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

Diagnosis: Gynecological. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Hormone treatments for medical necessity. The denial is upheld in whole. 

The patient is a female with a history of leiomyomatosis. The patient underwent a laparotomy total hysterectomy and bilateral salpingectomy with excision of peritoneal fibroids. She has been recommended for treatment with leuprolide acetate. 
At issue is the medical necessity of Hormone treatments. 

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

The requested health service/treatment of Hormone treatments is not medically necessary for this patient. 

There is no data from well conducted, prospective or randomized trials to show that use of this medication is effective and safe in the treatment of leiomyomatosis. The requested hormone treatment is not supported by the peer reviewed data, it is not the standard of care to use this hormone treatment, and it is not supported by professional organizations. 

Therefore, the requested health service/treatment of Hormone treatments is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/Prescription drugs. 

The insurer denied: Durolane. 
The denial is upheld. 

The patient is a male with a complaint of bilateral knee pain and known bilateral knee osteoarthritis. The provided records document that the patient had plain radiographs obtained which revealed severe tri-compartment knee arthrosis with bone spur formation in both knees. The provider in this case recommended proceeding with bilateral Durolane viscosupplementation injections. The patient's health plan denied the requested Durolane injections for this patient. The issue at hand is the medical necessity of the requested Durolane knee injections. 

The health plan's determination is upheld in whole. 

The requested health service/treatment of Durolane viscosupplementation injections are not medically necessary for this patient. Based upon a recent article published by Tammachote and colleagues in The Journal of Bone and Joint Surgery in 2016, "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week". Therefore, the health plan alternatives including steroid injections in knee [e.g., triamcinolone, methylprednisolone, or betamethasone] would be an effective treatment for this patient's condition based upon the recommendations of the peer-reviewed literature. An article published by Jevsevar and colleagues in the Journal of Bone and Joint Surgery concluded that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid treatment over placebo. When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of nonblinded or improperly blinded trials." Therefore, the requested Durolane viscosupplementation injections are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dysphagia

Treatment: D6010 dental implant teeth #18, #19, #30 and #31

The insurer denied coverage for D6010 dental implant teeth #18, #19, #30 and #31.

The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in areas enumerated above.  The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits a heavily restored dentition and oligodontia in the mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. Further the documentation provided does not support, justify, or substantiate the requested treatment.  Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

The health care plan did act reasonably and with sound medical judgement and in
the best interest of the patient. D6010 dental implants teeth #18, #19, #30, and #31 are not considered medically necessary.

Uphold denial of coverage for dental implants as not medically necessary, as an appropriate alternative standard of care treatment would be conventional removable dentures and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable partial dentures. Therefore, other acceptable alternative treatments are appropriate, and the documentation provided does not support the recommended treatment this renders the endosteal implants and associated services not medically necessary.

Based on the above, the medical necessity for the D6010 dental implant teeth #18, #19, #30 and #31 is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic Short Stature 

Treatment: Norditropin

The insurer denied coverage for Norditropin

The denial is overturned.

This is a child male diagnosed with idiopathic short stature (ISS). This request is for Norditropin. 

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines  [4, [5, [6, [7, [8, [9]. FDA [Food and Drug Administration] approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS [standard deviation score] less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient had a pretreatment height less than or equal to -2.25 SD [standard deviation]. The patient's height velocity would not allow the patient to reach a normal adult height. The patient is losing percentiles. The request therefore meets idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary. The references provided are the most current/relevant to the case.

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

Based on the above, the medical necessity for the Norditropin is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman with BMI (body mass index) of 34.6. She presented with complaint of lipodystrophy of the abdominal wall and an umbilical hernia with diastasis recti.  The records do not indicate that she has other significant comorbid disease.

The patient underwent a combined surgical procedure that included liposuction of the axilla and flanks and abdominoplasty performed by a plastic surgeon, and umbilical hernia repair that was performed by a general surgeon.  Surgical drains were placed at the time of abdominoplasty.  The surgical procedure was completed without complication.

The patient was tolerating liquids, and her vital signs were normal following surgery.   Her diet was advanced, and the patient was discharged from the hospital with the indwelling surgical drain.

The health plan rationale for denial of this inpatient admission is that the services could have been performed with a lower level of care.

No, the Inpatient admission was not medically necessary.
The records document that this patient presented to the hospital for a scheduled abdominoplasty and umbilical hernia repair procedure. She underwent this procedure and the post-surgical course was uncomplicated. The records indicate that she was admitted to the hospital overnight for monitoring of the surgical drains. She remained stable, diet was advanced and pain management was with oral medications. She was discharged home with the surgical drains.

