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

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

The patient is a woman who presented to the hospital with pain and swelling of the right lateral thigh for the past 10 days and stated that she recently underwent abdominal liposuction and gluteal implants. At that time, she noticed an increase in size, pain and swelling of the thigh and hip. She also reported nausea, headache, fever and chills. She denied chest pain and shortness of breath. On physical exam, heart was regular and breath sounds were normal. She had a 15 centimeter (cm) x 7 cm area of induration with tenderness to palpation in the right lateral/proximal thigh with overlying warmth. The surgical incision sites were healed without discharge. Vital signs showed temperature 36.6 Celsius, heart rate 81, and blood pressure 111/71. Labs showed white blood cell count (WBC) 10.37, hemoglobin 10.0, platelets 496, sodium 139, potassium 3.9, and creatinine 0.59. Computed tomography (CT) imaging demonstrated hematoma versus abscess in the right thigh region. The patient was admitted for thigh abscess and iron deficiency anemia. 

The inpatient hospital admission was not medically necessary. The patient was hemodynamically stable, had no fever, tachycardia or elevated white blood cell count, and had no acutely concerning findings on imaging beyond the presence of hematoma versus possible abscess. CT imaging was done at the time of presentation and when reviewed by the interventional radiology, their assessment was that there was no drainable collection. Overall, it was thought that the collection was more likely a hematoma rather than an abscess. For this reason, she could have been managed safely and effectively at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Withdrawal.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history of alcohol abuse and recent discharge. He presented with hearing music, hand shaking and nausea.

The patient's vital signs were as follows: Temperature 98.4, pulse 98, respiration rate 18, blood pressure 139/93, pulse oximetry 97%. His exam was unremarkable. His labs were as follows: Na (sodium) 138, K (potassium) 4.1, CO2 (carbon dioxide) 26, BUN/Cr (blood urea nitrogen/creatinine) 18/.61, WBC (white blood count) 4.33, H/H (hemoglobin/hematocrit) 12.2/359, Plt (platelets) 64, EtOH (alcohol) 17.5. His CXR (chest x-ray) revealed NAD (no active disease).

The patient was admitted with acute alcohol withdrawal. Psychiatry hospitalization was not indicated. Plan of care included IVF (intravenous fluids) and CIWA (clinical institute withdrawal assessment) protocol.

The patient's vital signs were stable. His CIWA (clinical institute withdrawal assessment) score was 4. He complained of tremor, sweating, visual hallucination, anxiety and epigastric abdominal pain. His exam showed epigastric tenderness and hand tremors. Change from Ativan to Librium protocol was noted. Omeprazole for alcohol-induced gastritis was noted.

The patient's vital signs were stable. His CIWA (clinical institute withdrawal assessment) score was 4. He as feeling better. He denied symptoms. He clinically improved. He was cleared for discharge.

No, the Inpatient Admission was not medically necessary.

Medically necessary services are those which are:
safe
effective
generally accepted national standard of medical practice
not provided primarily for convenience of the patient or the practitioner
the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested inpatient admission was not medically necessary, because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.

This patient with a known history of alcohol intoxication/withdrawal was admitted for alcohol withdrawal after presenting with auditory hallucinations and alcohol intoxication.  The patient did not have active comorbid conditions.  The patient was hemodynamically stable and afebrile.  His CIWA (clinical institute withdrawal assessment) score was less than 8.  At time of admission, he did not have tachycardia or arrhythmia. His labs were remarkable for alcohol induced thrombocytopenia and hepatitis.  He did not have severe electrolyte abnormalities.  The patient was admitted with plan for IVF (intravenous fluids) and CIWA (clinical institute withdrawal assessment) protocol.  He remained hemodynamically stable during hospitalization with CIWA (clinical institute withdrawal assessment) score less than 8.  The patient was clinically stable and did not have findings of severe alcohol withdrawal.  He had not failed management at a lesser level of care and did not have symptoms that required an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crowding
Treatment: D8080 - Braces
The insurer denied the D8080 - Braces.
The denial is upheld. 

The patient is a male requesting dental benefits for Orthodontic treatment (Braces). The patient presents with midline discrepancy, Class II molar right side, Class III canine and molar left side. He has overbite of 4 mm (millimeters), and overjet of 6 mm (millimeters). He has procumbent lower incisors.

No, the proposed treatment of orthodontic therapy (braces) is not medically necessary.
The patient does exhibit some crowding with the lower incisors and the midline is slightly off center, however these conditions are more cosmetic in nature, and they do not compromise function.

Additionally, the dental clinical summary states that the patient has a class III canine and molar on the left side. However, this is not supported by the x-rays and photos submitted. The amount of overbite is only 1 mm (millimeter) greater than normal, and the reported overjet of 6 mm (millimeters) is not apparent when examining the photos submitted.

