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

Diagnosis: Fall
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) following a fall down steps. Comorbid health conditions included high cholesterol, hypertension, alcohol abuse, and coronary artery disease. He complained of right arm pain at the time of presentation. He was initially evaluated in the emergency department (ED). Vital signs were normal with a heart rate of 77 beats/minute and a room air oxygen saturation of 95%. His breathing was unlabored. Imaging with a right arm x-ray showed a comminuted displaced fracture of the proximal right humeral shaft. A computed tomography (CT) scan identified right sided rib fractures of ribs 5 and 6.
He was admitted to the hospital. An orthopedic consultation was obtained with the recommendation for a coaptation splint. This was applied. The plan was for outpatient open reduction internal fixation (ORIF) of the right humerus fracture. He was treated with multimodal pain medication, incentive spirometry, Clinical Institute Withdrawal Assessment (CIWA) protocol, and alcohol brief intervention. He was without new complaints. His diet was advanced. The pain was adequately controlled with oral analgesia. He did not have a fever and the vital signs were normal. He was discharged from the hospital.
At issue is the medical necessity of an inpatient stay.
Inpatient care was not medically necessary for this patient.
This patient presented to the ED after a fall in which he sustained 2 right rib fractures and a right humeral fracture. He was clinically stable at the time of presentation with normal heart rate and labs. He was treated with splinting of the right arm fracture in anticipation of outpatient open reduction internal fixation (ORIF). He was able to ambulate and was able to tolerate a diet. He was provided pain medications and was able to participate with physical therapy. He remained clinically stable throughout the period of monitoring.
Inpatient admission may be indicated in the setting of rib fractures for hemodynamic instability, 3 or more rib fractures, flail chest, acute respiratory failure, pain management, associated injury, infection, hypoxemia, tachypnea, immediate surgery needed or other condition. The right humerus fracture was treated with splinting in anticipation of future outpatient ORIF.
This patient had 2 rib fractures and a fractured right humerus. Pain management was with multimodal analgesia and could have been rendered with only oral medications. He was able to operate the incentive spirometer and participate with physical therapy. He was hemodynamically stable with normal pulse oximetry. He did not require an acute operative intervention or an intensity of medical care that mandated inpatient admission. Care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Liver Problem and Withdrawal From Alcohol.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male. He was admitted for management of severe, worsening nausea, vomiting, tremors and auditory hallucinations.

The patient's CIWA (clinical institute withdrawal assessment) score was 11, consistent with moderate alcohol withdrawal. The labs were as follows: Platelets 42, INR (international normalized ratio) 2.40 Prolonged PT (prothrombin time) 25.2, Prolonged PTT (partial thromboplastin time) 48.8 sec, tbili (total bilirubin) 7.7, AST (aspartate aminotransferase) 161, ALT (alanine aminotransferase) 42, ALK PHOS (Alkaline phosphatase) 216. X-ray ribs revealed no fractures, no pleural effusion or pneumothorax. Ultrasound Abdomen revealed hepatomegaly with diffuse fat depositions vs diffuse hepatocellular disease and splenomegaly.

Yes, the Inpatient admission was medically necessary.

The patient was treated with IV (intravenous) Ativan, IV (intravenous) fluids. The plan was to initiate systemic steroids for the patient severe alcoholic hepatitis, but despite counseling by the medical team, the patient left against medical advice the next day.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
As the patient had alcohol withdrawal and acute alcohol induced hepatitis, an in-patient level of care was medically necessary. For alcohol withdrawal, monitoring for complications and administration of IV (intravenous) Ativan was necessary. This patient had an INR (international normalized ratio) of 2.4, indicating severe liver disease. For the acute alcohol hepatitis, monitoring for worsening liver disease and treatment accordingly was necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bariatric surgery
Treatment: Laparoscopy Procedure (liver biopsy- code 47379)
The insurer denied the Laparoscopy Procedure (liver biopsy- code 47379).
The denial is upheld.

