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

Diagnosis: Barrett's Esophagus.
Treatment: Endoscopy (43239).
The insurer denied the Endoscopy (43239).
The denial is overturned.

This male has a history of Barrett esophagus. Per documentation there was evidence of esophageal nodule.

The denial letter indicates the reason for denial is that endoscopy is not indicated for screening or surveillance of Barrett esophagus no mentioning of dysphagia is an indication. Per the denial letter "a scope test (EGD- esophagogastroduodenoscopy) is usually done every 3 to 5 years to take pieces of tissue and to look at the cells for these changes. In addition, your patient's doctor requested an EGD (esophagogastroduodenoscopy) to do this but your patient had an EGD less than 3 years ago. For this reason your request for another EGD (esophagogastroduodenoscopy) is denied as not medically necessary at this time as your patient need to wait at least 3 years from their last EGD (esophagogastroduodenoscopy) unless your patient had new problem."

- EGD (esophagogastroduodenoscopy), irregular Z-line biopsies taken no strictures no evidence of possible etiology of dysphagia.

-The appeal letter details the reason why the endoscopy was done documenting that the patient was complaining of dysphagia and has a history of Barrett's esophagus for which the patient was recommended to have an endoscopy.  So the main diagnosis is dysphagia rather than screening or surveillance for Barrett's esophagus.

Yes the proposed treatment is medically necessary.
Per the American College of Gastroenterology (ACG) Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease "We recommend endoscopy as the first test for evaluation of patients presenting with dysphagia"

Per the attending physician documentation in the appeal letter, the patient complained of dysphagia during the evaluation and the patient has a history of Barrett's esophagus for which the patient was recommended to have an endoscopy.  This is a medically appropriate indication for the endoscopy. The patient's main diagnosis is dysphagia rather than screening or surveillance for Barrett's esophagus. Therefore, the proposed treatment is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. Per the diagnosis of dysphagia, which was documented by the attending physician, the endoscopy is indicated in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth decay; fractures. 
Treatment: Porcelain Onlay Over Tooth Number 19. 

The insurer denied the Porcelain Onlay Over Tooth Number 19. 
The denial is overturned. 

The patient is a male. The request is for a 4 (or more) surface porcelain onlay on tooth #19. The health plan denied coverage for the request due to lack of documentation. The denial is being appealed. 

Yes, the Porcelain Onlay Over Tooth Number 19 was medically necessary. 
The removal of a large amalgam resulted in exposure of much unexpected decay, as well as fractures in the mesial and distal marginal ridges. The onlay was a more conservative procedure than a full crown in restoring tooth #19. 

Therefore, given the above, the onlay was medically necessary, per the description provided by the provider. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient hospital admission 

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

The patient has a history of diabetes and opioid use disorder and presented with chest and abdominal pains. He was interested in a heroin detox. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The white blood cell (WBC) count was 25 and the glucose was 459. A CT (computed tomography) scan showed a diffuse colitis as well as possible gastritis. The stool occult blood was negative. Intravenous (IV) hydration was given, and antibiotics were started for gastroenteritis. Insulin was given and the glucose improved. 

Clinical indications for admission for gastroenteritis [MCG (Milliman Care Guidelines) M-170] include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration that does not correct with appropriate intravenous treatment, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

Clinical indications for admission for Gastritis (MCG M-560) include hemodynamic instability, gastric outlet obstruction, peritoneal signs, severe pain, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had a gastroenteritis and gastritis. IV hydration, PPI (proton pump inhibitor) therapy, and antibiotics could have been given with observation care. There was an increase in the creatinine to 1.63 but this could have been managed in the emergency room (ER) with IV hydration. The diabetes was poorly controlled but was amenable to outpatient management. He did not meet MCG criteria for admission for either Gastroenteritis or Gastritis. 

The health care plan acted reasonably and with sound medical judgment. An inpatient hospital admission was not medically necessary. 

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

Diagnosis: Multiple Sclerosis
Treatment: Formulary exception for Vumerity 231mg Capsule DR (delayed release)
The insurer denied: Formulary exception for Vumerity 231mg Capsule DR (delayed release)
The denial is upheld.