The overall severity of the clinical conditions as described in the dental clinical summary is not supported by the documentation submitted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypospadias. 
Treatment: Inpatient admission. 

The insurer is denied coverage for inpatient admission. 

The denial is overturned. 

This male patient has a history of severe hypospadias and asthma.  The patient presented to the hospital for a repair of urethral diverticulum with tunica vaginalis graft and penoplasty.  The patient had the procedure without complication under general anesthesia.  The patient was admitted postoperatively, and was given 2 grams of intravenous (IV) Unasyn every six hours, IV gentamicin every 8 hours.  Patient-controlled epidural analgesia (PCEA) with Fentanyl, and acetaminophen, IV morphine was given for pain.  The patient remained hemodynamically stable throughout the admission.  The patient was discharged home on oral (PO) Tylenol/ibuprofen and oral Augmentin for 9 days. 

Per the MCG Health (24th Edition) Urethroplasty, the patient does not appear to meet the Optimal Recover Course discharge parameters within 24 hours post procedure.  The patient still had Foley in place, was still receiving two days of intravenous (IV) antibiotics, as well as patient-controlled epidural analgesia (PCEA) fentanyl and IV morphine.  The patient had history of two prior hypospadias repairs and apparently was traumatized by the aftermath of these surgical procedures.  The patient was kept on IV Unasyn and IV gentamicin postoperatively for prevention of post-surgical enterococcus infection. The patient also received epidural administration of fentanyl/bupivacaine.  The patient went on a regular diet, was hemodynamically stable, but did require inpatient interventions from for intravenous (IV) antibiotics, pain control, Foley/dressing care, etc.  Penoplasty is also listed on InterQual's (2018) Guidelines for Surgery/Procedure in the Inpatient setting. 

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

The insurer's denial of coverage for the inpatient admission is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastritis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient with a history of iron deficient anemia and heavy menstrual periods.  She presented to the hospital with abdominal pain and vomiting.  She was afebrile and the vital signs were stable.  There was no abdominal rebound or guarding.  A computerized axial tomography (CAT) scan revealed thickening of the gastric wall.  An endoscopy found gastritis.  The hemoglobin was 6.2 but there was no evidence of gastrointestinal bleeding.  She was transfused a unit of packed red blood cells (PRBC's) for menorrhagia.  The stool hemoccult was negative.  She was started on proton pump inhibitor (PPI) therapy. 

Clinical indications for admission for undiagnosed abdominal pain, based on Milliman Care Guidelines (MCG) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, and the need for a procedure that cannot be performed on an ambulatory basis.  The patient did not have these conditions.

Clinical indications for admission for iron deficient anemia, based on MCG, include hemodynamic instability, active bleeding that cannot be controlled, altered mental status, recurrent syncope, serious cardiac arrhythmias, severe thrombocytopenia, acute renal failure, and signs of cardiac ischemia.  The patient did not have these conditions.

This patient had gastritis.  She was stable for an outpatient endoscopy and PPI therapy.  She was not actively bleeding and could have been transfused with observation status.  She did not meet MCG criteria for admission for either undiagnosed abdominal pain or anemia.  The healthcare plan acted reasonably and with sound medical judgment.  An inpatient stay was not medically necessary.  

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Paraplegia. 
Treatment: RT300 Functional Electrical Stimulator Therapy System.

The insurer denied the RT300 Functional Electrical Stimulator Therapy System.  The denial is upheld. 

The patient is a female. She has a history of T8 (eighth thoracic spine vertebra) level paraplegia due to a spinal cord injury due to a cavernous malformation. She has had impaired motor and sensory function below her level of injury. Prior to her injury, she was physically active, which included participation in golf and running. She has been recommended to use a functional electrical stimulation cycle ergometer at home in order to maintain her muscle mass and for other health benefits.

No, the health plan should not cover the RT300 Functional Electrical Stimulator Therapy System.

The device in question provides passive exercise in persons with neurological weakness (e.g., due to spinal cord injury) by using strategically placed electrical stimulation leads to activate weakened or totally paralyzed limb muscles to drive a stationary cycle. The device in question ostensibly provides cardiovascular and musculoskeletal exercise.

The extant data from the medical literature, however, have not demonstrated that exposure to the proposed service improves function or health outcomes in a clinically significant manner for any neurological condition, including paraplegia due to a vascular malformation. The service does not promote neurological recovery beyond natural recovery in any clinically appreciable manner (Hofer AS and Schwab ME). The service does not improve cardiovascular health, pulmonary health or other health parameters in any clinically significant manner (Ralston KE, et al.; Mayson TA and Harris SR,; Deley G, et al., Nardone R, et al.,; Soleyman-Jahi S, et al., Phadke CP, et al., Farrow M, et al.). The service may help to improve or maintain muscle mass in the paralyzed limbs, but this provides no significant health or functional benefit in this clinical setting because the muscle tissue that is gained or spared does not provide any clinical or functional benefit. It does not obviate the need for pressure relief.