The patient is a female with BMI (body mass index) of 44 who underwent a RYGB (Roux-en-Y gastric bypass). The request is for coverage for routine laparoscopic liver biopsy for fatty liver 47379.  Coverage was previously denied by the insurer given that it was not considered medically necessary due to no LFT (liver function test) abnormalities and the treatment for fatty liver is weight loss which would be expected to occur with weight loss surgery.  Diagnosis was also not expected to change treatment, per insurer. The insurer additionally found that the surgeon routinely performed liver biopsies and billed separately far out of proportion to the average bariatric surgeon. Thus, the request for coverage was denied.

No, the Laparoscopy Procedure (liver biopsy- code 47379) was not medically necessary.
Concurrent liver biopsy during weight loss surgery in this instance was not in accordance with generally accepted standards of medical practice, as it exposed the patient to additional risk of complication without apparent benefit to the patient. Ascertaining the degree of steatohepatitis would not be expected to change treatment plan.  Less morbid alternatives exist.

Yes, the health plan acted with sound medical judgement and in the best interest of the patient.
There are no RCTs (randomized controlled trials) or recent studies endorsing routine liver biopsy during bariatric surgery for NASH (nonalcoholic steatohepatitis).  The data do suggest that NASH (nonalcoholic steatohepatitis) is prevalent among bariatric patients, appropriate treatment includes bariatric surgery, and the risk of complication from adding routine liver biopsy when it is unlikely to change management is not supported in the literature.  Additionally, the data show this is not a procedure that is commonly routinely performed by bariatric surgeons empirically during bariatric surgery and there is no position statement by the ASMBS (American Society for Metabolic and Bariatric Surgery) to support this practice.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission

The denial is upheld

According to the documentation submitted, this is the case of a patient with a history of breast cancer with brain metastasis status post brain surgery and radical mastectomy on chemotherapy, deep vein thrombosis (DVT), seizure disorder, hypertension (HTN), and diabetes mellitus type 2 (DM). The patient was seen in the Emergency Department (ED) after having a tonic-clonic seizure the prior day lasting 5 minutes.  She complained of chest pain with 1 episode of vomiting.  She also endorsed weakness to the bilateral lower extremities.  The physical examination revealed an antalgic gait.  There was 4/5 strength to the bilateral lower extremities.  She was recommended to undergo laboratory diagnostic studies in addition to a neurosurgery consultation.  The documentation indicated computed tomography (CT) was positive for right anterior encephalomalacia and the CT angiogram was negative for central or subsegmental embolus, incidental thyroid nodule was visualized.  The documentation indicated she was admitted and continued with treatment that included additional medications and diagnostics.  The recommendation was made for further surveillance.  She continued with treatment and did not have any further decline.  She was recommended for discharge 2 days after admission with instruction to follow-up.

The patient had a history of metastatic breast cancer with metastases to the brain with defined history of seizures, on Keppra, who presented to the ED after a prolonged seizure. The patient was evaluated in the ED and admitted to the hospital. There was no report of additional seizures. She underwent a CT of the head which demonstrated a zone of chronic encephalomalacia, but no acute changes were identified. She was treated with medical management. Care provided, including specialty consultation, medical management, and diagnostic imaging could have been performed at an observation level of care. Inpatient admission was not medically necessary.

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity

Treatment: Procedure code 47379, liver biopsy

The insurer denied coverage for procedure code 47379, liver biopsy.

The denial is upheld.

This patient has a history of obesity with a body mass index (BMI) of 42.27. She meets the National Institute of Health (NIH) consensus statement for medical necessity of bariatric surgery. A Roux en y Gastric bypass was performed. The surgeon evaluated her liver which looked fatty infiltrated and he opted to perform a wedge liver biopsy. Pathology revealed minimal macro vesicular steatosis.

Several articles were included in the review package. Aminian, et al (4) concluded in their paper that "Among patients with NASH (nonalcoholic steatohepatitis) and obesity, bariatric surgery, compared with nonsurgical management, was associated with a significantly lower risk of incident major adverse liver outcomes and MACE (major adverse cardiovascular events)." A second reference included was Shalhub, et al (8), who noted that "Routine liver biopsy documented significant liver abnormalities in a larger group of patients compared with selective liver biopsies, thereby suggesting that liver appearance is not predictive of NASH." They recommended "routine liver biopsy during bariatric operations to determine the prevalence and natural history of NASH, which will have important implications in directing future therapeutics for obese patients with NASH and for patients undergoing bariatric procedures." The final paper referenced by Mahawar, et al (7) states "Routine liver biopsy can help early and accurate diagnosis of obesity-associated liver conditions. This has led some surgeons to argue for routine liver biopsy at the time of bariatric surgery. However, most bariatric surgeons remain unconvinced and liver biopsy is currently not routine practice with bariatric surgery."   