The health plan rationale for denial of this inpatient admission is that the services could have been performed with a lower level of care. Based on the submitted medical records, the medical necessity of inpatient hospital stay is not established. A lower level of care would have satisfied the clinical needs of this patient during this time.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The submitted records support that this patient presented to the hospital for a scheduled surgical procedure as is detailed above. She underwent surgery, and the initial recovery was without complication. The care and treatment provided could have reasonably been provided with a lower level of care than inpatient status.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Crohn's disease status post partial colectomy
Treatment: Stelara 90mg/ml syringe every 4 weeks
The insurer denied the Stelara 90mg/ml syringe every 4 weeks.
The denial is overturned.

The patient is a female with Crohn's disease status post partial colectomy. The request is for dose escalation of Stelara from every 8 weeks to every 4 weeks. The patient has tried and failed Remicade, natalizumab, Entyvio, Uceris, mesalamine. While on Stelara, a colonoscopy showed persistent severe colitis.

Yes, the health plan should cover the Stelara every 4 weeks.

Dose escalation of Stelara may be required in some patients.

In a retrospective multicenter cohort study was performed on patients with CD (Crohn's disease), dose escalation was required in 17 patients (16.3% [percent]); response was recaptured in 9/17 (52.9%) (Ma C, et al, Inflamm Bowel Dis). In another multicenter open-label study, dose escalation was effective in 8 of 11 (73%) patients (Khorrami S, et al. Inflamm Bowel Dis.). In a single center retrospective open-label observational study, dose escalation was required in 47.7% of the patients and was successful in 61.1% of them (Kapylov, et al. J Crohns Colitis.).

In a retrospective study to determine the effectiveness of ustekinumab dose interval shortening, 506 patients with CD (Crohn's disease) who received subcutaneous ustekinumab 90 mg (milligrams) every 8 weeks at a single center was reviewed. Data from 110 patients who initially received subcutaneous ustekinumab 90 mg (milligrams) every 8 weeks and then had their interval shortened to every 4 weeks was studied. Harvey Bradshaw Index (HBI) scores before and after the dose interval shortening was available for 78 patients in the cohort (71%), levels of C-reactive protein (CRP) for 60 patients (55%), and levels of fecal calprotectin for 8 patients (7%).

Following dose interval shortening, the patients' median HBI (Harvey Bradshaw Index) decreased from 4.5 to 3, the median level of CRP (C-reactive protein) decreased from 8 mg/L (milligrams per liter) to 3 mg/L (milligrams per liter), and median level of fecal calprotectin decreased from 378 g/g (micrograms per gram) to 157 g/g (micrograms per gram). Among patients who had an HBI (Harvey Bradshaw Index) > (greater than) 4, a level of CRP (C-reactive protein) 5mg/dL (milligrams per deciliter), a level of fecal calprotectin > (greater than) 250 g/g (micrograms per gram), or endoscopic evidence for disease activity before dose interval shortening, after the dose interval was shortened, 28% achieved clinical remission (an HBI [Harvey Bradshaw Index] score 4), 22% had a normal level of CRP (C-reactive protein) (< [greater than] 5 mg/dL (milligrams per deciliter)), 50% had reduced levels of fecal calprotectin, and 36% achieved endoscopic remission (Ollech JE, et al, Clin Gastroenterol Hepatol.).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Crohn's disease status post partial colectomy
Treatment: Stelara 90mg/ml syringe every 4 weeks
The insurer denied the Stelara 90mg/ml syringe every 4 weeks.
The denial is upheld.

The patient is a female. The patient has a history of Crohn's disease and she is status post partial colectomy. The patient was being treated with Stelara. As the patient began to evidence symptoms attributable to her disease process, the provider has requested an increase in dosing frequency to every 4 weeks from the standard maintenance dose of every 8 weeks.

No, the health plan should not cover the requested Stelara every 4 weeks.

A review of the literature indicates that there have been no significant studies to date demonstrating the safety and efficacy of Stelara dose escalation to every 4 weeks in Crohn's disease other than anecdotal reports, e.g. (for example) as follows:

Per Greenup A., et al, in the absence of therapeutic drug monitoring, empirical dose escalation has been considered as a strategy to optimize response in patients with either primary or secondary non-response. Efficacy and safety of UST (ustekinumab) 90mg (milligrams) subcutaneous (SC) every 4 weeks is not known.

