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

Diagnosis: Wound dehiscence
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is an adult male. He presented with wound dehiscence over the site of a recent femoral-tibial bypass. The graft was found to be exposed when he was seen at an office visit, roughly three weeks after surgery. He was immediately referred to the emergency room and was admitted for debridement and wound closure. The surgical procedure was performed the next day. The patient stayed in the hospital as an inpatient for one more day after surgery. Coverage for the inpatient hospital stay has been denied by the health plan as not medically necessary. The denial is being appealed.

The Inpatient Hospital Admission was medically necessary.

This patient presented with a very serious clinical problem, namely, wound exposure with exposure of a vascular bypass. This condition is urgent and mandates immediate hospitalization to (1) reduce contamination of the site, (2) monitor the site for bleeding, and (3) prepare the patient for wound closure. For these reasons, the inpatient hospital stay was medically necessary. The procedure was performed on the next day. This means that there was no inappropriate delay between the time of the admission and performance of the surgery. The patient was kept in the hospital one day after surgery. This additional period of inpatient stay was medically necessary to monitor for wound breakdown, bleeding, and graft thrombosis. It would have been inappropriate to discharge the patient to a different level of care on the same day as the surgery to cover an exposed bypass graft because the risk of complications is high. As per the above discussion, the inpatient stay was medically necessary independent of any co-morbid factors because the patient's condition was inherently quite serious. However, it is worth noting that this patient had significant co-morbid factors including history of HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) and coronary disease. The patient was classified as ASA (American Society of Anesthesiologists) level 4, indicating a high risk for anesthetic complications. These factors further increase the need for inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Otezla
The insurer denied the Otezla.
The determination is upheld.

The patient has psoriasis. She also has psoriatic arthritis. She has failed tacroliomus ointment and betamethasone cream, clobetasol solution. The medication under review is Otezla.

The requested health service/treatment of Otezla is not medically necessary for this patient. There is no documentation provided that the patient has tried and failed, has a contraindication to, or intolerance to the preferred treatments methotrexate and cyclosporine, which have been shown to be effective for psoriasis.

According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines such as methotrexate are effective treatments for the management of psoriasis (1, 2).

Within the peer-reviewed literature, West et al 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2 percent (%) [95% confidence interval 34.160.0] of patients achieve psoriasis area and severity index (PASI) 75 at primary endpoint, Thus, methotrexate is an effective first-line treatment for the management of psoriasis (3).

The evidence-based literature is consistent. The preferred agent methotrexate is appropriate for the treatment of the patient's psoriasis. Methotrexate should be tried and failed prior to initiating Otezla.

It is noted that the patient has tried and failed tacrolimus ointment. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Otezla prior to the formulary alternatives such as methotrexate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polyarticular Juvenile Idiopathic Arthritis (JIA).
Treatment: Weekly Humira.
The insurer denied: Weekly Humira.
The denial is: Overturned.

The patient is a female who has polyarticular juvenile idiopathic arthritis (JIA) and has been on Humira every 14 days, however, has subtherapeutic Humira levels and continues to have inflammation in the joints. The patient has been prescribed Humira every week however it was denied. The patient is not able to take methotrexate. The subject under review is the medical necessity for weekly Humira for this patient.

The health plan's determination is overturned.

Treatment with Humira weekly is medically necessary for this patient. It is Food and Drug Administration (FDA) approved weekly for rheumatoid arthritis. It is standard of care to use this medicine weekly when every other week is not effective. JIA is also an inflammatory arthritis, and this medicine can be used weekly. Those who do not respond to every other week Humira are placed on weekly medication. This is medically necessary for this patient.
Per Wolf, et al. Escalation to weekly adalimumab dosing demonstrated clinical benefits for patients who lost response to therapy and may be beneficial for patients not initially responding to induction therapy. No new safety risks were identified with weekly dosing.
Per Leonardi et al. By 12 weeks after dose escalation, one-quarter achieved substantial clinical improvement. Safety results were similar between patients who dosage-escalated and those who did not.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia.
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 112 hours per week; 16 hours per day; 7 days per week.
The insurer denied: Consumer Directed Personal Assistance Services (CDPAS) 112 hours per week; 16 hours per day; 7 days per week. 
The denial is: Upheld.

