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

Diagnosis: Urinary Tract Infection.
Treatment: Inpatient hospital admission. 
The insurer denied coverage for an inpatient hospital admission. 
The denial is upheld.

The patient presented with epigastric pain, chest pain, and nausea. She was afebrile and her vital signs were stable. There was no abdominal rebound or guarding. The EKG (electrocardiogram) did not have any acute changes. A computed tomography angiography (CTA) was negative for a pulmonary embolism. An abdominal CAT (computed tomography) scan was negative for acute disease. The WBC (white blood cell count) was 21.7. The leukocytosis was noted to be a chronic problem and the WBC was usually around 16. The lactic acid was normal. She was diagnosed with possible pyelonephritis and started on antibiotics. The chest pain was determined to be non-cardiac. Urine and blood cultures were negative. An outpatient hematology workup was advised.

Clinical indications for an inpatient hospital admission for a urinary tract infection (MCG [Milliman Care Guidelines] M-300) include hemodynamic instability, altered mental status, worsening clinical findings, ureteral obstruction, bladder outlet obstruction, renal abscess, and acute renal failure. The patient did not have these conditions.

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient had urinary tract symptoms but did not have evidence of an acute urinary tract infection. She had leukocytosis but that was a chronic problem. She required a hematology consultation for the leukocytosis, but it could have been done as an outpatient. Blood and urine cultures could have been done with an observation status. She did not meet MCG criteria for an inpatient hospital admission for either Urinary Tract Infection or Undiagnosed Abdominal Pain. The health care plan acted reasonably and with sound medical judgment. An inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: muscle weakness
Treatment: physical therapy
The insurer denied physical therapy. The health plan's determination is overturned.

The patient is a male who has a diagnosis of lack of coordination, muscle weakness (generalized), unspecified abnormalities of gait and mobility, delayed milestone in childhood, specific developmental disorder of motor function.

The requested physical therapy is medically necessary for this patient.
Per results of the Peabody Developmental Motor Scores performed the patient was less than 10th percentile in all domains he does meet the criteria for medical necessity.

The patient's developmental delays do meet the threshold for which specialized intervention is warranted.  The patient has some areas of improvement though deficits still are present. The therapy in question does meet these standards of care for medical necessity. Physical therapy is medically necessary when there is documentation that it is improving a patient's current condition, or preventing or slowing further deterioration of the patient's condition,  or to help a person keep, learn or improve skills and functioning for daily living to maintain the patients current condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Stelara subcutaneous (SQ) 90 mg (milligrams). 

The insurer denied Stelara subcutaneous (SQ) 90mg.  The denial is overturned. 

The patient is a female with severe refractory Crohn's disease status post diverting ileostomy. She has failed Remicade, Humira, and Entyvio. She started Stelara. She has had gradual dose escalation of Stelara to the current dose of 90 mg every 4 weeks. She has had disease exacerbations and hospitalizations while on the increased dose of Stelara 90mg every 4 weeks.

At issue is the medical necessity of Stelara SQ 90mg.

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

The requested health service/treatment of Stelara SQ 90mg is medically necessary for this patient.

The request to continue Stelara 90mg every 4 weeks is supported as medically necessary in this case. Stelara is United States Food and Drug Administration (FDA) approved for the treatment of Crohn's disease, and 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. [1-3] Guidelines for the treatment of Crohn's disease recommend the use of Stelara. [4] A study showed dosing intensification (90mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response. [5-7] One study showed that dose escalation was required in approximately half of patients, and successful in 61.1% of dose escalation attempts. [5] Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted. [7] Additionally, the American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy." [4]

In this case, the patient has failed the other biologic medication classes recommended by guidelines for the treatment of Crohn's disease (Entyvio, and the anti-tumor necrosis factor medications Remicade and Humira), failed Stelara every 8 weeks, and had active disease despite the use of Stelara 90mg every 4 weeks. Decrease of Stelara dosing, or discontinuation of Stelara (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for further surgery, or other complications of Crohn's disease. For all of these reasons, the request to continue Stelara 90mg every 4 weeks is supported as medically necessary for the treatment of Crohn's disease in this case.