The proposed device is not a necessary part of rehabilitation in the setting of paraplegia. Health and well-being in this patient population should be promoted with active exercise using volitionally intact muscles and general encouragement of active participation in educational, social, recreational, avocational and vocational activities, e.g., at a wheelchair level (Wyndaele JJ,; Tweedy SM, et al.).

No, the RT300 Functional Electrical Stimulator Therapy System is not likely to be more beneficial.

The FES (functional electrical stimulation) cycle ergometer for home use that is under review is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, i.e., active exercise using residual musculature that is still under volitional control (i.e., in the upper body), and independently performed passive range of motion therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Paraplegia.
Treatment: RT300 Functional Electrical Stimulator Therapy System.

The insurer denied the RT300 Functional Electrical Stimulator Therapy System.  The denial is upheld. 

The patient is a female with paraplegia as a result of a cavernous malformation with spinal cord injury. She has loss of volition motor function below T10 (tenth thoracic spine vertebra) in the trunk and both lower extremities. Light touch sensation and proprioception are absent below T10 (tenth thoracic spine vertebra). Her condition causes muscle wasting, chronic pain, and pressure ulcers.   According to the patient's neurologist, the patient has pursued various therapy avenues for help strengthen and improve her function.

The patient had been evaluated on the RT300 FES (functional electrical stimulation) Therapy System and also utilized it as part of her rehabilitation program and had excellent response, as her peripheral nerve supply is intact and allows her to respond to the electrical stimulation. The patient's neurologist opines that the patient is an excellent candidate for the therapy due to the nature of her diagnosis and her results so far.

No, the health plan should not cover the RT300 Functional Electrical Stimulator Therapy System.

There is no expectation in sustainable and significant health gains with the treatment proposed, cycling based functional electrical stimulation, for the patient's severe spinal cord injury with paraplegia. There is no evidence stemming from practice parameters or treatment guidelines, and not from published medical literature, to indicate that cycling based functional electrical stimulation as proposed by the treating provider, would benefit the patient's health to the extent greater than standard therapies such as stretching, home exercise and physical therapy.

No, the requested therapy is not likely to be more beneficial than standard therapy such as a range of motion exercises and physical therapy. 

Systematic review of published medical literature does not provide any evidence of sustainable benefits of cycling based functional electrical stimulation in patients with severe spinal cord injuries leading to paraplegia. According to reference 3, "There is some suggestion that NMES [neuromuscular electrical stimulation] increases voluntary strength in partially paralyzed muscle following SCI [spinal cord injury]. However, there is no strong evidence to affirm the superiority of NMES [neuromuscular electrical stimulation] over other treatment strategies used to gain strength in partially paralyzed muscles after SCI [spinal cord injury]. These findings need replicating in large high-quality randomized controlled trials."
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Paraplegia.
Treatment: RT300 Functional Electrical Stimulator Therapy System.

The insurer denied the RT300 Functional Electrical Stimulator Therapy System.  The denial is upheld. 

The patient is a female with T8 (eighth thoracic spine vertebra) paraplegia. Her provider is requesting RT300 FES (functional electrical stimulation) system.

No, the  health plan should not cover the RT300 Functional Electrical Stimulator Therapy System.

No, the requested FES (functional electrical stimulation) cycle is not likely to be more beneficial for the enrollee than any available standard therapy.

There are no high quality clinical trials supporting that FES (functional electrical stimulation) cycling systems improve outcomes for person with spinal cord injury and subsequent paraplegia. The studies published in the medical literature to date, including those submitted by the provider, lack appropriate controls, are small, only involve short term follow-up, are limited to the laboratory use of this device or are not-randomized. There is no evidence to support that FES (functional electrical stimulation) cycling improves any long term, clinically meaningful outcome measure for persons with paraplegia outside of the laboratory setting compared to current standard of care interventions (e.g., stretching, pressure relief, upper body ergometer). For example, a systematic review (Alashram et al.) regarding the effect of FES (functional electrical stimulation) cycling on spasticity concluded, "further randomized controlled trials with a large sample size strongly warranted to confirm our findings."  Standard of care guidelines do not support routine use of this intervention to prevent complications of chronic spinal cord injury.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Labwork/Blood Tests. 
The insurer denied Adalimumab antibody testing. 
The denial is overturned. 

