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

Digestive System
Pharmacy/prescription drugs

Diagnosis: Crohn's disease
Treatment: Humira
The insurer denied Humira 40mg (milligrams) weekly. The health plan's determination is overturned. 

The patient is a male with moderate to severe Crohn's disease of the small bowel and colon status post resection complicated by anastomotic strictures. Under review is the medical necessity of Humira 40mg (milligrams) weekly.

Humira 40 mg weekly is medically necessary in this case.
The American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should have their medication dose adjusted in order to attempt to optimize therapy", and the American Gastroenterological Association guidelines for therapeutic drug monitoring recommend increase in dose if drug level is low. The American Gastroenterological Association guidelines for therapeutic drug monitoring recommend dose escalation of Humira when the drug level is low, as it was in this case on the standard dose of Humira. Current medical literature has shown improved Crohn's disease outcomes when dose escalation is used to recover lost response.
In this case, the patient had symptoms and a low drug level on the standard dose of Humira (Humira 40 mg every two weeks) until Humira was increased to 40 mg weekly and has occasional breakthrough symptoms on Humira 40 mg weekly. Reduced dosing to 40 mg every two weeks could result in complications of disease activity, such as disease flare, recurrent fistula, need for surgery again, hospitalization, or colonic dysplasia leading to colorectal cancer. For these reasons, the use of Humira 40 mg every week is medically necessary in this case.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease and Gastritis.
Treatment: Omeprazole / Sodium Bicarbonate Capsules, Pre-service.
The insurer denied the Omeprazole / Sodium Bicarbonate Capsules, Pre-service.
The denial is overturned.

The patient is a female with gastroesophageal reflux disease (GERD) and gastritis. She has failed omeprazole, pantoprazole, Dexilant, rabeprazole and esomeprazole. The attending physician is requesting treatment with omeprazole-sodium bicarbonate.

Yes, the health plan should cover the proposed treatment.
In order for prior authorization criteria for omeprazole-sodium bicarbonate to be met, the patient must have tried and failed three preferred formulary alternatives. As the patient has tried and failed the preferred formulary alternatives omeprazole, pantoprazole and Dexilant, the prior authorization criteria for omeprazole-sodium bicarbonate are met, and the health plan should cover the proposed treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems-Impacted teeth.
Treatment: D8080 (comprehensive orthodontic treatment of the adolescent dentition) and D8670 (periodic treatment visit x 12).

The health plan denied the D8080 (comprehensive orthodontic treatment of the adolescent dentition) and D8670 (periodic treatment visit x 12).  The decision has been overturned.

The patient in question has  impacted teeth # (number) 11 and #29. Both teeth are completely blocked out and will be unable to erupt without orthodontic intervention. He presents with a skeletal Class I malocclusion and significant crowding. He is treatment planned for 36-42 months of braces with premolar extractions to address the crowding and impacted teeth, but treatment was denied due to lack of medical necessity.

It is in the best interest of patients to be referred to an orthodontist and oral surgeon when an impacted tooth is discovered (1).

If left untreated the damage that will likely occur to the patient's teeth will be more time consuming and costly to correct than the patient's existing orthodontic problem. 

Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisors (2).  For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Melena. 
Treatment: Inpatient Admission. 

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

The patient is a female. She presented to the emergency department of the facility filing the appeal with the complaints of ongoing melena. The patient had a history of tobacco use in the past, OSA (obstructive sleep apnea) on CPAP (continuous positive airway pressure), COPD (chronic obstructive pulmonary disease), rheumatic valve disease, LA (left atrium) thrombus, multiple admissions for CHF (congestive heart failure), a mechanical AVR (aortic valve replacement) on anticoagulation, ICD (implantable cardioverter defibrillator) placement, Barrett's esophagus, and gastritis.

The patient was fecal occult blood positive. The initial hemoglobin was 11.9. The INR (international normalized ratio) was 2.8. The patient's Coumadin treatment was held, and the patient was started on IV (intravenous) PPI (proton pump inhibitor) therapy.

The patient was admitted with upper GI (gastrointestinal) bleeding. The patient was allowed to continue on her home medications, including aspirin. The patient's hemoglobin trended downwards to less than 10. The patient underwent an EGD (esophagogastroduodenoscopy). The patient underwent treatment for a non-bleeding AVM (arteriovenous malformation) in the duodenum. The patient was restarted on her Coumadin and evidenced no further bleeding.