A retrospective, observational study of compassionate use of UST (ustekinumab) in CD (Crohn's disease) was conducted at a Canadian tertiary center. Results indicate that real-life experience of UST (ustekinumab) use in patients with CD (Crohn's disease), maintenance dose escalation to 90mg (milligrams) every 4 weeks had a modest benefit in achieving a clinical response. This may be suggestive of the mechanism of loss of response to UST (ustekinumab) being driven by factors other than low bioavailability due to processes such as rapid clearance. Further assessment in larger cohorts as well as the use of therapeutic drug monitoring will be important to evaluate the usefulness of dose escalation for patients on UST (ustekinumab).

Reports such as the above are anecdotal and involve small numbers of patients. Therefore, the usefulness, efficacy and safety of dose escalation of Stelara in patients with refractory Crohn's disease requires further study and would not be considered medically appropriate.

Despite the patient's presentation and history, there is no cogent medical literature or society guidelines to recommend dosing Stelara at an interval of every 4 weeks for maintenance. There is no medical literature to show that this dosing frequency has a positive effect on healthcare outcomes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female with history of asthma, presented to the emergency room with wheezing and shortness of breath.

The patient was treated for asthma exacerbation in the emergency room with albuterol and ipratropium nebulizations, as well as oral prednisone. The patient was admitted to acute inpatient level of care for the further management of asthma exacerbation. Patient was discharged home the next day.

The acute hospitalization was denied by the health plan due to lack of medical necessity.

No, the Inpatient admission was not medically necessary.
The patient had mild asthma exacerbation, likely due to dust exposure. The patient's symptoms improved significantly with emergency room care with oral prednisone and duonebs.  At the time of admission, the patient was hemodynamically stable. The patient was not on any Intravenous medications. The patient was tolerating oral diet and oral medications. The patient's asthma exacerbation resolved within 24 hours.

The acute inpatient level of care was not medically necessary, as the patient could have been safely and effectively treated at a lower level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Postpartum preeclampsia
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female. She presented to the hospital 5 days post Cesarean section complaining of unremitting headache and blood pressures measured at home to be in the 150/100 range. Her pregnancy was complicated by gestational hypertension.

On initial evaluation in the emergency department, the patient's blood pressure was noted to be as high as 151/106, and the headache was again noted. She was admitted to the hospital with a diagnosis of postpartum preeclampsia with severe features and was given magnesium sulfate infusion and started on labetolol 200 mg (milligrams) tid (three times daily). A transthoracic echocardiogram was performed which was normal. Her blood pressure and headache resolved and she was discharged on hospital day #2.

The health plan's denial reason was because the health plan states she did not have severe problems such as chest pain or seizures or other signs that other organs in the body were affected and cites MCG (Milliman Care Guidelines) Hypertensive Disorders of Pregnancy. The reason for appeal is that the facility contends that the admission was medically necessary and unavoidable due to cerebral symptoms of severe headache and cites MCG (Milliman Care Guidelines) criteria for admission.

Yes, the Inpatient admission was medically necessary.
The patient meets standard criteria for preeclampsia with severe features as defined by the American College of Obstetricians and Gynecologists.  Her blood pressure was in preeclamptic range, and she had an unremitting new onset headache that was unresponsive to analgesic and other measures.  Per the relevant practice bulletin of the American College of Obstetricians and Gynecologists, the appropriate standard care for this condition postpartum is admission to the hospital and administration of a course of magnesium sulfate for seizure prophylaxis as well as close observation for development of further end-organ complications.  The bulletin states that ambulatory management at home is not appropriate for patients with preeclampsia with severe features.  If left untreated postpartum preeclampsia can lead to seizures, intracranial hemorrhage, hypertensive crisis, PRES (posterior reversible encephalopathy syndrome) syndrome and blindness, renal failure, severe liver complications, coagulopathy, hemorrhage, pulmonary edema, and death.  Therefore the admission and magnesium treatment, which requires admission, were medically necessary.

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: Oligodontia

Treatment D6010 surgical placement of implant #2, 3, 10, 13, 14, 15, and 20

The insurer denied coverage for D6010 surgical placement of implant #2, 3, 10, 13, 14, 15, and 20.

The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in areas as enumerated above.  The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in both the maxilla and mandible. As regards endosteal implant placement, although implants are an acceptable treatment restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. Further the documentation provided does not support, justify, or substantiate the requested treatment.  Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

The health care plan acted reasonably and with sound medical judgement and in
the best interest of the patient, as an appropriate alternative standard of care treatment would be conventional removable dentures and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable partial dentures. Therefore, as other acceptable alternative treatments are appropriate, and the documentation provided does not support the recommended treatment this renders the endosteal implants and associated services not medically necessary.

Based on the above, the medical necessity for the D6010 surgical placement of implants #2, 3, 10, 13, 14, 15, and 20 is not substantiated. The insurer's denial is upheld.