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

Diagnosis: Facial Pain and Infected Tooth. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission.  The denial is upheld. 

This patient is a male, who was admitted and treated in a hospital for an acute odontogenic infection. Tooth # (number) 17 was deeply decayed. The patient had a patent airway per an ear nose and throat (ENT) evaluation. There was facial and submandibular swelling and an elevated white blood cell count. The patient had a fever max of 101 and odynophagia. The computed tomography (CT) scan showed a well-defined abscess cavity. The patient required surgical intervention and abscess drainage with tooth removal to properly treat this infection. Intravenous antibiotics were also administered. 

No, the proposed inpatient admission was not medically necessary.  Admission versus observation was not supported by the records; observation stay was the appropriate hospital level of care. 

The patient had severe pain, white blood cell count of greater than 11 supporting systemic infection, and facial swelling with abscess clearly identified on computed tomography (CT) scan. Finally there was need to remove a tooth, drain an abscess, and give medications to protect airway patency. Therefore, the patient required surgery and general anesthesia. The patient underwent the surgery and anesthesia with no noted complications. However, the proper stay is Observation level of care as the ear nose and throat (ENT) specialist cleared the airway as patent with no obstruction from the infection. The records did not support the use of a inpatient stay. The inpatient stay is therefore not medically necessary based on all the information provided. 

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient. 

The patient was discharged on post-operative day one and from the records provided, there was no evidence that the patient was sent to a specific floor for post surgical airway maintenance which may support an inpatient admission. The patient was sent to the general ward with routine instructions and discharged the following morning. This is consistent with an observation stay.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems.
Treatment: Pharmacy/Prescription Drugs-Edarbi. 

The health plan denied the formulary exception as the patient did not fail the formulary alternatives. 

The reviewer has overturned in whole the health plan's determination. 

The patient has a history of hypertension and obesity. Previous treatment with multiple angiotensin receptor blockers (ARBs), including losartan, irbesartan, Olmesartan, telmisartan and valsartan was ineffective in controlling his blood pressure. He has been treated with Edarbi (azilsartan) 80 milligrams (mg) daily with good control. On Edarbi, his blood pressure was 130/80 millimeters of mercury (mmHg). 

The patient has had previous trials of five formulary alternatives (losartan, irbesartan, telmisartan, Olmesartan and valsartan), all of which were ineffective. All of the agents tried, like azilsartan (Edarbi) are angiotensin receptor blockers (ARBs). In multiple trials, azilsartan has proven superior to other ARBs in reducing systolic, diastolic and 24-hour average blood pressure. Moreover, as compared to other ARBs, it has been shown to have additional benefits in terms of amelioration of deleterious effects of angiotensin II such as cardiac hypertrophy, fibrosis and insulin resistance, and stabilization of coronary plaques. 

In this particular case, azilsartan has already proven more effective than five of the formulary alternative ARBs (losartan, irbesartan, telmisartan, Olmesartan and valsartan). While the patient has not had a trial of candesartan, in a randomized controlled trial, azilsartan was significantly more effective than candesartan in reducing systolic, diastolic, mean and 24-hour average blood pressure, with similar safety and tolerability profiles. Thus, all of the alternative ARBs on the formulary would be expected to be less effective than azilsartan. 

The remaining formulary alternatives are combinations of one of the formulary ARBs with a second drug, hydrochlorothiazide (HCTZ). The addition of a diuretic, such as HCTZ, to an ARB would be expected to result in additional blood pressure reduction. However, this approach would require treating this patient with two drugs, when one has been effective. The addition of HCTZ in this particular case would place the patient at risk for the adverse metabolic effects of thiazide diuretics, including hyperglycemia, hyperuricemia, hypokalemia, and dyslipidemia, which could potentially decrease the expected cardiovascular benefit of lowering blood pressure in hypertensive patients. Accordingly, it is this reviewer's opinion that all of the formulary alternatives would be expected to be less effective than azilsartan in this situation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic Arthritis. 
Treatment: Orencia ClickJect 125 milligrams per milliliter subcutaneous solution auto injector (SOAJ). 

The insurer denied coverage for Orencia ClickJect 125 milligrams per milliliter subcutaneous solution auto injector (SOAJ). 