The patient is a female with medical history of fistulizing Crohn's disease, status post right hemicolectomy. She had failed Azulfidine, methotrexate, azathioprine, and Remicade. She has started Pentasa and Humira. She presented with a Crohn's disease flare (unintentional weight loss of 15 pounds over 3 months) while on Humira, as well as recent diagnosis of rectal stricture, and then rectovaginal fistula followed by perirectal abscess. She had testing for Humira drug level and anti-Humira antibodies. 

At issue is whether antibody testing is likely to be more beneficial for this patient.

The test is supported as likely to be more beneficial than any standard treatment or treatments for the insured's Crohn's disease. In this case, Humira level and anti-Humira antibody level were checked after the patient had symptoms of uncontrolled Crohn's disease, including stricture, fistula, abscess, and unintentional weight loss. Although not recommended for routine disease monitoring, this test is recommended by guidelines in patients with ongoing disease symptoms or signs of uncontrolled disease. According to the American Gastroenterological Association (AGA) Guideline on Therapeutic Drug Monitoring in Inflammatory Bowel Disease, "In adults with active inflammatory bowel disease treated with anti-tumor necrosis factor agents, the AGA suggests reactive therapeutic drug monitoring to guide treatment changes" [1]. According to the AGA Clinical Care Pathway guidelines for the treatment of Crohn's disease, drug concentration and anti-drug antibody levels should be checked if there is a loss of response to an anti-tumor necrosis factor (TNF) medication such as Humira, with a subsequent change in management (switch within drug class, assess for inflammation, or increase dose) [2]. American College of Gastroenterology guidelines for the management of Crohn's disease also recommend drug level testing, stating "If active Crohn's disease is documented, then assessment of biologic drug levels and antidrug antibodies (therapeutic drug monitoring) should be considered... recent guideline has suggested minimal "therapeutic" target trough levels" [3]. Current medical literature concurs with the studies cited in the guidelines [4]. For these reasons, the request for testing of Humira drug levels and anti-Humira antibodies is supported given possible loss of response to Humira.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Labwork/Blood Tests. 
The insurer denied Adalimumab antibody testing. 
The denial is overturned. 

The patient is a female under management for Crohn's Disease (CD). The patient has had greater than (>) 30 years of disease. The patient had a right hemi-colectomy many years ago. The patient has been on Humira for 1 year. The patient has a symptomatic rectovaginal fistula and anal stenosis. The provider is concerned her Humira is not optimized and recommended checking drug and antibody levels.

The patient underwent testing for adalimumab antibodies. This test was denied by the plan, which considers it not standard of care.

The subject under review is whether the testing is likely to be more beneficial than any standard treatments for this patient's disease.

The testing is likely to be more beneficial than any standard treatment.

The provider is recommending performing proactive drug monitoring in order to optimize adalimumab for this patient. [1] In a large randomized controlled trial of pediatric patients with CD, the authors found that proactive monitoring of adalimumab trough concentrations and adjustment of doses and intervals resulted in significantly higher rates of corticosteroid-free clinical remission than reactive monitoring (measuring trough concentration after loss of response). [2] In a recent study, 152 patients had adalimumab drug and antibody samples matched with C-reactive protein (CRP) and fecal calprotectin. [3] Patients in biologic remission had significantly higher adalimumab levels compared with others (12.0 g/mL vs 8.0 g/mL, probability [P] less than [<] 0.0001). Receiver operating characteristic curve analysis demonstrated an optimal adalimumab level of > 8.5 g/mL for predicting biologic remission. Multivariable logistic regression revealed that adalimumab levels > 8.5 g/mL were independently associated with biologic remission (odds ratio, 5.27; 95% confidence interval, 2.43-11.44; P < 0.0001). In totality, the literature favors proactive testing in order to optimize the drug level which translates into better disease control in CD.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperhidrosis of the scalp.
Treatment: Botox 100 Unit Injections.

The insurer is denied coverage for Botox 100 Unit Injections.  The denial is overturned. 

This female patient has a history of diabetes. The patient presented to the neurologist's office for a consultation regarding hyperhidrosis of the scalp. The patient reported excessive sweating of the scalp for the past 10 years. The patient has tried 25 milligrams (mg) of amitriptyline at bedtime for the past 3 months without relief. The patient needs a fan on her face for 95% of the day. The practitioner requested 100 units of Botox to treat scalp hyperhidrosis and a trial of glycopyrrolate.

Hyperhidrosis can be treated by systemic (e.g., anticholinergic) or local intervention (e.g., Botox). Systemic interventions risk cardiovascular and cognitive side effects, whereas local agents such as Botox are well-tolerated. Botox injection is the preferred treatment in this case. 

As per review of the literature and the medical record, Botox 100 Unit Injections to treat Hyperhidrosis is considered medically necessary for this patient.

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

The carrier's denial of coverage for the Botox 100 Unit Injections is overturned.  The medical necessity is substantiated.