The patient is a female with medical history notable for congestive heart failure, incontinence, and dementia. The patient was approved for 80 hours per week of consumer directed personal assistance services (CDPAS). The patient and her health team requested an increase to 112 hours per week of CDPAS (16 hours per day), and this request was partially denied by the health plan. The plan did approve 24-hour live-in 7 days per week CDPAS. This partial denial is the subject under review.

The health plan's determination is upheld in whole.

The requested health service of Consumer Directed Personal Assistance Services (CDPAS) 112 hours per week; 16 hours per day; 7 days per week has not been demonstrated to be medically necessary for this patient.
The plan has approved 24-hour live-in care, acknowledging the patient's need for assistance with personal care tasks. Live-in care requires that aides be able to sleep for a minimum of 5 hours per night uninterrupted. Therefore, 24 hour live-in care is appropriate for patients that do not have personal care needs that would preclude a 5 hour window of rest. Per the daughter's own attestation, this window has been possible for the patient.
Documentation from the physician regarding the patient's personal care needs was inconsistent; in some notes there is a request for 24-hour care, whereas others state that this is not necessary. Furthermore, the letter which stated that 24-hour care was not necessary specifically requested 13-16 hours per day to address her needs; live-in care is the equivalent of 13 hours per day and meets this criterion. The patient likely has a need for 24-hour care supervision due to her dementia, but personal care aides cannot be for safety monitoring alone in patients with dementia; there must be a demonstrated personal care need to approve additional hours. There is no clear evidence of personal care needs that would not be met by a 24-hour live-in personal care aide.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Seizures. 
Treatment: Keppra XR (extended release) 500 mg (milligrams) Tablet. 

The insurer denied coverage for Keppra XR 500 mg Tablet. 

The denial is overturned. 
 
This case involves an adult with a request for medication management. The pathology report noted spongiotic dermatitis from the right mid back as well as perivascular and interstitial dermatitis with mild spongiosis from the left neck. A determination letter reported the request for Keppra was denied as there is no indication that the patient could not utilize formulary alternatives. The letter stated the patient has been under the provider's care for many years for seizures. Since then, the patient seizures have been controlled with Lamictal and Keppra. It was reported that the patient developed a body rash when trying generic versions of the medications and a skin biopsy confirmed an allergic reaction to the generic versions. The patient was recommended for ongoing use with brand names. 

In this case, the formulary exception is supported. The generic version of the medication is non formulary. It is documented that prior attempts of utilization of the generic version resulted in a body rash. This response is confirmed by a pathology report. The patient has been stable on a current medication regimen for many years. Therefore, switching to another medication would not be advised. The formulary drug(s) is likely to cause the patient an adverse reaction. The formulary drug(s) has been ineffective based on the patient's clinical history with a side effect. The requested drug would be more effective than the formulary drug given the history with a side effect. As such, there is a formulary exception for the use of Keppra XR 500 mg Tablet. 

The formulary drugs are expected to cause adverse effects. The formulary drugs were tried, and the patient did have an adverse reaction or contraindication. The formulary drug is expected to be ineffective. The non formulary drug is expected to be more effective that the formulary alternatives. 

The carrier's denial of the Request for a Formulary Exception for Keppra XR 500 mg Tablet is overturned.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Idiopathic chronic constipation

Treatment: Formulary Exception for Motegrity (prucalopride)

The insurer denied Formulary Exception for Motegrity (prucalopride)

The denial is overturned.

The patient has a diagnosis of idiopathic chronic constipation. She has previously been treated with Linzess but after 6 months was no longer tolerating the medication. Her nurse practitioner writes that she does not feel that the other formulary drug, which is Amitiza, would be beneficial since it would likely also have the same side effects. She was started on Motegrity and she is tolerating it well and without side effects. Her constipation has improved, and she is not having diarrhea.

UpToDate has an article titled "Management of chronic constipation in adults." The article discusses pharmacological therapy. It states that prucalopride is a serotonin type 4 (5-HT4) prokinetic agent that has been shown to be superior to a placebo and well tolerated for the treatment of constipation. The improvement in quality-of-life scores was maintained up to 18 months. It has Food and Drug Administration (FDA) approval for the treatment of chronic idiopathic constipation in adults. 