The denial is overturned. 

This case involves a patient diagnosed with psoriatic arthritis, ulcerative colitis, and systemic lupus erythematosus. 

According to an encounter, the patient was seen regarding psoriatic arthritis.  The patient had COVID-19 (2019 Coronavirus) earlier in the prior month with a sore throat and upper respiratory infection.  She was not feeling well and had severe fatigue since COVID-19.  There was pain in the upper extremities along with swelling.  There was difficulty with dexterity, gripping, and holding objects.  There was also stiffness in the knee.  The patient had maintained therapy with Otezla and was unable to start Cosentyx due to COVID-19.  On examination, there was no pedal edema.  Tenderness and trigger points were in the trapezium and bilateral cervical paraspinal muscle groups.  There was tenderness with circumduction of the left arm.  Tenderness was present in the left knee and quadricep tendon.  The patient was recommended for Orencia. 

The patient was diagnosed with systemic lupus erythematosus, ulcerative colitis, and psoriatic arthritis.  The patient had active psoriatic arthritis despite prior trials of synthetic DMARDs (disease modifying anti-rheumatic drugs) Otezla.  The patient was not a candidate for tumor necrosis factor (TNF) blockers due to history of systemic lupus and risk for drug-induced lupus. 

This patient with an overlap disorder as well as other documented autoimmune conditions such as idiopathic thrombocytopenic purpura (ITP).  She appears to be in a flare as documented by her rheumatologist. 

She has been on Otezla and did not tolerate Leflunomide.  The clinical guidelines for the treatment of active psoriatic arthritis (PsA) do say that the next appropriate biologic would be a TNFi (tumor necrosis factor inhibitor) over another OSM (oral small molecule), an IL 17 (interleukin 17) biologic, an IL 12/23i (interleukin 12/23 inhibitor) biologic, abatacept or tofacitinib. The provider explained the reasons why he is reluctant to prescribe a JAK (Janus kinase) inhibitor or a TNFi for this patient. This patient will be at higher risk for the specified complications (she already has a diagnosis of systemic lupus erythematosus (SLE) and therefore a TNFi is not appropriate.  She is already at increased risk for cardiovascular events secondary to her SLE diagnosis as well. 

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

The insurer's denial of coverage for the medication Orencia ClickJect 125 milligrams per milliliter subcutaneous solution auto injector (SOAJ) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Skilled Nursing Facility (SNF). 

The insurer denied Skilled Nursing Facility care. 
The denial was overturned in whole. 

This is a male with history of fall from ladder with subarachnoid hemorrhage (SAH), intraventricular hemorrhage (IVH), intracerebral hemorrhage (ICH) who is status/post (s/p) decompressive craniectomy and ventriculoperitoneal (VP) shunt for hydrocephalus. He was planned for Skilled Nursing Facility (SNF) level transfer but this was denied by the health plan. The health plans denial is overturned. The requested treatment is medically necessary. As per Milliman Care Guidelines (MCG) guidelines this patient warrants a SNF level of care at this time. He had a VP shunt adjustment, and his cognition shows signs of improvement. Traumatic brain injury (TBI) patients evolve slowly and this patient may make functional gains in speech therapy. It is inappropriate to consider this patient custodial care. Additionally, he has sacral wound care needs, catheter needs, percutaneous endoscopic gastrostomy (PEG) needs and trach care needs. As such all MCG guideline criteria are met, and the care is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Fibroids

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient is a female with a history of symptomatic fibroids. She underwent an exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy, lysis of adhesions and small bowel serosal repair, laparotomy with supracervical hysterectomy, bilateral salpingectomy and a cystoscopy. Blood loss was 350 cc (cubic centimeters). The hospital course was uneventful. The patient was discharged after a period of medical stability. 

This patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in hospital for 48 hours. 

On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, clear liquids are started. 

On postoperative day 2, if the patient is passing flatus, and tolerating regular diet she is discharged home.

This patient was managed according to the guidelines and the standard of care. The admission should be approved based on MCG (Milliman Care Guidelines) Laparotomy.

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain.
Treatment: Intracept Procedure.
The insurer denied the Intracept Procedure.
The determination is upheld.