The member is an adult male with multiple sclerosis (MS). He has not been treated with any disease modifying agent. The provider has requested Vumerity. The requested medication was denied coverage as he has not tried and failed the preferred formulary agents.

The health plan should not cover the proposed treatment, formulary exception of Vumerity.
There is no reason the patient cannot be treated with the preferred formulary agents for his condition. All of the preferred agents are Food and Drug Administration (FDA) approved for his condition based on high quality clinical trials published in the peer reviewed medical literature (McGinley et al., 2021). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Vumerity relative to the preferred agents. There is no evidence that switching to a preferred agent would jeopardize his clinical stability or have an adverse effect for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcoholic hepatitis
Treatment: Private room during hospitalization
The insurer denied the private room during hospitalization.
The determination is upheld.

The patient has a past medical history (PMH) of hypertension (HTN), alcohol abuse, cirrhosis and hepatitis and was admitted with complaints of (c/o) abnormal blood work with an elevated bilirubin. The vital signs were notable for a pulse (P) of 102 and blood pressure (BP) 150/79. The physical exam was notable for no apparent distress (NAD), palpable liver, jaundice, slow speech but appropriate answers and awake, alert, and oriented times 3 (AAOx3). Lab work was significant for a total bilirubin (T bili) of 10.3, ammonia 60, aspartate aminotransferase (AST) 100, and ethanol 0. Imaging studies, a computed tomography (CT) scan of the head showed no acute intracranial abnormality. The patient was diagnosed with alcohol use disorder and risk of withdrawal and treated with a Clinical Institute Withdrawal Assessment (CIWA) protocol, clinical monitoring, vitamin repletion. gastroenterology (GI) evaluated the patient and recommended discharge with lactulose. The patient was discharged in stable condition. At issue is the medical necessity of a private room during hospitalization.
A private room during hospitalization was not medically necessary.
The patient presented to the emergency department (ED) with complaints of an elevated bilirubin on lab work. The patient did not have an acute co-morbid illness, high risk for delirium tremens, long-term intake of large amounts of alcohol, serious psychiatric condition (e.g., suicidal ideation, psychosis), or severe alcohol withdrawal symptoms. The patient was not significantly altered and was hemodynamically stable throughout the hospital stay. This patient was found to be at risk of alcohol withdrawal, was treated with CIWA, benzodiazepines (BZDs), intravenous fluids (IVF), and telemetry. On ED documentation and the admission history and physical (H&P), the patient was documented to be AAOx3 and GI evaluated the patient and recommended discharge within 24 hours of admission.
The patient did not have a contagious disease requiring isolation to prevent its spread, there was no infection with serious risk to the patient, radiation implants, severe burns, and the patient was not a danger to themselves or others, nor was there a severe psychological condition, or need for 1-on-1 care. Therefore, a private room was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Renal Colic
Treatment: Inpatient Stay
The insurer denied: Inpatient Stay
The denial is: Upheld

The patient is a male who was admitted with vomiting and right renal colic. Vital signs showed temperature 96.9, blood pressure 161/92, pulse 120. The white blood cell (WBC) count was 8300. The creatinine was 1.35. Computed tomography (CT) imaging demonstrated a persistent 3 millimeter (mm) right distal ureteral calculus with hydronephrosis that had been diagnosed 4 days prior. Intravenous (IV) pain medications, nausea medications, IV antibiotics and intravenous fluids (IVF) were administered.
He had a right ureteroscopy with laser lithotripsy, stone extraction and stent placement. He was discharged home. He was afebrile and hemodynamically stable throughout the stay.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

An inpatient stay was not medically necessary for this patient. Care could have been provided at a lower level of care. The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis. Following admission, there were no unstable vital signs reported. He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting. Pain control, IV antibiotics and IVF followed by ureteroscopy/laser lithotripsy/stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Epstein-Barr virus (EBV) -positive diffuse large B-cell lymphoma.
Treatment:  Inpatient hospital admission.