The patient's hospitalization extended for a duration of nine days. 

No, the Inpatient admission was not medically necessary. The care was medically appropriate, but not medically necessary at the level at which it was delivered.
The patient evidenced GI (gastrointestinal) bleeding, and an endoscopy revealed a non-bleeding AVM (arteriovenous malformation). The patient was clinically stable with no high-risk endoscopic findings. As such, the patient did not require a full hospital admission. The patient would have been able to receive all the care as provided at a lower level in its entirety.  The patient's co-morbid conditions were chronic in nature. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an upper GI (gastrointestinal) bleed; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring, need for blood products or transfusion, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preeclampsia

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a female with a history of cesarean delivery. The patient was diagnosed at that time with preeclampsia and received magnesium sulfate. She was sent to the hospital from the Obstetrician's office with elevated blood pressure. She was admitted with the diagnosis of preeclampsia. The plan was to administer again intravenous magnesium sulfate, increase Labetalol dosage to 200 milligrams three times a day, obtain follow up blood pressures, and obtain pre-eclamptic labs. Her blood pressure in the hospital was 140-150/80. There is no evidence that a urinalysis was done to evaluate urinary protein. The patient's lactate dehydrogenase was minimally elevated. She was discharged after a period of medical stability. 

This patient presented 1 week after delivery with elevated blood pressure. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery. 

The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman: 

Systolic blood pressure greater than or equal to140 millimetre of mercury or diastolic blood pressure great than or equal to 90 millimetre of mercury, and
Proteinuria greater than or equal to 0.3 grams in a 24-hour urine specimen or protein: creatinine ratio greater than or equal to 0.3, or
Signs of end-organ dysfunction (platelet count <100,000/microliter, serum creatinine >1/1 milligrams per deciliter or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration).

This patient had elevated blood pressure. No protein in the urine was documented and no elevated liver function tests and no end organ dysfunction. This patient did not have a diagnosis of preeclampsia. She had significant elevation in her blood pressure.

Ideally this patient would have been observed in the Emergency Department. Once her blood pressure was controlled, the patient could have been discharged home on home blood pressure monitoring and to return if any worsening of her blood pressure. Admission to the hospital was not medically necessary. 

The health care plan acted reasonably and with sound medical judgment and 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: Overturned

Diagnosis: Obstructive Sleep Apnea

Treatment: Pre-Service Request for an Outpatient Procedure (64568 x 1, 0466T x 1)

The insurer denied coverage for Pre-Service Request for an Outpatient Procedure (64568 x 1, 0466T x 1)

The denial is overturned

The patient is a male with a history of obstructive sleep apnea and chronic rhinitis.  The submitted documentation does include a sleep study where the patient's Apnea-Hypopnea Index was 42.6.  The submitted documentation also detailed the patient is 5'11 weighing 227 pounds.  The patient has also undergone a drug-induced examination.  The patient did have evidence of nasal septal deviation with turbinate enlargement.  There was evidence of palatal obstruction.  There was also a lateral pharyngeal closure in the hypopharynx and oropharynx with a moderate amount of base or tongue collapse-near complete to complete.  The patient was seen for a follow-up.  The documentation does indicate this patient has a history of obstructive sleep apnea and has attempted to utilize a continuous positive airway pressure however he has not tolerated use secondary to feelings of suffocation and the inability to sleep with the machine.  The patient did report nasal obstruction was worse at night.  He did indicate he was falling asleep throughout the day and complained of ongoing fatigue.  It was recommended he continue with the continuous positive airway pressure trial and undergo treatment with an inspire implantation.

This procedure (insertion of hypoglossal nerve stimulator) is medically necessary and appropriate for this patient.  

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

This patient meets all inclusion criteria to be a candidate for this device, which are:  body mass index<32, age >18, moderate to severe obstructive sleep apnea, intolerance to continuous positive airway pressure therapy, <25% central apneas, no concentric collapse of the velopharynx on drug induced sleep endoscopy.  This device is Food and Drug Administration approved. 