This patient has a diagnosis of chronic idiopathic constipation and is no longer able to tolerate Linzess. Due to its mechanism of action, her health care provider does not feel that lubiprostone would be beneficial and would have similar side effects to the Linzess. In addition, Up to Date notes regarding lubiprostone note that "The role of lubiprostone in the treatment of chronic constipation remains to be determined. There have been no comparisons with other options for treatment of severe constipation, and its long-term safety is not yet established. Until further data are available (and because it is expensive compared with other options and induces nausea), it is best reserved for patients with severe constipation in whom other approaches have been unsuccessful."

Therefore, the formulary drugs are likely to cause an adverse reaction. Linzess is no longer effective and has caused an unacceptable side effect. It is likely that the Motegrity would be more beneficial as the patient has already demonstrated a good response to this drug. The denial of Motegrity is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet
Treatment: Braces and Monthly Visits
The insurer denied: Braces and Monthly Visits
The denial is: Upheld

The patient is a female. She has a Class II malocclusion with protrusive maxillary incisors. She has 6 millimeter (mm) overjet and a 3 mm deep bite. She has moderate maxillary and mandibular crowding. She is treatment planned for orthodontics with extraction of four first premolars to correct this malocclusion but her health plan rejected the claim on the basis that treatment is not medically necessary.

The health plan's determination is overturned.

The treatment of braces and monthly visits are medically necessary for this patient. Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma.  1. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Additionally, all reviewers agree this patient's overjet is 6mm. Overjets of this magnitude are shown to negatively affect the oral health quality of life of patients.  2. For these reasons treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hematoma
Treatment: Inpatient admission 
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This case involves a male child who presented to the emergency room after falling off a bed. After falling, the patient was inconsolable and continued crying. The trauma history and physical examination was relatively unremarkable. The patient had a Glasgow Coma Scale of 15 with stable vital signs. He had mild swelling and tenderness at the right side of the forehead area measuring 2 centimeters (cm) x 2 cm with no palpable bony defect. Bone survey x-rays were negative for acute findings. He was admitted to trauma service for the Pediatric Intensive Care Unit (PICU) for observation and monitoring. He was subsequently discharged the following day. The hospital admission was denied coverage with claims that there were no severe problems wanting a full hospital admission. An appeal was submitted stating that the patient had a scalp hematoma after falling 3 feet from a bed and striking his head on the floor. A skeletal bone survey was done with claims that the patient required close inpatient monitoring and serial neurologic examinations. 

According to the Milliman Care Guidelines, inpatient care was not necessary. The patient did not meet any of the criteria to support this level of treatment. The patient did not have hemodynamic instability, he did not require resuscitation, nor did he present with a Glasgow Coma Scale score of less than 13. Additionally, the patient did not have evidence of worsening neurologic function post presentation, no new focal signs on neurologic examination, no new signs or symptoms that were severe while persistent despite observation care. He did not have evidence of altered mental status that was severe persistent, no evidence of increased intracranial pressure, no new intracranial pathology on imaging that required intervention or monitoring beyond the observation care timeframe, nor did he have a cerebrospinal fluid leak. There were no recurrent seizures, no significant respiratory or cardiac abnormality secondary to brain injury, and no increased intracranial pressure or cerebral edema monitoring needed. Based upon the provided information, the patient could have been sufficiently observed and monitored in an outpatient or observational basis. He did not require acute level of treatment to justify the hospital admission. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the hospital admission services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Impacted wisdom teeth

Treatment: cone beam computed tomography (CT) scan (D0367) services

The insurer denied cone beam computed tomography (CT) scan (D0367) services

The insurer's denial was upheld.

The patient has the medical diagnosis of an impaction consultation due to complaints of dental pain. This patient was evaluated for her symptomatic wisdom teeth. The patient was noted to have all four wisdom teeth and was having intermittent pain. The roots of 17 and 32 were impinging on the inferior alveolar nerve. The dentist ordered a cone beam computed tomography (CBCT) which was denied. 

In the Final Adverse Determination letter, it was written that the cone beam CT scan (D0367) is not medically necessary because it has not been demonstrated that the patient has facial abnormalities, implants, or skull fractures and therefore does not meet the clinical criteria for radiographic services.

A CBCT allows the surgeon to view the proximity of the nerve and the roots. This makes the decision to remove versus other accepted techniques. 

