Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a male with Crohn's disease (ileocolitis).  He has had multiple hospitalizations for disease flares.  He has failed Pentasa, Remicade, and Humira (including weekly dosing).  After a finding of inflamed ileocecal valve stricture during colonoscopy, he was started on Stelara, with partial response.  Colonoscopy showed erythematous inflamed stricture of the ileocecal valve and colitis in the cecum, ascending colon, transverse colon, and descending colon.  He has had persistent symptoms of Crohn's disease, including lower abdominal cramping pain, occasional urgency, and rare diarrhea.

The health plan's determination is overturned.  Stelara 90 mg every 4 weeks is likely to be more beneficial for the treatment of Crohn's disease by current medical literature.  Stelara is FDA (Food and Drug Administration) approved for the treatment of Crohn's disease.  A large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's Disease that was resistant to anti-tumor necrosis factor (TNF) therapy, as this patient has.  In this case, the patient has severe disease (based on diagnose before age 30, and confirmed bowel stricture), has failed multiple alternatives, and has failed Stelara every 8 weeks given ongoing inflammation and stricture found on colonoscopy.  Continuation of dosing every 8 weeks may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery to address stricture, or other complications in this patient with severe disease.  Change to an alternative medication, even if started immediately, may result in complete loss of disease control and subsequent disease complications.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a male with Crohn's Disease (CD).  The patient was diagnosed with ileocolitis.  The patient was initially treated with Remicade followed by Humira, but over time patient developed breakthrough symptoms.  The patient was switched to Stelara.  The patient is described as having had a partial response thus far.  The patient had a surveillance colonoscopy, which shows a narrowed inflamed IC valve and mild-moderate inflammation in several areas of the colon.  A recent MRE (Magnetic Resonance Elastography) demonstrated no significant areas of stenosis or active inflammation.  Even more recently, the patient was noted to clinically be doing well.

The health plan's determination is upheld.  Stelara 90 mg/mL (milligrams per milliliter) Syringe every four (4) weeks is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.  Phase 3 clinical trials leading to the approval of Stelara for Crohn's disease compared Q8 week to Q12 week dosing.  There is no data from the related maintenance trial or long-term extension trials on Q 4 week dosing.  There are some registry trials which have looked at large cohorts in "real world" situations.  One of the largest is reference 3 below.  In this observational study 216 patients were followed.  At week 12, 2 patients were on Q4 week dosing.  At week 24, 3 patients were on a Q 4 week injection regimen.  At week 52, 11 patients were on Q 4 week dosing.  Four patients with extensive surgical and medical history and limited remaining treatment options received an intravenous (IV) re-induction with a subsequent q4w interval but failed to achieve remission.  Based on this very limited data giving ustekinumab Q 4 weeks is not likely to be more beneficial than dosing Q 8 weeks.
Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis: Digestive system /gastrointestinal/ abdominal pain 
Primary Treatment: Inpatient hospital

The patient presented to the emergency department (ED) with a history of progressively worsening abdominal pain. His evaluation included the physical examination, laboratory evaluation, and computed tomography (CT) scan. The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The operative notes describe an acute, non-perforated, but suppurative appendicitis. The health plan's determination is upheld in whole.

No, the inpatient admission was not medically necessary for this patient. The records do not document hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications of the procedure that required inpatient care. In this case the patient tolerated oral hydration, diet and medication and pain was well controlled. A lower level of care would have appropriately provided for presurgical assessment, laparoscopic appendectomy, and post-surgical monitoring. The care and treatment provided could have appropriately been rendered with a lower level of care. The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care designation would have provided for presurgical assessment, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Prostate Cancer
Nursing Services (including Private Duty Nursing)

The patient is a male with past medical history of hypertension, schizophrenia, hearing loss, tobacco abuse, emphysema, urinary incontinence, prostate cancer and benign prostatic hyperplasia (BPH) who is requesting personal care services 56 hours per week. His most recent assessment tool reported he was continent of bowel and bladder, had no nutritional issues, normal recall ability and had no issues with hygiene. He required extensive assistance with managing finances and managing medications. He required maximum assistance with meal preparation, ordinary housework and shopping. 