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

The patient has a history of hypothyroidism and hyperlipidemia. He presented to the hospital with worsening bilateral upper and lower extremity weakness, gait imbalance, and urinary hesitancy. He underwent a surgical decompression and fusion. He received diagnostic testing, laboratory work, post-operative care, and testing for cancer. 

An inpatient hospital admission was not considered medically necessary for this patient. Once the patient's drain was removed, he was ready for discharge and could have gone home with the indwelling urinary catheter. 

"As the patient with acute urinary retention is in discomfort, placement of a urinary catheter or suprapubic catheter (if the urethra is not accessible) should be done to decompress the bladder and relieve the lower tract obstruction. Urethral catheterization is particularly useful in patients where the cause of urinary retention is temporary, such as infection or medication. Urethral catheterization is contraindicated in patients with recent urologic surgery such as radical prostatectomy or urethral reconstruction. These patients should have suprapubic catheterization (SPC)" (Dougherty, J. M., & Aeddula, N. R., 2022).

"Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin lymphoma (NHL), accounting for 40% of adult NHL. Two major subtypes of DLBCL, germinal center B cell (GCB) and activated B cell (ABC), were divided based on genomic signatures. Approximately 10% DLBCL is EBV positive, which has been described in the World Health Organization (WHO) classification system. EBV-positive DLBCL is mainly identified in the elderly because the median age of these patients is 71 years, although in younger patients can also be found. The incidence of EBV among DLBCL patients is less than 5% in the United States and European countries but 1015% in Asian and Latin American countries. EBV-positive DLBCL is associated with activation of NF-B and JAK/STAT signaling pathways, but the detailed mechanisms of tumorigenesis will need to be further investigated" (Pei, Y., Lewis, A. E., & Robertson, E. S., 2017).

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

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

Diagnosis: Psoriasis. 
Treatment: Skyrizi Pen 150 MG/ML (milligrams/milliliter) injection. 
The insurer denied the Skyrizi Pen 150 MG/ML (milligrams/milliliter) injection. 
The denial is overturned. 

The patient is an adult female diagnosed with moderate to severe psoriasis involving the scalp, face and upper extremities. The patient has tried and failed methotrexate, topical steroids and calcipotriene. She is now being prescribed Skyrizi. The plan has denied the request for Skyrizi so the treating provider is appealing the denial. 

The proposed treatment with Skyrizi is medically necessary. 

The patient has failed one conventional systemic therapy. Due to the location of a sensitive area such as the scalp and face, treatment with ultraviolet (UV) therapy is contraindicated. Skyrizi has demonstrated superior efficacy over several biologic treatments. Thus, Skyrizi is medically necessary for this patient. 

The patient has contraindications to a trial of ultraviolet therapy based on disease location. The treating provider has also indicated that due to the inability of the patient to receive regular treatments of phototherapy, the likelihood of treatment success is small. 

Skyrizi is a superior treatment with no reported increase risk of skin cancer as seen with psoriasis patients receiving phototherapy, a treatment option that is no longer considered standard of care. 

Per Brownstone, ND et al (2021): "Risankizumab has been shown to have very high efficacy in many comparison trials. It has superior efficacy to adalimumab, ustekinumab, and secukinumab. Though the onset of action is as fast as the IL-17 agent secukinumab, it achieved much better efficacy by week 52. Additionally, it has been noted to have high durability." 

Per Blair, HA et al (2020): "In clinical trials, subcutaneous risankizumab was more effective than placebo, ustekinumab, adalimumab, secukinumab and fumaric acid esters in reducing the severity and extent of moderate to severe plaque psoriasis". 

Armstrong AW et al (2020) reports: " brodalumab, guselkumab, ixekizumab, and risankizumab-rzaa were associated with the highest PASI response rates in both short-term and long-term therapy."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Myeloid Leukemia. 
Treatment: Continued Inpatient Admission. 

The insurer denied: Continued Inpatient Admission. 
The denial is upheld. 