The insurer's denial of coverage for the Pre-Service Request for an Outpatient Procedure (64568 x 1, 0466T x 1) is reversed. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This female patient has a history of hyperlipidemia, fibroids, endometriosis and tobacco abuse. She presented to the Emergency Room (ER) with complaints of 10 out of 10 abdominal pain. She had a colonoscopy on the day prior to arrival. A computed tomography (CT) scan of the abdomen revealed no bowel perforation. In the ER the patient was given intravenous (IV) fluids and IV morphine. She was admitted for further care and initially kept on nothing by mouth (NPO) status. The patient was given 3.375 grams (g) of IV Zosyn every 8 hours (Q8H). Deep vein thrombosis (DVT) prophylaxis was used. Her diet was advanced as tolerated. Pain was well controlled with analgesics. The patient was able to pass flatus and ambulate without difficulty. She was discharged home in stable condition with instructions to follow up with the Gastroenterologist on an outpatient basis.  

This patient had no significant laboratory abnormality, no peritoneal signs or acute abdomen, no end-organ damage or abnormality that warranted inpatient status. The patient could receive IV fluids, antibiotics, and V pain meds in observation status and not have her health jeopardized. This patient could have been observed in ambulatory or outpatient setting rather than acute inpatient admission status while receiving the same level and quality of care. In the setting of severe sepsis or severe abdominal pain (guarding, rigidity, rebound tenderness) not responding to emergency setting care, admission to acute inpatient setting would have been appropriate. One medical record note even stated +/- rebound and guarding and this is not consistent with peritoneal inflammation or reason for inpatient admission. An acute abdomen would be appropriate for inpatient acute admission. Patients that need hospitalization are those with the following signs and symptoms: Volume depletion/dehydration, altered mental status, significant rectal bleeding, prolonged symptoms (more than a week), severe abdominal pain, comorbidities such as HIV and diabetes (immunocompromised status), age >=65 years, recent hospitalization or antibiotics, pregnancy, or weight loss.

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

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

Diagnosis: Hiatal hernia.
Treatment: Full hospital admission.
The insurer denied coverage for the full hospital admission.
The denial is upheld. 

This is a male patient with gastroesophageal reflux disease (GERD) and a hiatal hernia who was admitted to the hospital for a robotic-assisted hiatal hernia repair.  There were no reported postoperative complications.  On post-operative day (POD) #0, the patient's pain was noted to be controlled and the patient reported frequent belching.  A clear liquid diet was started.  On POD#1, clinical documentation notes that the patient had some nausea that was controlled with medications.  There was painful belching.  The patient was able to tolerate clears with some pain.  The patient was discharged on POD#3.  

Per Milliman Care Guidelines (MCG) General Surgery or Procedure, hernia repairs that are non-emergent, non-complex, and in which there are no co-morbid conditions, can be performed in the ambulatory setting.[1] There were no reported complications that would warrant and exception to the ambulatory surgery criteria.[2] Per provided clinical documentation, the full hospital admission was not medically necessary.

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

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

Diagnosis: Gastroenteritis.
Treatment: Inpatient admission.

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

The patient is a male patient who underwent an acute hospitalization for the diagnosis of gastroenteritis. The patient reported a lifelong history of stomach problems. The patient presented with the report of nausea and emesis with abdominal pain. These episodes started 1.5 years prior. This latest episode had started two days ago prior. He was informed he had blood in his urine and it was presumed he had a kidney stone. The patient had an endoscopy and colonoscopy the week prior with a polyp as the only finding. There was no bleeding or fevers reported. The white count was 14.4. The potassium was 3.1.  A computed tomography (CT) scan showed kidney stones and colon thickening versus deflated bowel walls.

No, the proposed inpatient level of care was not medically necessary.  The care as provided was appropriate but not medically necessary at the level at which it was provided.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection in his bowels; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level for the entire duration of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-Chronic Pain Syndrome
Treatment: Pharmacy/Prescription Drugs-Belbuca
The health plan denied the treatment of Belbuca as the patient did not meet the pharmacy criteria. 
The reviewer has overturned in whole the health plan's determination.