Based upon the information provided, liver biopsy at the time of this bariatric surgery was not indicated. This is based upon review of the literature and as well based upon the articles that the provider referenced. 

Finally, an additional paper on the question of the utility of liver biopsy in these patients by Jones, et al (5) reviewed adolescents who received bariatric surgery at their institution over a range of years. In the past, all patients routinely received intraoperative liver biopsy. More recently, biopsy was performed selectively on an individual basis for transaminitis or clinical concern. They concluded that "Routine intraoperative liver biopsy during adolescent bariatric surgery possesses questionable benefit, as it does not appear to impact short-term postoperative management." Thus, given the more recent literature, the liver biopsy was not medically necessary.

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

The insurer's denial of coverage for procedure code 47379, liver biopsy, is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Hemiparesis

Treatment: Power Operated Vehicle (POV), Group 1 Standard, up to 300 lbs (pounds)

The insurer denied coverage for Power Operated Vehicle, Group 1 Standard, up to 300 lbs.

The denial is upheld.

This patient has multiple medical problems including cervical stenosis, lumbar fusion, thrombocytosis, and a cerebral vascular accident (CVA) with left hemiparesis and foot drop.  Currently under review is the medical necessity for a requested power operated vehicle (POV) group 1 standard up to 300 pounds.

Additional information is required regarding the safety risks posed by the requested POV (motorized scooter).  According to his treating physician, the patient's "left arm/hand is extremely impaired."  He also notes the patient has a "gait disorder requiring a left AFO (ankle foot orthotic)."  Demonstrated training and safety (with documentation) using a motorized scooter (given the patient's underlying impairments) are necessary.
 
From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical probability, the requested POV group 1 standard up to 300 pounds is not medically necessary.

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

The insurer's denial of coverage for a Power Operated Vehicle, Group 1 Standard, up to 300 pounds (lbs) is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Mellitus
Treatment: Januvia (sitagliptin)

The insurer denied the Januvia (sitagliptin).
The denial is upheld.

The patient is a female with type 2 diabetes. Her diabetes was uncontrolled on metformin and glipizide. The request for Januvia is under review. The prior request was denied as documentation was not submitted supporting a trial and failure of metformin or metformin ER (extended release) for 3 consecutive months. The attending physician is appealing this determination as the patient is currently stable on Januvia, metformin, and Actos. Her A1C (glycated hemoglobin) was 5.9%.

No, the requested Januvia is not medically necessary.
This request is for Januvia for the treatment of type 2 diabetes. The patient is stable on Januvia, metformin, and Actos. The documentation supports that the Januvia was started. There are no documented A1C (glycated hemoglobin) levels of 7% or higher or documented elevated glucose levels to support the initiation of Januvia at that time. Januvia has risks, including rashes. Therefore, no, the proposed Januvia is not medically necessary.

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

The requested Januvia was not medically necessary and was appropriately denied.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Kidney Injury.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the hospital with weakness and a poor appetite four days after a  robot-assisted total laparoscopic hysterectomy (RATLH) and bilateral salpingo-oophorectomy (BS) for a fibroid uterus. She also reported 2 episodes of vomiting. She stated that she was urinating without difficulty and denied abdominal pain. Vital signs showed that she was afebrile with a pulse of 91, a respiratory rate of 16, and a blood pressure of 137/95.
Lab results showed a creatinine of 5.7, a blood urea nitrogen (BUN) of 46, a sodium of 128, a potassium of 4.8, a carbon dioxide (CO2) of 23, white blood cell count (WBC) of 12.7 and a hemoglobin of 14.6. A urinalysis showed 100 protein, 100 glucose, trace ketones, large blood, negative nitrate, moderate leukocyte esterase, and negative bacteria. A bedside ultrasound showed distension of her bladder and a Foley catheter was placed. A formal renal ultrasound showed medical renal disease and a collapsed bladder around a Foley catheter. At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary.  The patient was admitted for an acute kidney injury and hyponatremia and was started on intravenous (IV) fluids. Nephrology and gynecology were consulted. The creatinine improved to 2.4 and the sodium improved to 134 later that same day. The creatinine continued to improve and normalized at 1.0 overnight. She was discharged home in stable condition.
This patient presented with a severe acute kidney injury, notable for a creatinine well above 4 milligrams per deciliter (mg/dl) (5.4mg/dl) which is an absolute indication for admission based on the Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 25th Edition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness, imbalance. 
Treatment: Inpatient admission. 