The patient has complaints of low back pain. The pain is rated 7 out of 10 and is localized to the low back with radiation down the left leg to the ankle. The pain is described as shooting, dull, and is worsened with activity. There is a prior history of a lumbar (L) 4-5 microdiscectomy. Medications include multiple oral agents. A lumbar spine magnetic resonance imaging (MRI) scan shows multilevel degenerative changes. The patient has had multiple lumbar spine injections. The physical exam demonstrated lumbar spine extension, mild restriction. Motor strength is 5 out of 5, sensory normal. At issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This procedure is not recommended as despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as a treatment modality. In general, there is lack of substantial support for this procedure. As such, the proposed health service or treatment intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain.
Treatment: Intracept Procedure.
The insurer denied the Intracept Procedure.
The determination is overturned.

The patient has a long-standing history of low back pain. She has a history of a lumbar (L) 4-5 discectomy. She previously underwent epidural injections, radiofrequency ablation (RFA) of the facet joints and sacroiliac (SI) injections. She had failed other conservative treatments including non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. She rates the pain level at 7/10. On physical exam (PE) there is no tenderness in the lumbar paraspinal region and a negative straight leg raise test. The patient had normal electromyography (EMG). Magnetic resonance imaging (MRI) revealed retrolisthesis at L3-4 with increased paracentral protrusion, a slight posterior lateral disc bulge, loss of disc height and Modic changes at L4-5 level with scar tissues in the left lateral recess.
The issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes. The Intracept system was designed to treat low back pain from the vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient's persistent back symptomatology is consistent with vertebrogenic pain. She had tried extensive treatments including epidural injections, facet blocks, and pain medications without adequate improvement. Her pain is level is at 7/10 which is severe enough to have a significant impact of activities of daily living (ADLs). Further interventions are medically necessary to improve the pain and functional level. Other potential treatment options are long-term use of medications (nonsteroidal anti-inflammatory drugs (NSAIDs), opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carry significant risks and complications. Given this clinical scenario, the Intracept procedure is medically necessary as the appropriate next step intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female with no significant medical history. She presented with fever, nausea and abdominal pain.

Pyelonephritis was noted on imaging, and she was admitted to inpatient level of care. The patient was treated with fluids intravenously and with intravenous antibiotics. The patient was Hemodynamically stable and tolerating oral intake. Her abdominal complaints improved, and she was converted to oral antibiotics and subsequently discharged to home.

No, the Inpatient admission was not medically necessary.
Inpatient level of care was not medically necessary, as it would not be considered a generally accepted national standard of medical practice, it was provided primarily for convenience of the patient or the practitioner, and it was not the least intensive and/or most appropriate alternatives among diagnostic and treatment options. The inpatient admission was not in the least intensive setting available, as the treatments would have been clinically appropriate at a lower level of care.

The inpatient level of care was not medically for the requested dates of service, as the patient could have been safely and effectively managed at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath. 
Treatment: Inpatient admission. 

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

The patient is an adult female with a history of hypertension (HTN), chronic obstructive pulmonary disease (COPD), and status post coronavirus months prior. She is now on home oxygen (O2) at 2 liters (L) via nasal cannula (NC). The patient noted that her baseline heart rate (HR) was around 100. The patient presented to the emergency department (ED) with complaints of shortness of breath (SOB) and cough for 2-3 days. Her vital signs at presentation were temperature 98.5, HR 106, respiratory rate (RR) 20, blood pressure (BP) 149/85 and O2 saturation 97% (percent) on 1L via NC. Her white blood cell (WBC) count was 17.8, hemoglobin (Hgb) was 12.1, blood urea nitrogen (BUN)/creatinine (Cr) was within normal limits. Chest x-ray and computed tomography (CT) revealed a LUL (left upper lobe) infiltrate. The patient was given intravenous (IV) fluids in ED and also given Zofran. She improved after treatment. The patient was admitted to hospital for COPD and pneumonia. 