Therefore, the requested health service/treatment of Stelara SQ 90mg is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male with a past medical history of coronary artery disease and prior myocardial infarction, atrial fibrillation on anticoagulation, and gastroesophageal reflux disease.  He presented to the emergency department for evaluation of left-sided chest pain as well as left lower quadrant abdominal pain.  

On arrival to the emergency department, the patient had a temperature of 100.1 degrees Fahrenheit and was hemodynamically stable.  He was saturating well on room air.  Initial electrocardiogram (EKG) demonstrated sinus arrhythmia with no acute ischemic changes.  Initial labs were notable for a white blood cell (WBC) count of 10.6, hemoglobin of 12.4, and platelet count of 351.  Initial troponin was within normal limits.  Chest x-ray showed left lower lobe consolidation with a small pleural effusion.  This may represent pneumonia versus post-obstructive changes.  A computed tomography (CT) scan of the chest/abdomen/pelvis was obtained which showed a density within the left lung base, consistent with atelectasis or less likely pneumonia.  The patient was admitted to the inpatient unit for further management.

No, the proposed inpatient hospital admission was not medically necessary.
Based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care. Observation level of care would have been appropriate in this case. This patient presented with chest pain in the setting of a possible pneumonia. He was ruled out for acute coronary syndrome and there was no evidence of acute ischemia based on his electrocardiogram and cardiac biomarkers. Furthermore, although he did have pneumonia, there was no evidence of sepsis. He was hemodynamically stable and there was no evidence of end organ malperfusion. He did not have hypoxia and/or mental status changes.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The health plan acted appropriately with sound medical judgement. There is sufficient evidence to support that care could have been safely rendered at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal reflux.
Treatment: Procedure code 43239, esophagogastroduodenoscopy (EGD).

The insurer denied coverage for procedure code 43239, EGD.  The denial is upheld.

The patient reported having episodes of heartburn which were worse at night. An endoscopy was performed, and no abnormalities were found. The esophageal biopsies did not show any significant pathological change.

Milliman Care Guideline (MCG) ACG: A-0203 lists indications for Upper Gastrointestinal (GI) Endoscopy. Gastroesophageal reflux is an indication for the procedure if it is associated with other risk factors. The listed criteria include anemia, dysphagia, epigastric mass, failure of medical therapy, gastrointestinal bleeding, recurrent vomiting, severe erosive esophagitis, and weight loss. Other indications include achalasia, Barrett's esophagus, epigastric mass, gastrointestinal bleeding, and suspected cancer. The patient did not have these conditions.

This patient had reflux symptoms but had not failed a trial of proton pump inhibitor (PPI) therapy. There was also no history of gastrointestinal bleeding or other associated risk factors. She did not meet MCG criteria for doing an esophagogastroduodenoscopy. 

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 43239, esophagogastroduodenoscopy is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urine Retention

Treatment: Inpatient hospital admission

The denial is upheld

This is a male with past medical history diabetes, hypertension, hyperlipidemia, atrial flutter, and status post rotator cuff repair. The patient presented to be emergency room with complaint of urine retention. Urology placed a catheter and bladder was drained of 800 ml (milliliter). The foley was removed and the patient successfully passed a trial of void. He remained clinically and hemodynamically stable. He was discharged home later that day after a period of medical stability. The insurer has denied coverage for the inpatient hospital admission as not medically necessary. They noted that the patient could have been placed in observation under monitoring, there was no hemodynamic, pulmonary, Neurological or metabolic reason to treat the patient at an acute LOC (level of care). Per MCG (Milliman Care Guideline) Health (25th) Urologic Disease - GRG (General Recovery Care), patient fails to meet clinical indications for admission to inpatient care under subsection:

	Retention that persists despite observation care
	Hemodynamic instability
	Acute kidney disease requiring inpatient care
	Acute neurologic etiology (cauda equina)
	Dehydration or other complication not manageable in observation care

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

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

Diagnosis: Class II occlusion 
Treatment: braces
The insurer denied braces/monthly visits. The health plan's determination is upheld. 