The health plan's determination is overturned. The Increase Personal Care Assistance Service Hours to Total of 56 Hours per Week is medically necessary for this patient. In order for the patient to live independently, it is medically necessary for him to have an increase in his personal care assistance services to 56 Hours per Week. Since the last assessment tool was done the patient had significant changes in his medical and psychiatric condition which warranted the need for more help with managing finances, managing medications, toileting and continence care, hygiene and memory/reliability. The 56 Hours per Week of personal care assistance services is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient has maxillary and mandibular spacing.  The  patient has 7-millimeter (mm) overjet and 5mm overbite.  Teeth J and K are still present and there are several unerupted permanent teeth, including all second molars.  The health plan's determination is upheld in whole.

Orthodontic treatment is not medically necessary.  While the patient has spaces between their teeth, there is no indication supplied of a functional impairment due to the position of the  teeth.  There is no evidence of wear or periodontal recession, and no narrative of potential tooth pain has been supplied.  If the teeth were corrected it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health.

There are several unerupted permanent teeth, but it appears there is enough room for them to emerge, which is likely.  It is not as if any teeth are so crowded they would be prevented from erupting, which left untreated could damage the roots of other permanent teeth leading to more invasive procedures than orthodontic treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Phenylketonuria (PKU)

Treatment: Molecular Pathology Testing (Procedure Code 81406).

The insurer denied coverage for Molecular Pathology Testing (Procedure Code 81406). The denial upheld.

This patient is a female who was seen by her internist for concerns regarding her lifelong diagnosis of Phenylketonuria (PKU).  She had reportedly read things about seizures, skin problems, and anxiety in adults who were not on a phenylalanine-restricted diet. Per the records, she was diagnosed at birth, and was on diet until she was school age.  Almost 3 decades ago she saw a metabolic specialist discussing treatment and having an initial discussion of the concerns of maternal PKU. She was on diet prior to and during her pregnancy, and she also saw her metabolic specialist over 2 decades ago. Her internist planned on sending her to a specialist. A phenylalanine level and PKU gene sequencing were ordered. She was found to be a compound heterozygote for two Phenylalanine Hydroxylase (PAH) mutations (c.912+1G>A and c.1315+1G>A). 

The Mayo Clinic (2018) states, "Newborn blood testing identifies almost all cases of phenylketonuria.  All 50 states in the United States require newborns to be screened for PKU. Many other countries also routinely screen infants for PKU".  They go on to state, "A PKU test is done a day or two after your baby's birth.  The test is done after your baby is 24 hours old and after your baby has ingested some protein in the diet to ensure accurate results".

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. In an individual with Phenylketonuria (PKU), genotyping is not always predictive of a response to certain treatments, such as ones using tetrahydrobiopterin in addition to the standard phenylalanine-restricted diet.  Guidelines state to begin someone on the diet regardless of diet, and when a newborn is diagnosed, American College of Medical Genetics (ACMG) (2019) guidelines do not show a necessity to confirm the diagnosis or do a genotype-phenotype correlation by genotyping.      

The patient has been documented to have PKU.  The genotyping confirms the diagnosis, but is redundant given her previous diagnosis from newborn screening and documentation of elevated levels in the past.  Individuals without PKU do not develop levels above 24 as she has had in the past.  The genotyping was not necessary to support a diagnosis or guide treatment.