As per admission history and physical (H&P), the patient's vital signs were 99.2, HR 110, RR 20, BP 134/82, O2 saturation 98% on 2L via NC. The patient was not using any accessory muscles. There were no rales or wheezes. She was started on IV Ceftriaxone, Doxycycline, Solumedrol and bronchodilators. The patient remained stable after admission. She had some tachycardia, but other vitals were stable. O2 saturation were greater than 90% on 2L which was her baseline. The patient was tolerating an oral diet. As per Progress notes, the patient was improving. She was afebrile, and other than some tachycardia, she was stable. No rales or wheezing heard. WBC had decreased to 12,000. The plan was to taper steroids to oral. The patient was discharged home on oral antibiotics and tapering steroids. 

The patient's pneumonia (PNA) was mild. CURB 65 (confusion, uremia, respiratory rate, BP, age >= 65 years) score was Zero. Her O2 saturation were at baseline on baseline supplemental O2. The patient was tolerating oral. She could have been placed on observation status for up to 48 hours while diagnostic testing and treatment were initiated. She could have been treated with IV antibiotics and steroids initially and switched to oral. The patient could have been discharged home with close follow up as outpatient. 

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fatty infiltration of liver
Treatment: Liver biopsy
The insurer denied the liver biopsy.
The determination is upheld.

The patient underwent bariatric surgery (laparoscopic loop gastric bypass and concomitant liver biopsy). The records support that he had a body mass index (BMI) of 45.7 kilograms per square meter (kg/m2). The operative dictation states that there was fatty infiltration of the liver and a wedge liver biopsy was obtained from the left lobe of the liver. There is no description of suspected liver pathology other than fatty infiltration of the liver. The submitted records do not include any pre-surgical lab, imaging or clinical data to indicate liver pathology. The pathology report provides the diagnosis of mild steatosis.
At issue is the medical necessity of current procedural terminology (CPT) code 47100 liver biopsy, wedge.

The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of loop gastric bypass. There is no documentation of liver pathology as might be obtained by preoperative imaging or lab data to warrant a liver biopsy.
According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery. Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy.
In this case, the patient has morbid obesity and had hepatic steatosis and mild steatohepatitis on biopsy. Lab data and preoperative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology. The operative dictation also does not describe specific liver pathology to warrant liver biopsy. The steatohepatitis identified on the biopsy is an anticipated pathologic condition in the setting of morbid obesity and does not mandate biopsy.[1,2]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall trauma
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld

The patient is a male with a history of dementia and coronary artery disease who
presented to the emergency room for further evaluation/management status post
fall injury. Trauma workup including head computed tomography (CT), cervical
spine computed tomography (CT), facial bones computed tomography,
electrocardiography (ECG) and labs were within normal limits. The patient was
subsequently admitted to the inpatient medical service for further
evaluation/management. He remained stable and was ultimately discharged in
stable condition.

No, the proposed treatment of inpatient admission is not deemed medically necessary.
The patient is a male with a history of dementia and coronary artery disease who
presented to the emergency room for further evaluation/management status post
fall injury. Trauma workup including head computed tomography (CT), cervical
spine computed tomography (CT), facial bones computed tomography,
electrocardiography (ECG) and labs were within normal limits. He was
subsequently admitted to the inpatient medical service in stable condition. He
responded well to the prescribed therapies and was subsequently discharged in
stable condition. There is no evidence of intensification of services throughout the
course of this patient's hospital stay. Hence, patient's care could have been safely
furnished in a less intensive setting without adversely affecting patient's safety or
outcome.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Stelara. 

The insurer denied Stelara dosed every 4 weeks. The health plan's determination is overturned. 

The patient is a female with fibrostenotic and fistulizing Crohn's disease status post small bowel resection. She has failed mesalamine and Humira. She started Stelara. Magnetic resonance enterography showed a 4 centimeter (cm) narrowing in the distal ileum with mucosal thickening, hyperenhancement, and proximal dilation. Since, she has had diarrhea. C-reactive protein was elevated at 5.7. A Colonoscopy showed active Crohn's disease. 

Stelara every 4 weeks is medically necessary. The American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy". 
In this case, the patient has failed multiple other medications for the treatment of Crohn's disease, and failed Stelara every 8 weeks, with symptoms of active disease and evidence of active disease on magnetic resonance enterography and colonoscopy. Continuation of dosing every 8 weeks, or discontinuation of Stelara (even if an alternative therapy 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 medically necessary.