The patient in question is a male with a Class II occlusion with 4 millimeter (mm) overjet and 6 mm overbite. The maxillary and mandibular arches have mild crowding. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion. Under review is the medical necessity of braces/monthly visits.

Braces and monthly visits are not medically necessary. The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. The provided photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 4mm overjet but research shows this amount of overjet does not affect oral health related quality of life. If his teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal - osteoarthritis. 
Treatment: Home Health Care. 
The insurer denied Consumer Directed Personal Assistance (CDPAP) 7.5 hrs (hours) per day, 5 days a week, for a total of 37.5 hrs. per week. 
The denial is overturned.

The patient is a female with past medical history of hypertension and osteoarthritis. The review is regarding medical necessity of Consumer Directed Personal Assistance Program (CDPAP) 7.5 hours per day, 5 days a week, for a total of 37.5 hours per week. The patient was assigned services based on assessment assessing the patient with modified independence with no memory problems. There were Minimal hearing difficulty and minimal vision difficulties. The patient was assessed to require total dependence with task of meal preparation and total dependence for housework, and limited assistance with medications. The patient was assessed at extensive assistance with task of bathing, personal hygiene, dressing upper body and dressing lower body, limited assistance with walking, toilet transfer and limited assistance with toilet use, independent with bed mobility and with eating. Patient is frequently bladder incontinent and occasionally bowel incontinent. Activities of daily living (ADL) Status had declined with a deterioration in self-sufficiency in the last 90 days. It was noted that patient was wheelchair bound and requires assistance with turning in repositioning in bed and chair. Patient assessed to require 22.5 hours of assistance weekly.

Patient underwent a re-assessment assessing the patient with modified independence with no memory problems. There were minimal hearing difficulty and minimal vision difficulties. The patient was assessed to require maximal assistance with task of meal preparation and total dependence for housework, and maximal assistance with medications. The patient was assessed at extensive assistance with task of bathing, personal hygiene, dressing upper body and dressing lower body, walking, toilet transfer and limited assistance with toilet use, extensive assistance with bed mobility and limited assistance with eating. The patient is frequently bladder incontinent and occasionally bowel incontinent. ADL status had declined with a deterioration in self-sufficiency in the last 90 days. The patient was assessed to require 30 hours of assistance weekly.

The health plan's determination is overturned.

The requested increase in assistance was not solely for safety and supervision but to assist the patient with safely completing ADLs and Instrumental activities of daily living (IADLs). The patient has had a decline in function since the initial assessment justifying the need for increased hours. The patient now requires hands-on assistance with toilet transfers and was assessed to require 30 hours of assistance at the last assessment Consumer Directed Personal Assistance Program (CDPAP). 7.5 hours per day, 5 days a week, for a total of 37.5 hours per week is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II Occlusion.
Treatment: Comprehensive Orthodontic Treatment.
The insurer denied Comprehensive Orthodontic Treatment. 
The health plan's determination is overturned. 

The patient in question is a female with a Class II Division 2 occlusion with 2 millimeters (mm) overjet. She has a 100% overbite with wear on the lower incisors and the cephalometric radiograph indicates she is biting on her palate. She has minor maxillary and mandibular crowding. She is treatment planned for orthodontics to correct her malocclusion.

Comprehensive Orthodontic Treatment is medically necessary for this patient.  
The patient's occlusion is causing her lower incisors to contact right at the lingual gingival margin of the maxillary incisors. This is a traumatic occlusion. Not only does it have a positive correlation with periodontal disease, but studies also indicate an increased appearance of periodontal radiolucencies on the maxillary incisors. It is believed these periodontal lesions are related to gingival surface injury and food impaction due to the deep bite. Therefore, correcting the patient's malocclusion with orthodontic treatment will create a clinically significant improvement in the patient's periodontal health. Orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld

This is a male patient who presented to the emergency department with worsening memory loss and uncontrolled hypertension. The patient has a history of hypertension and a cerebrovascular accident (CVA) with residual right-sided weakness. The patient was referred by their primary care provider due to uncontrolled hypertension. There was no loss of consciousness or acute events. Initial vital signs were a blood pressure of 166/88 mmHg (millimeters of mercury) with a heart rate of 82 bpm (beats per minute). The documentation notes that the patient was alert and oriented x 4 (person, place, time, and situation). A CT (computed tomography) scan of the head indicated changes consistent with subacute to chronic infarct. An MRI (magnetic resonance imaging) of the brain did not demonstrate any acute abnormalities. Clinical documentation noted that the patient had been having worsening memory loss over the past year. 