The carrier's denial of coverage for the Molecular Pathology Testing (Procedure Code 81406) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Influenza A

Treatment: Inpatient hospital admission

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

This patient is a male with a past medical history of a loss of kidney following a gunshot wound, hypertension, and end-stage renal disease (ESRD) on hemodialysis. The patient presented to the emergency room with subjective complaints of flulike symptoms.  The patient was brought from dialysis by ambulance.  It was noted the patient was not dialyzed due to tachycardia.  The patient's initial vital signs included a blood pressure of 141/65, pulse of 102, and a temperature 102.7.  The oxygen saturations were 90%.  The patient was found to be influenza A positive.  The chest x-ray revealed findings compatible with congestive heart failure or fluid volume overload.  There was a small focus of pneumonia that might be present at the right base.  The CT scan of the chest revealed right lower lobe pneumonia.  The assessment and plan provided included that the patient was septic with fever, tachypnea, hypoxia, and fluid overload. The patient was admitted with sepsis due to influenza A and right lower lobe pneumonia. The patient underwent an Infectious Disease consultation and a Nephrology consultation. The patient was treated with medications including Tylenol, calcium gluconate, 1 g, vancomycin, cefepime, and Tamiflu.  The patient was stabilized and discharged.

The hospital stay was previously denied as the insurer affirmed the reason for the admission and stated that the criteria were met as the patient did not have abnormal vital signs. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission was medically necessary for this patient. 

Per MCG guidelines, admission is warranted for chronic renal failure when accompanied by severe infection (i.e. sepsis) not treatable in the outpatient setting as well as severe respiratory findings (tachypnea) and a moderate/high risk pneumonia severity index score.

The patient was admitted with pneumonia and influenza A and required IV antibiotics and antiviral medication. He exhibited signs of sepsis on arrival manifested by fever (temp 103.1F), tachycardia (HR 117), and tachypnea (RR 32). He also was found to have hyperkalemia (potassium 5.4mmol/L) and fluid overload on chest x-ray. His admission required consultations by both infectious diseases and nephrology. His pneumonia severity index was calculated as moderate/high risk (97).

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Testicular mass and pain

Treatment:  Inpatient hospital admission

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

This patient is a male who presented to the Emergency Department (ED) with complaint of pain in the testes for two weeks with a subsequent development of a mass.  The patient had undergone a scrotal ultrasound the day prior to presentation, and he was told that he had a testicular mass.  The patient was seen by urology, and the plan was for a right orchiectomy with placement of a testicular prosthesis.  Triage vitals included a blood pressure of 126/70, a temperature of 99.8F, and a heart rate of 84.  The patient went to the Operating Room (OR) for a right inguinal orchiectomy and placement of a right testicular prosthesis.  The patient tolerated the procedure well.  Postoperatively, he was in pain at a pain level of 5/10 and was groggy.  The patient shortly thereafter was alert, awake, and tolerating oral fluids.  After further monitoring, the patient was discharged home with oral Keflex/ibuprofen.

The insurer denied the acute inpatient hospital admission as not medically necessary. Per MCG Health (23rd Edition) Urologic Surgery or Procedure GRG, the patient is noted to have met the General Recovery Course discharge parameter within 23 hours post procedure.  This procedure is normally performed as an Ambulatory Surgery procedure.  Also per MCG Health (23rd Edition) Orchiectomy, the patient is noted to have met the Optimal Recovery Course discharge parameter within 23 hours post procedure.

The healthcare plan acted reasonably and with sound medical judgment and in the best interests of the patient.  The inpatient hospital admission is not considered medically necessary for this 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: Syncope; head trauma
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a male. He has a past medical history significant for diverticulosis and alcohol abuse. He presented to the ER after a syncope, fall and head trauma. The patient had been drinking alcohol prior to the event. 

In the ER, the patient was found to have atrial fibrillation with heart rate documented at 82.  The patient was hemodynamically stable. Cardiac troponin was negative. The patient underwent head and neck CT in the ER, which revealed no acute brain injury. Skin laceration was sutured. 

The patient was admitted for syncope in the setting of new onset atrial fibrillation. He spontaneously converted to normal sinus rhythm. An echocardiogram was obtained to assess LV (left ventricle) function, and was unremarkable. The patient was deemed to be at low risk for stroke (CHADS-VASC [congestive heart failure, hypertension, age >= 75, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age, sex category] score of 0), a decision was made not to anticoagulate the patient, and he was discharged home on low dose aspirin.

