ED for a wound check, and reported that she had not been able to pick up the antibiotic prescription. The wound looked erythematous, and there was concern for cellulitis, and she was given a dose of intravenous (IV) Ancef in the ED and discharged on oral Clindamycin. She returned to the ED, the wound was reported as unchanged; she was given another dose of Ancef, and was discharged.
She returned reporting increased pain at the wound site, increased redness, and subjective fevers. At this ED visit, the exam noted a left knee laceration with sutures, that was erythematous, tender, and warm. 
She was admitted with a diagnosis of left (L) knee cellulitis that failed outpatient therapy with clindamycin and Keflex, and hyperkalemia, and started on intravenous (IV) Vancomycin every 12 hours (q12h). She was given a dose of Lokelma for hyperkalemia, her home oral hypoglycemics were held and she was placed on sliding scale (SS) insulin, and given Lovenox for deep vein thrombosis (DVT) prophylaxis.
She remained afebrile and hemodynamically stable. She was noted to have some improvement in the appearance of the cellulitis and was deemed improved for discharge. She was discharged home on oral double strength Bactrim twice daily (BID) and Keflex four times a day (QID) times (x) 7 days, with arrangement for outpatient follow up. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary for this patient. The patient was hemodynamically stable throughout, was alert and oriented, and never had altered mental status. She did not have a preseptal, periorbital or perineal infection. The patient did not have a necrotizing soft tissue infection, did not have a limb threatening infection, was not septic, did not require any surgical intervention, did not have uncontrolled pain, was able to take by mouth (PO). She had an uncomplicated hospital course and was transitioned to oral antibiotic therapy and discharged in improved condition. Her treatment could have been provided at a lower level of care.