The patient in this case is an adult male with acute myeloid leukemia. He was treated with Vyxeos and developed progressive pancytopenia. He was admitted to the hospital. In addition to pancytopenia he had evidence of liver injury based on significant elevations in liver enzymes. This had been evident before he started chemotherapy and it was felt to be due to his leukemia. He required transfusions during his hospital stay for red cells and platelets. Bone marrow biopsy had been done and revealed evidence of residual AML (acute myeloid leukemia). He had anal pain and mucositis felt related to his low white cell count. He had worsening pain during his hospital say and required IV (intravenous) Dilaudid. 

There were no acute overnight events from the prior night. Pain was noted to be well controlled with Dilaudid. Labs were notable for improvement in his blood counts. Liver enzymes had nearly normalized. He was planned for repeat bone marrow biopsy at some point. He was continued prophylactic antimicrobial agents orally. It was noted that he had a lung mass which would be addressed before he could get a stem cell transplant. He continued on topical treatment for mucositis and was also continued on Dilaudid 1mg (milligram) every four hours as needed for pain. 

Twelve days post admission it was noted that there had been no acute events. The patient requested a reduction in Dilaudid dose. Bone marrow biopsy had been done the day before. He was without fevers and had no pain. Blood counts were stable and he did not require any transfusions. He was continued on current treatments. A Foley catheter was removed. It had been placed earlier in his admission for treatment of urinary retention. 

The patient was discharged the following day. 

The continued inpatient admission was not medically necessary. 

This patient was admitted with pancytopenia, mucositis and also with anal pain found to be due to an anal fistula. While in the hospital, he periodically required transfusions. His pain was treated with IV (intravenous) Dilaudid, but on the dates in question he was only using oral pain medications. On the dates in question, there were no acute events. The patient required no transfusions and was well-managed with oral pain medications. His blood counts were stable or improving. There was no clear need for continued acute inpatient hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite, Malocclusion
Treatment: Braces and monthly visits
The health plan denied the braces and monthly visits.
The health plan's determination is overturned.

The patient is a male with an anterior crossbite. He presents with a Class II malocclusion with crowding in the maxilla and mandible. He has a posterior crossbite on the right. He has treatment planned for 30-36 months of orthodontics to address the crowding and crossbites.

At issue is the medical necessity of braces and monthly visits.

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

The requested health service/treatment of braces and monthly visits is medically necessary for this patient. This patient presents with an anterior crossbite on tooth 7, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. If left untreated, the damage that will occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, the treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Febrile seizures
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is overturned.

The patient is male with a history of febrile seizures who presented after multiple episodes of abnormal movements. He was in his usual state of health until the day of admission when he became dizzy while riding his bicycle. He went to his mother who subsequently noted his eyes rolling to the back and then an episode of arm shaking and limpness for a few seconds. He also had 2 episodes of emesis.
In the emergency department, he had 4 more similar episodes, which included staring spells, eye movements to the right, and upper extremity jerking, with no post ictal period. He reported not remembering the episodes. An intravenous line was placed and he was given a bolus of normal saline. Laboratory values were obtained which were normal. He was evaluated by the neurology team and was subsequently admitted to the hospital for further evaluation and monitoring of paroxysmal episodes with abnormal movements and possible seizures. 

Inpatient Hospital Admission was medically necessary for this patient.
This is a young boy with a history of febrile seizures who presented with multiple paroxysmal events thought to be possible seizures. He continued to have these events while being evaluated in the emergency department setting. He received specialist consultation from the neurology service and was recommended for an inpatient admission with continuous electroencephalogram (EEG) monitoring and additional treatments as needed. This level of care would not be appropriate for the outpatient setting. This patient was having recurrent paroxysmal events without a clear etiology. He required inpatient care for specialist consultation, continuous EEG monitoring, and additional treatments as needed to prevent subsequent morbidity.
The decision making at the time of admission for this patient was consistent with his young age, the presence of multiple abnormal events possibly consistent with seizures, and the need for close monitoring in an inpatient setting with specialist consultation, continuous EEG, and close monitoring for potential deterioration of clinical status.