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

The patient is a female who presented to the emergency ward with the complaint of dizziness, weakness and imbalance. At presentation, the patient was noted to have an unsteady gait. Computed tomography (CT) of the brain was negative for acute intracranial pathology. The patient was admitted for possible stroke. Magnetic resonance image (MRI) of the brain and cervical spine were negative for stroke and neurology consultation documented a normal neurological examination. 

No, the proposed treatment was not medically necessary. 

The patient presented with dizziness, weakness and imbalance with symptoms of gastroenteritis. She has a normal neurological examination. The clinical presentation and examination findings were unlikely related to stroke and the risk stratification guidelines for transient ischemic attack (TIA)/stroke do not support the need for acute inpatient evaluation in this clinical context (Mendelson and Prabhakaran; Cereda and Olivot). The clinical evaluation, diagnostic studies, and monitoring could have been safely and effectively provided at a lower level of care. 

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

Diagnosis: Hereditary Nephritis, End Stage Renal Disease
Treatment: Cinacalcet 30mg (milligrams) tablet daily for 30 days

The insurer denied coverage for cinacalcet 30mg tablet daily for 30 days.
The denial is overturned.

The patient has a history of hereditary nephritis, hyperparathyroidism due to renal insufficiency, and end stage renal disease. She had a peritoneal dialysis catheter inserted and was on dialysis 4 times per week. She underwent renal transplant. The Nephrologist has requested continuation of cinacalcet 30mg tablet daily for 30 days with 6 refills.

Hypercalcemia secondary to hyperparathyroidism can cause further kidney damage due to nephrocalcinosis and kidney transplant failure, other options to treat hyperparathyroidism are not feasible due to the side effects of hypercalcemia

Therefore, per standard of care, Sensipar is medically necessary to treat this member's condition.

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

The insurer's denial of coverage for cinacalcet 30mg tablet daily for 30 days is overturned. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Arrhythmia/Atrial fibrillation.
Treatment:  Eliquis.
The health plan denied Eliquis.  
The reviewer has overturned in whole the health plan's determination.

The patient has a history of atrial fibrillation and is treated with Eliquis (apixaban). As this is not on formulary, it was recommended by the health plan that Eliquis be changed to Xarelto (rivaroxaban) or warfarin. Per the appeal letter, it was recommended that she stay on Eliquis due to higher bleeding risk with Xarelto.

It is recommended that the health plan's determination be overturned in whole.

The formulary drugs Warfarin and Xarelto both carry higher risk for adverse effects and would not be as effective as Eliquis. The formulary drug, Xarelto, has been associated with increased risk for adverse effects. In the study by Wayne et al. (1) of over 580,000 patients with atrial fibrillation, treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events. In the main ARISTOTLE trial (2), apixaban was superior to warfarin in prevention of stroke and systemic emboli in patients with atrial fibrillation.

This patient has been stable on Eliquis, and it is recommended that she continue it. The other 2 formulary medication options carry higher risk for adverse effects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite with gingival attachment loss.
Treatment braces and monthly visits.
The insurer denied coverage for braces and monthly visits.
The denial is upheld.
 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth (mandibular left canine) when clinical attachment loss and recession of the gingival margin are present, to support orthodontic necessity. 

It is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer score on the HLD index attains 14 points (4 overjet, 8 anterior open bite, 2 labiolingual spread) which is below the require 26 points.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies referenced below. 

Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this bas been determined to represent an appropriate approach for assessing orthodontic need.

The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient. Braces and monthly visits are not considered medically necessary for this patient.

The insurer's denial of coverage for braces and monthly visits is upheld. Medical Necessity is not substantiated.