The patient presented for evaluation of syncope and new onset atrial fibrillation with controlled heart rate. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. There was no evidence of CVA (cerebrovascular accident) clinically or by imaging. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. The patient did not require cardioversion, IV medications for rate control or hemodynamic support or any invasive procedures. Echocardiogram was unremarkable. The patient was deemed low risk for thromboembolic events and did not require anticoagulation. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

The is a patient with recurrent gastroesophageal reflux disease (GERD). The submitted records include a surgical history and physical exam that details symptoms and prior treatment efforts. The patient has undergone the transoral incisionless fundoplication (TIF) procedure for the condition of GERD. He now has recurrent GERD symptoms.
He has completed evaluation for this condition with:
Esophagogastroduodenoscopy (EGD) that showed anatomic changes of prior gastric plication no significant wrap in place. There was an irregular Z-line and a 2-centimeter (cm) hiatal hernia.
An esophagram showed spontaneous gastroesophageal (GE) reflux and two small outpouchings of the distal thoracic esophagus.
Esophageal motility showed normal peristalsis. Esophageal amplitudes were normal.
Potential of hydrogen (pH) testing showed a DeMeester score of 26.4 (normal less than [<] 14.7).
The treating surgeon has proposed the LINX procedure as treatment of refractory GERD and as an alternative to surgical fundoplication. The health plan's determination is upheld. This patient has symptoms of recurrent GERD in the setting of prior transoral incisionless fundoplication. The requested LINX procedure in this clinical setting would be considered by the general medical community to be not more beneficial than standard treatment.
In this case the submitted clinical data indicates that this patient has undergone a prior endoluminal procedure for gastroesophageal reflux. Listed contraindications or precautions to implantation of the LINX device (per the manufacturer) include conditions such as scleroderma, suspected or confirmed esophagogastric cancer, prior esophageal or gastric surgery or endoscopic intervention, esophageal motor pathology, symptoms of dysphagia more than once per week, esophageal stricture or other gross anatomic abnormalities, esophageal or gastric varices, lactating, pregnant or plan to become pregnant, morbid obesity, or age less than (<) 21. In this case the patient has undergone prior esophagogastric intervention with endoluminal plication. The use of LINX for the treatment of GERD in this clinical setting is not established.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a patient with long standing gastroesophageal reflux disease (GERD) despite long term medication use. An upper gastrointestinal (UGI) study revealed GERD. An esophagogastroduodenoscopy (EGD) revealed 2 centimeter (cm) hiatal hernia, failed transoral incisionless fundoplication (TIF), GERD and esophagitis without Barrett's esophagus. A 24 hour potential of hydrogen (pH) study was consistent with GERD with a very elevated DeMeester score. Outside manometry was reported to be normal.
The health plan's determination is overturned.
This patient has GERD refractory to medical management as well as failure of endoscopic treatment (TIF). Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and the Food and Drug Administration (FDA) approved LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The only current exclusion is adolescents and a history of prior gastric/bariatric surgery which this patient has not had.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective disorder
Treatment: Continued inpatient admission
The continued inpatient admission was medically necessary.

The patient represented an acutely elevated risk of dangerous behaviors and there was no less-restrictive treatment environment appropriate.  The acute risk factors of depression with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were they to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  

The patient represented an elevated risk of dangerous behaviors including self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained depressed.  The patient had multiple static risk factors for potentially dangerous behaviors, including substance abuse, prior suicidality, and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained depressed and with ongoing medication changes were acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a skeletal Class I occlusion, mild maxillary crowding and moderate mandibular crowding. Overjet and overbite are mild. The proposed treatment is braces. The issue under review is the medical necessity for braces.
The health plan's determination is upheld.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 23 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces are not medically necessary for this case.