Per MCG (Milliman Care Guidelines), an inpatient admission for hypertension is indicated for the following: hypertensive encephalopathy, cerebral infarction, intracranial hemorrhage, myocardial ischemia or infarction, heart failure, aortic dissection, increased creatinine, papilledema, retinal hemorrhage, microangiopathic hemolytic anemia, seizures, or acute or worsening end organ damage. Systolic blood or diastolic blood pressure must be greater than 180 mm Hg or 120 mmHg, respectively. [1] Hypertensive encephalopathy occurs in severe hypertension and include cerebral edema with changes in mental status, seizures, altered mental status, visual field loss, or headache. Malignant hypertension is defined as severe hypertension with associated retinal hemorrhages, exudates, or papilledema. [2] The patient did not have any acute mental status changes. There were no signs of end organ damage. There was only one blood pressure reading with a systolic blood pressure greater than 180 mm Hg (185/105 mm Hg). Per provided clinical documentation, the requested inpatient stay was not medically necessary.

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

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

Diagnosis: Atopic Dermatitis.
Treatment: Opzelura.
The insurer denied the Opzelura.  
The determination is overturned.

The patient has atopic dermatitis. Her face is affected. She has tried and failed hydrocortisone, Elidel cream and halobetasol. The medication under review is Opzelura.

The requested health treatment of Opzelura is medically necessary for this patient. Opzelura is medically necessary for this patient. The patient has tried and failed all the conventional therapies for atopic dermatitis. Opzelura has been shown to be very effective for atopic dermatitis. Papp et al. writes in "Efficacy and safety of ruxolitinib cream for the treatment of atopic dermatitis: Results from 2 phase 3, randomized, double-blind studies" that "RUX [Ruxolitinib]  cream showed anti-inflammatory and prompt antipruritic effects with superior efficacy versus vehicle and was well tolerated" (1). Baluvelt et al. writes "Ruxolitinib cream rapidly decreases pruritus in atopic dermatitis: Pooled results from two phase 3 studies" (2). Simpson et al. writes "In summary, ruxolitinib cream brought about substantial and clinically meaningful improvements in multiple patient reported outcomes (PROs)" (3). Given that the patient has failed numerous therapies, including methotrexate, Opzelura is medically necessary including in conjunction with Dupixent. While Opzelura cream in combination with Dupixent is not approved by the Food and Drug Administration (FDA) product labeling, this patient has failed all the standard of care therapies.  This combination is the accepted standard of care when all the standard of care, conventional therapies have failed.  Therefore, Opzelura is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Pain injection (sacroiliac [SI] joint injection)
The insurer denied: Pain injection (SI) joint injection
The denial is upheld.

The patient is a male with low back pain. The pain has been present for years and associated with worsening with activity. The pain can be as high as 9 out of 10. The patient has completed physical therapy and continues a home exercise program. The patient has difficulty with activities of daily living (ADLs). The physical exam showed sacroiliac (SI) joint tenderness on the right, positive sacral thrust test on the right, positive Patrick's test on the right, positive Stinchfield test for back pain, Patrick's test on the left causes right low back pain. The patient's diagnoses include sacroiliitis. There is a request for pain injection in the form of SI joint injection which was denied by the health plan due to lack of official imaging. This is the subject under review.

The health plan's determination is upheld.

The requested pain injection (SI joint injection) is not medically necessary.
There remains an absence of official imaging reports ruling out other sources of pain. Sacroiliac joint injections are only recommended when other causes of pain have been ruled out clinically as well as via imaging. Other sources of pain, such as facet joints, or disc displacement, must be ruled out prior to moving forward with the requested injection. Therefore, the requested treatment is not medically necessary for this patient.