This is a patient who was prescribed Belbuca. She has a diagnosis of complex regional pain syndrome type I of the left ankle/foot, failed neck syndrome and dysphagia due to a poorly healing esophageal diverticulum after surgery and has had trouble swallowing.
She underwent laryngoscopy, that revealed abnormalities in the hypopharynx. She complained of a baseline sore throat, and was known to have a number esophageal diverticuli with no esophageal leak. She was referred to speech language therapy.
An office note from her otolaryngology provider indicates a follow-up for deterioration and swallowing function, particularly over the previous two months. At that time, a repeat barium swallow was recommended. (Of note: Records from the otolaryngologist did not address her pain management.)
A follow-up note from neurology indicates 60% relief from the current regimen of Belbuca and morphine. The New York State external appeal application indicated that she had 70% improvement in pain from Belbuca in combination with liquid morphine for breakthrough pain. Diagnoses were complex regional pain syndrome type I of left lower extremity, cervicalgia, and failed neck syndrome. Medications were continued.
She has also been followed by her otolaryngologist for esophageal diverticulum. Records from this specialist did not address her pain management.
At issue is the medical necessity of Belbuca Mis 300 micrograms (mcg).

The patient was described as having severe pain and was utilizing opioids around-the-clock in the form of Belbuca (buprenorphine buccal film) with morphine for breakthrough pain.  She has a diagnosis of dysphagia due to a poorly healing esophageal diverticulum after surgery, and has had trouble swallowing. There is no rationale why the patient cannot utilize an alternative long-acting opioid such as an extended release preparation of morphine or oxycodone. Medical necessity is therefore met, with the patient requiring scheduled long-acting opioid in the form of Belbuca and morphine for breakthrough pain.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder. 
Treatment: Crowns teeth #7, #8, and #9. 

The insurer denied the Crowns teeth #7, #8, and #9. 
The determination is upheld. 

The patient presented with root canal treated teeth #7, #8, and #9. Crowns are being requested at this time and are under review for medical necessity. 

According to the provided radiographs, teeth #7, #8, and #9 are root canal treated with post-core. The root canals on teeth #7 and #8 are not fully obturated at the lower apical third of the tooth and the oburation on tooth #9 is short. Since the root canals on these teeth do not properly seal the apex, the chance of these teeth having re-infection is high. The root canal should be re-treated before placement of a crown. 

Therefore, the crowns on teeth #7, #8, and #9 are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Family history of pancreatic cancer.

Treatment: Code 81162, breast cancer (BRCA) testing.

The insurer denied coverage for code 81162, BRCA testing. 

The denial is upheld. 

This is a male patient with a family history of pancreatic cancer, and no personal history of pancreatic cancer. His paternal aunt had pancreatic cancer. The patient had breast cancer (BRCA) gene testing performed to determine the risk for hereditary cancer. 

The National Comprehensive Cancer Network (NCCN) Guidelines for Genetic/Familial High-Risk Assessment, Version 1.2020, have been expanded to provide information about pancreatic cancer in addition to recommendations regarding genetic testing in patients with breast and ovarian cancer. This update was necessary because of evidence suggesting that a sufficient number of patients with pancreatic cancer carry alterations in high-penetrance of breast and ovarian cancer susceptibility genes that warrant testing, including BRCA1, BRCA2, Cadherin 1 (CDH1), Partner and Localizer of BRCA2 (PALB2), Phosphatase and Tensin Homolog (PTEN), and tumor protein 53 (TP53) among others. Identifying a mutation in 1 of these genes in a patient could have significant implications for clinical decision making. The guidelines recommend that all patients with pancreatic cancer undergo genetic testing because the results of these tests can help determine the most effective treatments [eg, poly adenosine diphosphate ribose polymerase (PARP) inhibitors] and whether family members would benefit from screening and preventive action. The updated guidelines now include more information about specific genes associated with pancreatic cancer.      

Code 81162, BRCA testing is not considered medically necessary for this patient. In this case, the patient has a family history of pancreatic cancer, and does not have a personal history of pancreatic cancer. Literature and guidelines do not suggest testing based on family history only for pancreatic cancer.

"Screening is not cost-effective for population-based screening of pancreatic cancer (PC)" (Ngamruengphong et al 2016).  

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

This patient does not have pancreatic cancer. The NCCN does not recommend BRCA testing in this scenario.                                      

The insurer's denial of coverage for code 81162, BRCA testing is upheld. Medical necessity is not substantiated.