The previous request for coverage of the CBCT was denied as not medically necessary since it has not been demonstrated that the patient has facial abnormalities, implants, or skull fractures. This reviewer also found no evidence in submitted documentation, after reviewing the Panorex included for review the records, to support that this CBCT was considered medically necessary. The plan appears to have made a reasonable decision.

"Surgical extraction of an impacted mandibular third molar, either for therapeutic or prophylactic purposes, is a common procedure in oral surgery. It is often linked with complications like pain, swelling, bleeding, dry socket, infection, and trismus, which are often temporary in nature. The most troublesome complication of all is temporary or permanent damage to the inferior alveolar nerve (IAN). The known risk of transient IAN injury after mandibular third molar surgery ranges from 0.6-5.3%, whereas the risk of permanent IAN damage is <1%. Not only do such complications force the patients to undergo the ordeal of sensation loss, but the medicolegal implications are also extremely significant ." (Issrani, et al., 2021). 

"Conclusions: Three-dimensional radiographic imaging, in our patient group, does not significantly affect the risk for complications during the surgical removal of complex lower third molars. Therefore, it should only be utilized for risk assessment, especially in cases of symptom-free lower third molars. A preoperative orthopantomogram still can be accepted as standard for radiographic imaging. An intraoperative exposure of the IAN bundle does not necessarily predict simultaneous neurological damage. Exposure of the IAN bundle is no indication for a discontinuation of the surgery." (Klatt, et al., 2021).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for a cone beam computed tomography (CT) scan (D0367) services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough and trouble breathing
Treatment: Inpatient Stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a male toddler who was born prematurely. He has a medical history significant for necrotizing enterocolitis which was managed surgically with an ileostomy and mucous fistula subsequently taken down, pulmonary vein stenosis, intrauterine growth retardation, periventricular leukomalacia, congenital hypothyroidism, and bronchopulmonary dysplasia. He had an albuterol-responsive wheezing associated with a viral illness and he presented to the emergency department (ED) with a one-day history of a fever to 103, runny nose, and worsening cough. He was unable to tolerate an oral dose of steroids and did not improve with nebulized Saline and Albuterol.

His vital signs included a temperature 39.5 degrees Celsius, a heart rate of 162, a respiratory rate of 38, and his oxygen saturation was 97 percent (%) on room air. The patient's examination was significant for significant respiratory distress with tachypnea, decreased breath sounds bilaterally with wheezing and retractions, congestion with rhinorrhea, moist mucous membranes, and a non-focal neurologic exam.

Admission orders included continuation of Levothyroxine, enteral Prednisolone for a total of five days, Albuterol with every two hours spacing according to the asthma pathway, pulse oximetry, intravenous (IV) fluids, and asthma education. Endocrinology was consulted because he was due for a follow-up for his laboratory studies. He was deemed stable for discharge.

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

The requested inpatient admission was not medically necessary. He could have been safely managed at an alternate level of care. He was treated with three combonebs and enteral Prednisone. The patient's cough and bronchospasm persisted with only fair aeration. He was transitioned to parenteral Solumedrol and Magnesium. His chest x-ray was significant for mildly prominent interstitial markings. He had rapid testing was positive for respiratory syncytial virus (RSV). He was only able to tolerate spacing of treatments up to two hours so he was admitted for further management.
Endocrinology recommendations included continuing his current dose of Levothyroxine and following up with his usual endocrinologist. He was weaned from the IV fluids as his oral intake improved. He was able to tolerate gradual weaning of the Albuterol treatments to every four hours. He continued to have some mild congestion, but the wheezing resolved.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine fibroids
Treatment: Inpatient admission
The insurer denied the inpatient hospital stay.
The determination is overturned.

This is a female patient who had an abdominal myomectomy, bilateral salpingectomy, and lysis of adhesions secondary to uterine fibroids and pelvic pain. The surgery was without complications and she was admitted as an inpatient after surgery. She progressed well after surgery and was discharged home. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay is medically necessary for this patient.

The patient had an open, laparotomy incision with her abdominal myomectomy which supports up to 3 days of inpatient hospitalization without complications. The open incision requires acute, inpatient admission secondary to the risk of hemorrhage and fluid maintenance after surgery. There is a risk of hemorrhage, pain control, voiding difficulties secondary to the large open incision. It is standard of care to allow at least 2-3 days postoperatively for inpatient admission and monitoring. This patient was discharged the following day within the standard of care.